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 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. 
 
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 page(s) 36-38 of the Plan's 
2023 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 Medically Unlikely Edits (MUEs) for HCPCS codes with an MAI of 3 are per day edits 
based on clinical benchmarks. MUEs assigned an MAI of 3 are based on criteria (e.g., nature of service, 
prescribing information) combined with data such that it would be possible but medically highly unlikely that 
higher values would represent correctly reported medically necessary services. If contractors have evidence 
(e.g., medical review) that UOS in excess of the MUE value were actually provided, were correctly coded and 
were medically necessary, the contractor may bypass the MUE for a HCPCS code with an MAI of 3 during 
claim processing, reopening, or redetermination, or in response to effectuation instructions from a 
reconsideration or higher-level appeal. 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(V). 
 
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 417.414. 
 
The rules say that except for emergency and urgently needed services, Cost plans are not required to make 
payments for any services received by enrollees that are not provided directly by the Plan or through 
arrangements made by the Plan. You can find this rule at 42 CFR Section 417.448(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. The Plan 
contract also says that if your primary care physician recommends you have services with an out-of-network 
provider, he or she will submit a prior authorization request to the Plan. It is your responsibility to be sure that 
prior authorization is obtained and the services are approved by the Plan to be eligible for coverage at in-
network rates. You can find this information on page 29 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 state that if a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes 
will be considered part of the same panel. A panel constitutes a single procedural service, so 1 HCPCS codes 
must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims 
for genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering 
a panel or single genes, and additionally, the patients medical record must reflect that the service billed was 
reasonable and necessary. In general, 2 or more codes describing a genetic test billed on the same beneficiary 
on the same date may constitute a panel, and if so, the service must be billed as a single procedural service. 
You can find this information in Local Coverage Article (LCA): Billing and Coding: MolDX: Testing of 
Multiple Genes (A57880). 
 
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 Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. MUEs for codes with an MAI of 3 are per day edits based on clinical 
benchmarks. Codes with an MAI of 3 are based on criteria combined with data such that it would be 
possible, but medically unlikely, that higher values would represent correctly reported medically necessary 
services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, 
were correctly coded, and were medically necessary. 
 
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(V). 
 
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 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 $250 copayment for outpatient surgery, including services provided at 
hospital outpatient facilities. You can find this information on page(s) 96 to 99 of the Plan's 2023 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 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. 
 
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 the Plan has a Point-of-Service (POS) option to use either network providers or out-of-
network providers for certain covered services. Certain covered services may only be received from network 
providers. You can find this information on pages 32-33 of the Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract also says that out-of-network outpatient surgery is not covered. You can find this information 
on pages 100-102 of the Plan's 2023 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 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 48 one-way non-emergency ground transportation trips within the service area every year. You can 
find this information on page 103 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 rules say that all documentation must be maintained in the patients medical record and made available to 
the contractor upon request. The reason for referral and a clear diagnostic impression are required for each 
study. In cases where a review becomes necessary, either a hard copy of waveforms or a complete written 
report with an interpretation of the test must be submitted upon request. You can find this rule in the Local 
Coverage Determination for Nerve Conduction Studies and Electromyography, L35081.  
 
The rules say that if nerve testing (e.g., EMG, nerve conduction velocity) is performed to assess the level of 
paralysis during anesthesia or during mechanical ventilation, the range of CPT codes 95851-95941 are not 
separately reportable. These codes describe significant, separately identifiable diagnostic services requiring a 
formal report in the medical record. Electrical stimulation used to identify or locate nerves during a procedure 
involving treatment of a cranial or peripheral nerve (e.g., nerve block, nerve destruction, neuroplasty, 
transection, excision, repair) is integral to the procedure and is not separately reportable. You can find this rule 
in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter XI(L). 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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) 
procedures will be considered medically reasonable and necessary for the following indications: 

1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have 
not responded to non-surgical medical management (e.g., narcotic and/or non- narcotic medication, 
physical therapy modalities) with and without methods of immobility (e.g., rest, bracing). 
- Both PVP and PVA will be considered reasonable and necessary when ALL of the following 
criteria are met: 
o Acute (<6 wks) or subacute (6-12 wks)
18,28,42
osteoporotic VCF (T1- L5), based on 
symptom onset, and documented by advanced imaging demonstrating bone marrow 
edema on MRI or bone-scan/SPECT/CT uptake 
1-3,8,26,43
 and 
o The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating 
Scale [NRS] or Visual Analog Scale [VAS] pain score  8)
4-7
 or is non-hospitalized with 
moderate to severe pain (NRS or VAS 5) despite optimal non-surgical management 
(NSM)8
 with one of the following: 
 Worsening Pain or 
 Stable to improved pain (but NRS or VAS 5) when 2 or more of the following 
are present: 
o Progression of vertebral body height loss 
o > 25% vertebral body height reduction 
o Kyphotic deformity 
o Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire [RDQ] >17) 

You can find this rule at Local Coverage Determination (LCD) L34976: Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (eff. 7/11/21). 
 
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 also say that modifiers LT and RT apply to codes that identify procedures that can be performed on 
paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries. 
 
These modifiers should be used whenever a procedure is performed on only one side. Hospitals should report 
the appropriate RT or LT modifier to identify which of the paired organs was operated upon. Do not report 
modifiers RT and LT when modifier 50 applies. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 4, Section 20.6.3. 
 
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.
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 the Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied.   
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. Codes with an MAI of "2" have been rigorously reviewed and vetted within CMS and obtain 
this MAI designation because units of service on the same date of service (DOS) in excess of the MUE value 
would be considered impossible because it was contrary to statute, regulation, or subregulatory guidance. 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(V). 
 
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 contractor provides limited coverage for molecular Deoxyribonucleic acid/ribonucleic 
acid (DNA/RNA) biomarker tests for the diagnosis of prostate cancer that help differentiate men who may or 
may not benefit from a prostate biopsy when ALL of the following conditions are met: 

1. The patient must not have an established diagnosis of prostate cancer. 
2. The beneficiary is a candidate for prostate biopsy or repeat prostate biopsy, according to a consensus 
guideline [(i.e., National Comprehensive Cancer Network (NCCN), American Society of Clinical 
Oncology (ASCO), American Urological Association (AUA)]. 
a) For men  75 years of age - Prostate Specific Antigen (PSA) (or adjusted PSA in special populations, i.e., 
patients taking 5alpha-reductase inhibitors) OR repeat PSA are >3 and <10ng/mL AND/OR Digital Rectal 
Exam (DRE) findings are very suspicious for cancer. 
b) For men > 75 years of age - PSA (or adjusted PSA in special populations, i.e., patients taking 5-alpha-
reductase inhibitors) OR repeat PSA are 4 and <10ng/mL AND/OR DRE findings are very suspicious for 
cancer. 

You can find the rules 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.