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 transtelephonic electrocardiogram (EKG) transmissions (effective March 1, 1980) as a 
diagnostic service for the indications described below, when performed with equipment meeting the standards 
described below, subject to the limitations and conditions specified below. Coverage is further limited to the 
amounts payable with respect to the physicians service in interpreting the results of such transmissions, 
including charges for rental of the equipment. The device used by the beneficiary is part of a total diagnostic 
system and is not considered DME separately. Covered uses are to: 
        Detect, characterize, and document symptomatic transient arrhythmias; 
        Initiate, revise, or discontinue arrhythmic drug therapy; or, 
        Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI) 
 
You can find this information in the National Coverage Determination (NCD) for Electrocardiographic 
Services (20.15). 
 
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 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 L5781 describes a complete device that is an addition to a lower limb prosthesis. The 
primary function of the vacuum pump is to suspend the prosthetic limb. Additionally, products coded L5781 
provide residual limb volume management and moisture evacuation. The pump mechanism evacuates air and 
accumulated moisture between the limb and socket walls. The pump mechanism can be actuated by either 
external power and/or mechanical system(s). You can find this information in Medicare's Local Coverage 
Article: Lower Limb Prostheses - Policy Article (A52496). 
 
The rules say that the payment amount for a given service or item, whether rented or purchased, must be  
consistent with what is reasonable and medically necessary to serve the intended purpose (See the Medicare 
Benefit Policy Manual, Chapter 15). Additional expenses for "deluxe" features, or items that are rented or 
purchased for aesthetic reasons or added convenience, do not meet the reasonableness test. Thus, where a 
service or item is medically necessary and covered under the Medicare program, and the patient wishes to 
obtain such deluxe features, the payment is based upon the payment amount for the kind of service or item  
normally used to meet the intended purpose (i.e., the standard item.) You can find this information in the 
Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthesis, Orthotics, and 
Supplies (DMEPOS); 90 - Payment for Additional Expenses for Deluxe Features. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that codes 76376 and 76377 must be performed in conjunction with the base imaging procedure. 
Medicare would expect the base imaging procedure to be billed on the same claim as code 76376 or 76377 the 
majority of the time. Codes 76376 and 76377 are allowed only when billed in conjunction with another 
computed tomography, magnetic resonance imaging or other tomographic modality procedure codes. This rule 
is found in Local Coverage Article- Billing and Coding: 3D Interpretation and Reporting of Imaging Studies 
(A56526). 
 
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. 
 
Te rules say that a drug and alcohol counselor is not eligible to participate in Medicare. You can find this rule 
in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-08, 
Medicare Program Integrity Manual, Chapter 15, Section 15.4.8. 
 
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 we cover cessation counseling services. We cover two counseling quit attempts within a 12-
month period. You can find this information on page 98 of the 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 Decipher genetic testing may be covered for patients with localized or biochemically 
recurrent adenocarcinoma of the prostate (i.e., no clinical evidence of metastasis) who have a life expectancy of 
  
  greater than or equal to 10 years if they are a candidate for and are considering (or being considered for) at least 
1 of the following: 
 
- Conservative management and yet would be eligible for definitive therapy (radical prostatectomy (RP), 
radiation or brachytherapy), or; 
- Radiation therapy and yet would be eligible for the addition of a brachytherapy boost, or; 
- Radiation therapy and yet would be eligible for the addition of short-term androgen deprivation therapy 
(ADT), or; 
- Radiation therapy with short-term ADT yet would be eligible for the use of long-term ADT, or; 
- Radiation with standard ADT yet would be eligible for systemic therapy intensification using next generation 
androgen signaling inhibitors or chemotherapy, or; 
- Observation post-prostatectomy yet would be eligible for the addition of post-operative adjuvant 
radiotherapy, or; 
- Salvage radiotherapy post-prostatectomy yet would be eligible for the addition of ADT. 
 
You can find this information in the Local Coverage Determination (LCD): MolDX: Prostate Cancer Genomic 
Classifier Assay for Men with Localized Disease (L38433). 
 
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 field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative 
periods that apply to each surgical procedure. The payment rules for surgical procedures apply to codes with 
entries of 000, 010, 090, and, sometimes, YYY. Codes with 090 in Field 16 are major surgeries. Codes with 
000 or 010 are either minor surgical procedures or endoscopies. The Medicare approved amount for these 
procedures includes payment for the following services related to the surgery when furnished by the physician 
who performs the surgery. 
 
