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 the claims processing systems contain edits which identify exact duplicate claims and 
suspect duplicate claims. All exact duplicate claims or claim lines are auto-denied or rejected (absent 
appropriate modifiers). Suspect duplicate claims and claim lines are suspended and reviewed by the claims 
administration contractors to make a determination to pay or deny the claim or claim line. 
 
Claims or claim lines that have been determined to be an exact duplicate are rejected and do not have appeal 
rights. An exact duplicate for institutional claims is a claim or claim line that exactly matches another claim or 
claim line with respect to the following elements: 
Medicare beneficiary identifier;  
Type of Bill; 
Provider Identification Number; 
From Date of Service; 
Through Date of Service; 
Total Charges (on the line or on the bill); and 
HCPCS, CPT-4, or Procedure Code modifiers. 
 
You can find this information in the Medicare Claims Processing Manual, Chapter 1 - General Billing 
Requirements, Section 120 - Detection of Duplicate Claims. 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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.  
 
The Plan contract says that a referral or prior authorization is not required for care from out-of-network 
providers. You can find this information on page 47 of the Plans 2022 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 payment may be made for a one-time ultrasound screening for abdominal aortic aneurysm 
(AAA) for beneficiaries who meet the following criteria: 
 
1. Receives a referral for such an ultrasound screening for the beneficiary's attending physician, physician 
assistant, nurse practitioner, or clinical nurse specialist; 
2. Receives such ultrasound screening from a provider or supplier who is authorized to provide covered 
ultrasound diagnostic services; 
3. Has not been previously furnished such an ultrasound screening under the Medicare program; and 
4. Is included in at least one of the following risk categories: 
     a. Has a family history of abdominal aortic aneurysm; 
     b. Is a man between age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or 
     c. Is a beneficiary who manifests other risk factors in a category recommended for screening 
 
You can find these rules in the Medicare Claims Processing Manual Chapter 18, Section 110.2. 
 
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 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 also 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. 
 
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 section 1861(s)(2)(HH)(jjj) defines opioid treatment program services (OTPs) as those that 
enroll in Medicare and are certified by the Substance Abuse and Mental Health Services Administration 
(SAMHSA), accredited by a SAMHSA-approved entity, and meet additional conditions as the Secretary finds 
necessary to ensure the health and safety of individuals being furnished services under these programs and the 
effective and efficient furnishing of such 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 
39, Section 50.1(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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112. 
 
The rules say that the plan must pay for emergency and urgently needed services. This rule applies whether the 
services are obtained in or out of the plans network. This rule applies whether or not there is prior 
authorization for the services. The rules say that an emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules 
say that urgently needed services are those needed because of an unforeseen illness or condition and it is not 
reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside 
of the service area. You can find this rule at 42 CFR Section 422.113. 
 
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 they covers worldwide emergency services outside the United 
States under the following circumstances: You have a medical emergency which requires emergency care. 
A medical emergency is when you, or any other prudent layperson with an average knowledge of health and 
medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss 
of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe 
pain, or a medical condition that is quickly getting worse. Emergency Care is covered services that are: 1) 
rendered by a provider qualified to furnish emergency services; and 2) needed to treat, evaluate, or stabilize 
an emergency medical condition. You can find this information on page 48 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 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 preoperative visits after the decision is made to operate beginning with the day before the 
day of surgery for major procedures and the day of surgery for minor procedures is included in the global 
payment, but Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits 
occur due to complications of the surgery and Treatment for the underlying condition or an added course of 
treatment which is not part of normal recovery from surgery is not included. 
 
Further down in the section 40.2(a)(8), it talks more about the modifier -25: Modifier -25 is used to 
facilitate billing of evaluation and management services on the day of a procedure for which separate payment 
may be made. It is used to report a significant, separately identifiable evaluation and management service by 
same physician on the day of a procedure. The physician may need to indicate that on the day a procedure or 
service that is identified with a CPT code was performed, the patients condition required a significant, 
separately identifiable evaluation and management service above and beyond the usual preoperative and 
postoperative care associated with the procedure or service that was performed. This circumstance may be 
reported by adding the modifier -25 to the appropriate level of evaluation and management service. 
 
