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 when certain component codes or mutually exclusive codes are appropriately furnished, such 
as later on the same day or on a different digit or limb, it is appropriate that these services be reported using a 
HCPCS code modifier. Such modifiers are modifiers  E1 - E4, FA, F1 - F9, TA, T1 - T9, LT, RT, LC, LD, RC, 
-58, -78, -79, and -94. Application of these modifiers prevent erroneous denials of claims for several 
procedures performed on different anatomical sites, on different sides of the body, or at different sessions on 
the same date of service. The medical record must reflect that the modifier is being used appropriately to 
describe separate services.  You can find these rules in the Centers for Medicare and Medicaid Services (CMS), 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30. 
 
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 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 will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for equipment that is primarily and customarily used 
for nonmedical purposes or equipment used for a patients comfort or for the convenience of a person caring 
for the patient. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
The rules say that a seat lift mechanism is covered if all of the following are met: 
 
1. The enrollee must have severe arthritis of the hip or knee or have a severe neuromuscular disease.  
 
2. The seat lift mechanism must be a part of the treating practitioner's course of treatment and be prescribed to 
improve, or stop deterioration of, the enrollee's condition. 
 
3. The enrollee must be completely unable to stand up from a regular armchair or any chair in the home.  
 
4. Once standing, the enrollee must have the ability to walk. 
You can find this information in the Local Coverage Determination (LCD): Seat Lift Mechanisms (L33801). 
 
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 the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. The only exception is as 
follows:  
 
For the same date of service only one physician of the same specialty in the group practice may report code 
99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care 
services with CPT code 99292. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
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 pays for home health care services under a prospective payment system (HH PPS). 
Home health services under a plan of care are paid based on a 60-day episode of care. Payment for home health 
care episodes is usually made in two parts. To receive the first part of the HH PPS split payment, the home 
health agency must submit a Request for Anticipated Payment (RAP). Specific data elements are required to 
submit a RAP. The home health agency must enter the claim - Outcome and Assessment Information Set 
(OASIS) matching key output by the Grouper software. This is known as the Treatment Authorization Code. 
You can find this rule, a list of the data elements, and instructions for the 
 
Treatment Authorization Code in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 40.1. 
 
The rules say that after a RAP has been paid and a 60-day episode has been completed or the enrollee has been 
discharged, the home health agency must submit a claim to receive the rest of payment due for the episode. 
You can find this rule and detailed instructions for the claim in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 
40.2. 
 
The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid 
information for all of these elements may be returned as unprocessable. You can find this rule in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 1, Section 80.3.1. 
 
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 a PCD coded as E0675 is used in the treatment of peripheral arterial disease. Claims for 
E0675 will be denied as not reasonable and necessary. You can find this rule at Local Coverage Determination 
(LCD) L33829: Pneumatic Compression Devices (eff. 1/1/20). 
 
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 this is a non-coverage policy for genetic testing for thrombophilia testing for the Factor V 
Leiden (FVL) variant in the F5 gene, the G20210G>A (G20210A) variant in the F2 gene, and the MTHFR 
gene which encodes the 5,10-methylenetetrahydrofolate reductase enzyme. Genetic testing for these genes for 
all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-
covered except for pregnant patients. You can find this rule in Local Coverage Determination (LCD) MolDX: 
Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR 
L36089. 
 
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 does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 health 
Plan contract says that covered hearing services included 1 routine exam, fitting and evaluation for hearing aid 
once every 3 years and $1500 every three years for hearing aids, both ears combined. You must use Plan 
network providers for these services. You can find this information on page 67 of the Plan's 2022 Evidence of 
Coverage.
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 revenue codes and modifiers are reported only in the following combinations: 
- Revenue code 42x (physical therapy) lines with modifier -GP 
- Revenue code 43x (occupational therapy) lines with modifier  GO 
- Revenue code 44x (speech-language pathology) lines with modifier -GN 
 
You can find these rules in Medicare Claims Processing Manual Chapter 5, Section 20.1. 
 
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 percutaneous minimally invasive fusion/stabilization of the sacroiliac joint (SIJ) for the 
treatment of back pain is indicated for the treatment of SIJ pain for patients with low back/buttock pain who 
meet all of the following criteria: 
a. Have undergone and failed a minimum six months of intensive non-operative treatment that must 
include medication optimization, activity modification, and active physical therapy; 
b. Patients report of non-radiating, unilateral pain that is caudal to the lumbar spine (L5 vertebrae), 
localized over the posterior SIJ, and consistent with SIJ pain; 
c. Localized tenderness with palpation of the posterior SIJ in the absence of tenderness of similar severity 
elsewhere (e.g. greater trochanter, lumbar spine, coccyx) and other obvious sources for their pain do not 
exist; 
d. Positive response to the thigh thrust test OR compression test AND 2 of the following additional 
provocative tests: Gaenslens test, Distraction test, Patricks sign; 
e. Absence of generalized pain behavior (e.g. somatoform disorder) or generalized pain disorders (e.g. 
fibromyalgia); 
f. Diagnostic imaging studies that include ALL of the following: 
1. Imaging of the SI joint that excludes the presence of destructive lesions (e.g. tumor, infection) or 
inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion; 
2. Imaging of the ipsilateral hip (plain radiographs) to rule out osteoarthritis; 
3. Imaging of the lumbar spine to rule out neural compression or other degenerative condition that 
can be causing low back or buttock pain; 
g. At least 75 percent reduction of pain for the expected duration of the anesthetic used following an 
image-guided, contrast-enhanced SIJ injection on two separate occasions. 
 