Modifiers were established to simplify billing for visits and other procedures which are furnished during the 
postoperative period of a surgical procedure, but which are not included in the payment for the surgical 
procedure. Modifier -24 reports an unrelated evaluation and management service by same physician during a 
postoperative period. The physician may need to indicate that an evaluation and management service was 
performed during the postoperative period of an unrelated procedure. This circumstance is reported by adding 
the modifier -24 to the appropriate level of evaluation and management service. Services submitted with the 
-24 modifier must be sufficiently documented to establish that the visit was unrelated to the surgery. A 
diagnosis code that clearly indicates that the reason for the encounter was unrelated to the surgery is acceptable 
documentation. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40. 
 
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 also say that codes paid via the Physician Fee Schedule (PFS) have an assigned Professional 
Component (PC)/Technical Component (TC) Indicator. A PC/TC indicator of 3 means that the code is a stand-
alone code that describes the technical component (i.e., staff and equipment costs) of selected diagnostic tests 
for which there is an associated code that describes the professional component of the diagnostic tests only. 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 50.6. 
 
The rules also say that the outpatient prospective payment system (OPPS) recognizes that Current Procedural 
Terminology (CPT) code 99153 is a practice expense (PE) only code and are finalizing the proposed PE inputs 
for CPT code 99153. You can find this information in the Physician Fee Schedule Final Rule. 
 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). 
 
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 If you qualify for Medicare oxygen equipment coverage, then for as long as you are 
enrolled, our 
plan will cover: 
 Rental of oxygen equipment 
 Delivery of oxygen and oxygen contents 
 Tubing and related oxygen accessories for the delivery of oxygen and oxygen contents 
 Maintenance and repairs of oxygen equipment 
If you leave our plan or no longer medically require oxygen equipment, then the oxygen equipment 
must be returned to the owner. You can find this on page 3-11 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 the Medicare Code Editor (MCE) is a front-end software program that edits claims to detect 
incorrect billing data. The MCE addresses three basic types of edits which will support the Diagnosis Related 
Group (DRG) assignment. They include correct diagnosis and procedure coding, coverage, and clinical edits. 
 
The MCE addresses three basic types of edits which will support the MS-DRG assignment: 
 Code Edits - Examines a claim for the correct use of diagnosis and procedure codes. They include basic 
consistency checks on the interrelationship among a patient's age, sex, and diagnoses and procedures reported. 
 Coverage Edits - Examines the type of patient and procedures performed to determine if the services are 
covered. 
 Clinical Edits - Examines the clinical consistency of the diagnostic and procedural information on the claim to 
determine if they are clinically reasonable and, therefore, should be paid. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 3, 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.
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, for services paid on a fee schedule, Medicare secondary payment amounts are determined 
by a formula and are the lowest of: 
1) Excess of the actual charge minus the primary payment; 
2) The amount Medicare would pay if the services were not covered by a primary payer; 
3) The higher of the Medicare payment amount or the primary payers allowable charge minus the amount 
actually paid by the primary payer. 
 
You can find this information in 42 CFR Section 411.33. 
 
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. 
 
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 enrollees have a $233 deductible. You can find this information on the cover page 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 Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
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 certain dental services as a supplemental (extra) benefit. You can find this information 
in Chapter 4 on page 52 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 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 observation. You can find this 
information on page(s) 86 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 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 contract 
says that the Plan covers up to 100 days of SNF care per benefit period. You can find this information in 
Chapter 4 on pages 89 to 91 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 providers 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 active diagnoses are intended to code diseases that have a direct relationship to the residents 
current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or 
risk of death. One of the important functions of the Minimum Data Set (MDS) assessment is to generate an 
updated, accurate picture of the residents current health status. You can find this rule in the Centers for   
Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, 
Chapter 3. 
  
The rules state that all SNF Part A inpatient services are paid under a prospective payment system (PPS). This 
involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code. Under the new 
Patient-Driven Payment Model (PDPM), which is effective for services provided on or after 10/1/2019, the 
HIPPS code is structured differently, as a result of there being five case-mix adjusted rate components under 
the revised model. The first position represents the Physical and Occupational Therapy case-mix group. The 
second position represents the Speech-Language Pathology (SLP) case-mix group. The third character 
represents the nursing case-mix group. The fourth character represents the Non-Therapy Ancillary (NTA) case-
mix group. The fifth character represents the assessment indicator code. You can find this information in the 
Centers for Medicare and Medicaid Service, Internet-Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 6, Sections 10, 30, and 120. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.