You can find this information in the Medicare Claims Processing Manual, Chapter 12, Section 40.1(a-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 when submitting a prosthetic claim, the billed code for knee, foot, ankle and hip (HCPCS 
codes L5610, L5611, L5613, L5614, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, 
L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, 
L5840, L5848, L5856, L5857, L5858, L5859, L5930, L5961, L5970, L5971, L5972, L5973, L5974, L5975, 
L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987) components must be submitted 
with modifiers K0 - K4, indicating the expected beneficiary functional level. This expectation of functional 
ability information must be clearly documented and retained in the prosthetist's records. The simple entry of a 
K modifier in those records is not sufficient. There must be information about the beneficiary's history and 
current condition which supports the designation of the functional level by the prosthetist. 
 
Codes L5968, L5982, L5984, L5986 describe separate products which provide either a single motion or a 
combination of motions commonly attributed to the anatomic ankle. The use of these codes can be used to fully 
describe additional features or functions not found in the prosthetic foot system (L5969, L5970, L5971, L5972, 
L5973, L5974, L5975, L5976, L5978, L5979 L5980, L5981 and L5987). L5984 describes an endoskeletal 
device that allows an adjustable, or non-adjustable, amount of vertical twisting motion between the foot and 
pelvis during ambulation. Addition codes for lower extremity prostheses, L5970, L5971, L5972, L5974, 
L5975, L5976, L5978, L5979, L5980, L5981, L5987 are considered an upgrade to the SACH foot. The 
beneficiary may qualify for an upgraded prosthetic foot based on their assigned K-level modifier (K0-K4) as 
referenced in the LCD. A single addition code (L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979, 
L5980, L5981, L5987) can fully describe a complete foot and thus the use of more than one code would be 
considered incorrect coding (unbundling). 
 
L5987 describes a product that can be used for either endoskeletal or exoskeletal lower limb construction. All 
components are integrated as a single product, i.e., not an assembly of separate products or components. The 
product has an energy storing J-shaped keel design. Heel component is attached onto the J-shaped keel section. 
Vertical loading pylon allows controlled motion for shock absorption. This code does not describe vertical 
loading or shock absorption achieved from the inherent flexibility of the J-shaped keel section. L5987 includes 
foot cover.  

You can find these rules in the Local Coverage Article Lower Limb Prostheses - Policy Article A52496. 
 
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 or claim lines that have been determined to be exact duplicates of another claim or 
claim line are denied. However, such denials may be appealed. An exact duplicate for physician and other 
supplier claims is a claim that exactly matches another claim or claim line with respect to, among other items, 
provider number, date of service, procedure code, place of services, and billed amount. 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 120.2. 
 
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 say that the claims processing systems contain edits which identify exact duplicate claims and  
suspect duplicate claims. All exact duplicate claims or claim lines are auto-denied or rejected (absent 
appropriate modifiers). Suspect duplicate claims and claim lines are suspended and reviewed by the claims 
administration contractors to make a determination to pay or deny the claim or claim line. 
 
Claims or claim lines that have been determined to be an exact duplicate are rejected and do not have appeal 
rights. An exact duplicate for institutional claims is a claim or claim line that exactly matches another claim or 
claim line with respect to the following elements: 
Medicare beneficiary identifier;  
Type of Bill; 
Provider Identification Number; 
From Date of Service; 
Through Date of Service; 
Total Charges (on the line or on the bill); and 
HCPCS, CPT-4, or Procedure Code modifiers. 
 
You can find this information in the Medicare Claims Processing Manual, Chapter 1 - General Billing 
Requirements, Section 120 - Detection of Duplicate Claims. 
 
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 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 Medicare Physician Fee Schedule Database (MPFSDB) status indicator of X identifies a 
statutory exclusion. These codes represent an item or service that is not in the statutory definition of "physician 
services" for fee schedule payment purposes. No RVUs or payment amounts are shown for these codes and no 
payment may be made under the physician fee schedule. (Examples are ambulances services and clinical 
diagnostic laboratory 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 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. 
 
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 17-18 of the Plan's 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 Medicare Part B coverage is available for outpatient Opioid Treatment Program services 
provided by hospitals, critical access hospitals (CAHs), and Free-Standing Opioid Treatment Program 
facilities. You can find this information in the Medicare Claims Processing Manual, Chapter 39, Section 50  
Institutional Opioid Treatment Program (OTP) Services  A/B MAC (A).  
 
The rules say the codes describing bundled payments made to OTPs are Healthcare Common Procedure 
Coding System (HCPCS) codes G2067-G2075. Only an entity enrolled with Medicare as an OTP can bill these 
codes. You can find this information in the Medicare Claims Processing Manual, Chapter 39, Section 30.6  
Coding. 
 
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 70 of the Plan's 2023 Evidence of Coverage.