Percutaneous SIJ fusion for SIJ pain is not indicated in the presence of: 
- Systemic arthropathy such as ankylosing spondylitis or rheumatoid arthritis; 
- Generalized pain behavior (e.g. somatoform disorder) or generalized pain disorder (e.g. fibromyalgia); 
- Infection, tumor, or fracture; 
- Acute, traumatic instability of the SIJ; 
- Neural compression as seen on an MRI or CT that correlates with the patients symptoms or other more 
likely source for their pain. 
 
You can find these rules in Local Coverage Determination (LCD) Percutaneous minimally invasive 
fusion/stabilization of the sacroiliac joint for the treatment of back pain (L36000).  
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 special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The Plan must have written policies for determining enrollee eligibility and 
must document its determination that an enrollee is a chronically ill enrollee. You can find this information in 
42 CFR 422.102. 
 
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 Plan 
contract says that if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. You can find this information on page 57.
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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules state that only the following codes should be billed for Cardiovascular Disease Screening: code 
80061 (Lipid panel) which includes codes: 82465 (Cholesterol, serum or whole blood, total), 83718 
(Lipoprotein, direct measurement; high density cholesterol), and/or 84478 (Triglycerides). This rule is found in 
the Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services, Section 100.1 
 
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 repeat bariatric surgery is generally not reasonable and necessary. Medicare does not provide 
prior authorization for these services. Claims for more than one bariatric surgical procedure most likely will 
create a denial. However, in the appeals process, medical documentation may be submitted for review and the 
service may potentially be covered when clinical circumstances demonstrate reasonability and necessity. 
Appropriate ABN and modifiers should be appended to any services potentially to be denied. Refer to IOM 
Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 15 for more information. You 
can find this rule in Local Coverage Determination (LCD) Bariatric Surgical Management of Morbid Obesity 
L35022. 
 
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 Proton Beam Therapy (PBT) is a technology for delivering conformal external beam 
radiation with positively charged atomic particles to a well-defined treatment volume. PBT is approved by the 
U.S. Food and Drug Administration. 
 
Due to its unique dose deposition characteristics, PBT can, in certain situations, deliver the prescribed target 
dose while giving a lower dose to normal tissues as compared to photon-based forms of external beam 
radiotherapy. 
 
Proton delivery methods can be described in one of two forms: scattering or scanning. 
 
    In scattered deliveries, the beam is broadened by scattering devices, beam energies are combined by 
mechanical absorbers and the beam is shaped by placing material such as collimators and compensators into 
the proton path. 
    In scanning deliveries, the beam is swept laterally over the target with magnets instead of with scattering 
devices. Collimators and range compensators are still sometimes used for lateral and distal beam shaping, but 
field specific hardware is not always required because the scanning magnets allow the lateral extent of the 
beam to be varied with each energy level, a technique sometimes called intensity-modulated proton therapy 
(IMPT). 
 
The basic requirement for all forms of PBT treatment delivery is that the technology must accurately produce 
the calculated dose distribution described by the PBT plan. PBT dose distributions are sensitive to changes in 
target depth and shape and thus, changes in patient anatomy during treatment may require repeat planning. 
Such a change must be documented. 
 
Precise delivery is vital for proper treatment. Therefore, imaging techniques such as stereoscopic X-ray or CT 
scan (collectively referred to as Image Guided Radiation Therapy or IGRT) should be utilized to verify 
accurate and consistent patient and target setup for every treatment fraction. 
 
You can find this rule in the Local Coverage Determination (LCD) Proton Beam Therapy L35075. 
 
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 pays for up to 100 days of skilled care in a SNF in each benefit period. A benefit 
period begins upon admission to a hospital or SNF and ends after 60 days in a row without the patient receiving 
hospital or skilled SNF services. You can find this rule in the Social Security Act, Section 1862(a)(18), at 42 
CFR Sections 409.60(a) and (b) and Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, 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. The Plan 
contract also says that SNF benefits are covered for up to 120 days per benefit period. You can find this 
information on pages 4-68 to 4-69 of the Plan's 2022 Evidence of Coverage (EOC).