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 state that the Medicare approved amount for global surgery procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery.

   - Preoperative Visits
   - Intra-operative Services
   - Complications Following Surgery
   - Postoperative Visits
   - Postsurgical Pain Management
   - Supplies
   - Miscellaneous Services

You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 12, Section 40.1.

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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
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. The Plan 
contract says that enrollees must pay $250 copayment for ambulatory surgical center visit. You can find this 
information in chapter 4 on page 120 of the Plan's 2022 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 Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for a person who meets the following criteria: 

1.	The person must have a personal mobility deficit; 
2.	The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, grooming and bathing in customary locations within the home; 
3.	The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and
4.	The person must be capable of safely operating the PMD. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.3(B).

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 say that Medicare will cover sacral nerve modulation/stimulation for fecal incontinence effective 
March 1, 2012, when all of the following criteria are met: 
  
  - Chronic fecal incontinence with greater than two incontinent episodes on average per week and duration of 
incontinence greater than six months or for more than twelve months after vaginal childbirth; AND 
- Documented failure or intolerance to conventional therapy (e.g., dietary modification, the addition of bulking 
and pharmacologic treatment); AND 
- A successful percutaneous test stimulation, defined as at least 50 percent sustained (more than one week) 
improvement in symptoms; AND 
- Condition is not related to anorectal malformation (e.g., congenital anorectal malformation; defects of the 
external anal sphincter over 60 degrees; visible sequelae of pelvic radiation; active anal abscesses and fistulae) 
and/or chronic inflammatory bowel disease; AND 
- Incontinence is not related to another neurologic condition such as peripheral neuropathy or complete spinal 
cord injury. 
You can find this information in the Local Coverage Article: Billing and Coding: Sacral Nerve Stimulation for 
Urinary and Fecal Incontinence (A53017). 
 
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, 3.3.2.1. 
 
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. The contract 
says for additional details see your Delta Dental Certificate of Coverage. You can find this information on page 
77 of the Plan's 2021 Evidence of Coverage. 
 
The Plan contract says that general anesthesia and intravenous sedation is excluded from coverage for (a) 
surgical procedures unless medically necessary, or (b) restorative dentistry. The contract also says that all 
extractions and oral surgery are excluded from coverage. You can find this information on pages 11 and 13 of 
the Plan's 2021 Dental Certificate 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 to report a Molecular Diagnostic Test service, please submit the following claim information:

   - Select appropriate CPT code
   - Enter 1 unit of service (UOS)
   - Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:
       -- Loop 2400 or SV101-7 for the 5010A1 837P
       -- Box 19 for paper claim
    - Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:
       -- Line SV202-7 for 837I electronic claim
       -- Block 80 for the UB04 claim form

You can find this rule in the Local Coverage Article (LCA) for Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) (A56853).

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 an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of service. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.6.

The rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You can find this information in the MLN Matters article number MM7631, "Revised and Clarified Place of Service (POS) Coding Instructions".

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.

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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
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. The Plan 
contract says that enrollees must pay a $325 copayment for nuclear medicine services. You can find this 
information on page(s) 107 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 say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
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. The Plan 
contract says that enrollees must pay $25 copayment for specialist's office. You can find this information in 
chapter 4 on page 76-77 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay 20% coinsurance for Medicare Part B drug. You can find this 
information in chapter 4 on page 69 of the Plan's 2022 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 state that a semi-electric hospital bed (E0260) is covered if the beneficiary requires frequent changes in body position and/or has an immediate need for a change in body position. You can find this rule in Local Coverage Determination (LCD): Hospital Beds And Accessories (L33820).

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 must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) procedure code that describes the services performed. The rules also say that modifiers may be appended to procedure codes only if the clinical circumstances justify the use of the modifier. A modifier shall not be appended to a procedure code solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I.

The CPT Manual defines modifier 25 as a "significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service." Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s). You can find this information in the CPT Coding Manual.

The rules say that the Physician Fee Schedule Status Indicators E and X mean that these codes are statutory exclusions. 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, 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.

The rules state that PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with BOTH the following:

1. Inclusion criteria (ALL are required): 

    Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1 - L5) by recent (within 30 days) advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake)1-3,10,25,27
    Symptomatic (ONE):
        Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score = 8)4-7
        Non-hospitalized with moderate to severe pain (NRS or VAS =5) despite optimal non-surgical management (NSM)10* (ONE):
            Worsening pain
            Stable to improved pain (but NRS or VAS still =5) (with = 2 of the following):
                Progression of vertebral body height loss
                > 25% vertebral body height reduction
                Kyphotic deformity
                Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) >17)

* consider including pedicle periosteal infiltration7

c. Continuum of care10 (BOTH):

        All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis education for subsequent treatment as indicated.
        All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program.

You can find this information in the Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) L38737.

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 say that continued coverage of a PAP device (E0470 or E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy. For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is demonstrated by:

1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive sleep apnea are improved; and
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner.

Adherence to therapy is defined as use of PAP 4 or more hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as not reasonable and necessary. You can find this rule in Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718).

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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
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. The Plan 
contract says that enrollees must pay a $25 copayment for out-of-network Hearing services (Medicare 
covered). You can find this information on page 71 of the Plan's 2022 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 state that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-preferred brands).

You can find this information in the Medicare Managed Care Manual Chapter 4, Section 10.12.2.

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 say that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information [on pages 10-11 of the Plan's 
2022 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
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. The Plan 
contract says that enrollees must pay a $300 copayment for outpatient hospital services, including a 
colonscopy. You can find this information in chapter 4 on page 73 of the Plan's 2022 Evidence of Coverage 
(EOC).  
 
The Plan contract says that enrollees must pay a $45 copayment for each physician/practitioner service, 
including a specialist office visit. You can find this information in chapter 4 on page 77 of the Plan's 2022 
Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $15 copayment for Medicare-covered lab services. You can 
find this information in chapter 4 on page 72 of the Plan's 2022 Evidence of Coverage (EOC).