Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 48 one-way trips to Plan approved locations every year. You can find this information on page 108 
of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rate, facility or non-facility that a physician service is paid under the MPFS is determined by the Place of 
service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter 
with the physician, non-physician practitioner (NPP) or other supplier. In general, the POS code reflects the 
actual place where the beneficiary receives the face-to-face service and determines whether the facility or non-
facility payment rate is paid. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 12 Section 20.4.2. 
 
The rules state that when services are furnished by a mobile unit, they are often provided to serve an entity for 
which another Place of service (POS) code exists. For example, a mobile unit may be sent to a physician's 
office or a skilled nursing facility. If the mobile unit is serving an entity for which another POS code already 
exists, providers should use the POS code for that entity. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
26, Section 10.5. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
The rules say that, upon request, the entity that submitted the claim (e.g., the laboratory) must provide 
documentation of the order for the service billed as well as diagnostic or other medical information that the 
entity 
received from the ordering physician. If a laboratory bills for a diagnostic laboratory test and documentation to 
support the medical necessity of the test is not submitted, the claim is denied. You can find this rule at 42 CFR 
Section 410.32. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that some codes that are not on the list of therapy services should not be billed with a modifier. 
For example, outpatient non-rehabilitation HCPCS codes G0237, G0238, and G0239 should be billed without 
therapy modifiers.  
 
Modifiers are used to identify therapy services whether or not financial limitations are in effect. The claim must 
include the GP Services delivered under an outpatient physical therapy plan of care. Modifiers GN, GO, and 
GP refer only to services provided under plans of care for physical therapy, occupational therapy and speech-
language pathology services. They should never be used with codes that are not on the list of applicable therapy 
services.  
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 5, Section 20(C), and 20.1. 
 
The rules say that the Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 30.2.2. If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Elastic or other fabric support garments (A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, 
ANY TYPE)) with or without stays or panels do not meet the statutory definition of a brace because they are 
not rigid or semi-rigid devices. Code A4467 is denied as noncovered (no Medicare benefit).  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that an initial thermal radiofrequency ablation (RFA) of cervical, thoracic, or lumbar 
paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients 
who have had at least two (2) medically reasonable and necessary diagnostic medial branch blocks (MBBs), 
with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the 
duration of relief being consistent with the agent used). Repeat thermal facet joint RFA at the same anatomic 
site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform 
previously painful movements and activities of daily living (ADLs) as compared to baseline measurement 
using the same scale. 
 
You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L34892). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that effective for claims with dates of service on and after December 23, 2009, the Centers for 
Medicare and Medicaid Services (CMS) determines that the evidence is adequate to conclude that OIVIT does 
not improve health outcomes in Medicare beneficiaries. Therefore, CMS determines that OIVIT is not 
reasonable and necessary for any indication under section 1862(a)(1)(A) of the Social Security Act. You can 
find this in the Centers for Medicare and Medicaid Service, Internet-Only Manual, Publication Number 100-03, 
Medicare National Coverage Determinations Manual, Section 40.7. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1.  
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 The rules say that the National Correct Coding Initiative (NCCI) was developed to prevent inappropriate 
payment of services that should not be reported together. NCCI edits are organized in a Column I/Column 2 
table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of an edit 
pair, only the Column 1 code is payable. For edits with a modifier indicator of 0, the Column 2 code cannot be 
paid regardless of whether a modifier is used. You can find this in the NCCI Manual, Chapter I. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that procedures and examinations which are not covered under the portable x-ray provision 
include the following: procedures involving fluoroscopy, procedures involving the use of contrast media, 
procedures requiring the administration of a substance to the patient or injection of a substance into the patient 
and/or special manipulation of the patient, procedures which require special medical skill or knowledge 
possessed by a doctor of medicine or doctor of osteopathy or which require that medical judgment be 
exercised, procedures requiring special technical competency and/or special equipment or materials, routine 
screening procedures; and procedures which are not of a diagnostic nature. You can find this rule at the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication. 100-02, Medicare Benefit Policy 
Manual, Chapter 15, Section 80.4.4. 
 
The rules also say that when services are furnished in a mobile unit, they are often provided to serve an entity 
for which another place of service (POS) code exists. For example, a mobile unit may be sent to a physician's 
office or a skilled nursing facility. If the mobile unit is serving an entity for which another POS code already 
exists, providers should use the POS code for that entity. However, if the mobile unit is not serving an entity 
which could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15. You 
can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, Publication 
Number 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.5. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that if a claim contains services that result in an ambulatory payment classifications (APCs) 
payment but also contains packaged services, separate payment for the packaged services is not made since 
payment is included in the APC. Unconditionally packaged services are services for which separate payment is 
never made because the payment for the service is always packaged into the payment for other services. 
Unconditionally packaged services are identified in the Outpatient Prospective Payment System (OPPS) 
Addendum B with status indicator of N. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 4, Section 
10.4. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules also state that if the provider must discard the remainder of a single-use vial after administering the 
prescribed dosage, Medicare may cover the amount discarded along with the administered amount. For the 
discarded amount to be covered:  
1. Vial must be a single-use vial. Multi-use vials are not subject to payment for discarded amounts of the drug. 
2. Units billed should correspond with the smallest vial available for purchase from the manufacturer that could 
provide the appropriate dose for that patient to minimize wastage.  
 
You can find this information on the website for the Medicare Administrative Contractor (MAC) for the State 
of Ohio, at https://www.cgsmedicare.com/parta/pubs/news/2023/06/cope141092.html. 
 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that there are two applications of molecular biomarkers to risk-stratify patients at increased risk 
for prostate cancer: 
I. A non-invasive or minimally invasive test, the results of which are obtained to inform the decision to 
perform an initial biopsy (pre-biopsy). 
II. A test performed to further refine risk when a biopsy has been performed but does not clearly indicate 
malignancy on histopathologic examination (post-biopsy). Such a test can potentially obviate the need 
for a repeat biopsy. 
You can find this rule in Local Coverage Determination (LCD)MolDX: Molecular Biomarkers to Risk-Stratify 
Patients at Increased Risk for Prostate Cancer L39042. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that if a laboratory procedure produces multiple reportable test results, only a single 
HCPCS/CPT code shall be reported for the procedure. If there is no HCPCS/CPT code that describes the 
procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service. 
You can find this rule in the Centers for Medicare and Medicaid Services, National Correct Coding Policy 
Initiative, Chapter X (A). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than the close 
of the period ending 1 calendar year after the date of service. You can find this rule at 42 CFR Section 
424.44(a). 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The only dental 
service you received that is listed as a covered benefit is anesthesia. However, anesthesia is only covered as 
needed with a covered procedure. You can find this information on pages 90 through 92 of the Plans 2022 
Evidence of Coverage (EOC) 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that if a laboratory procedure produces multiple reportable test results, only a single 
HCPCS/CPT code shall be reported for the procedure. If there is no HCPCS/CPT code that describes the 
procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service. 
You can find this rule in the Centers for Medicare and Medicaid Services, National Correct Coding Policy 
Manual, Chapter X (A). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.