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 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 drugs eligible for the Transitional Drug Add-On Payment Adjustment (TDAPA) must billed 
with revenue code 0636 and modifier AX must be appended to the HCPCS.  
 
The rules also say that Items eligible for the Transitional Add-on Payment Adjustment for New and Innovative 
Equipment and Supplies (TPNIES) must billed with revenue code 027X and modifier AX must be appended to 
the HCPCS. 
 
You can find these rules in the Medicare Claims Processing Manual, Chapter 8, Section 20. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that an attendant control is covered in place of a beneficiary-operated drive control system if the 
beneficiary meets coverage criteria for a wheelchair, is unable to operate a manual or power wheelchair and has 
a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair. You can 
find this information in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). 
 
The rules say that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive control 
system, it will be denied as non-covered. You can find this information in Local Coverage Article: Wheelchair 
Options/Accessories (A52504). 
 
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 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 Plan 
contract also says that services considered not reasonable and necessary, according to Original Medicare 
standards unless these services are listed by this plan as covered services are excluded from coverage. You can 
find this information on page 82 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 to qualify for home health services, the patient must be: 
 
1. Confined to the home;  
2. Under the care of a physician or allowed practitioner;  
3. Receiving services under a plan of care established and reviewed by a physician;  
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) 
continuing occupational therapy.  
You can find this rule at 42 CFR Section 409.42. 
 
The rules say that eligibility for the home health benefit will be determined based on the certifying physician or 
allowed practitioners records. If the enrollee was directly admitted to home health from an acute or post-acute 
care facility, the facility records may be used instead. The medical records for the enrollee must contain 
information that justifies the referral for home health services. 
  
The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the 
enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face 
encounter visit. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and 
30.5.1.2. 
 
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 Grievance 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 state that DecisionDx-SCC gene expression testing is considered non-covered at this time. You can 
find this rule in the DEXTM Diagnostics Exchange Registry. 
 
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 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. This benefit includes 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. The core buildup, a pontic, and retainer crown are not covered by the Plan's dental benefits. You 
can find this information on pages 82 to 85 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 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. This benefit does not include 
the re-cement or re-bond of a crown. You can find this information on pages 59-60 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 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. This benefit includes the 
requested item or service but is limited to one D0210 every three years. You can find this information on pages 
104-106 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 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 denervation (also called radiofrequency ablation or RFA) is not considered reasonable and 
necessary for low back pain. You can find this rule in the Local Coverage Determination (LCD) L39464: 
Sacroiliac Joint Injections and Procedures. 
 
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 repeat epidural steroid injections (ESIs) when the first injection directly and significantly 
provided improvement of the condition being treated may be considered medically reasonable and necessary 
when the medical record documents at least 50 percent of sustained improvement in pain relief and/or 
improvement in function measured from baseline using SAME scale* for at least 3 months. If a patient fails to 
respond well to the initial ESI, a repeat ESI after 14 days can be performed, using a different approach, level 
and/or medication if appropriate, with the rationale and medical necessity for the second ESI documented in the 
medical record. You can find this information in Medicare's Local Coverage Determination (LCD): Epidural 
Steroid Injections for Pain Management (L38894). 
 
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 claims must specify whether equipment is rented or purchased. Modifier KH indicates a 
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) item, initial claim, purchase or 
first month rental. Modifier KI indicates a DMEPOS item, second or third month rental. Modifier KJ indicates 
a DMEPOS item, PEN pump or capped rental months four to fifteen. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 20, Section 130.9. 
 
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 positron emission tomography (PET) scans performed at rest or with pharmacological stress 
used for noninvasive imaging of the perfusion of the heart for the diagnosis and management of patients with 
known or suspected coronary artery disease using the FDA-approved radiopharmaceutical Rubidium 82 (Rb 
82) are covered, provided the requirements below are met: 
 
The PET scan, whether at rest alone, or rest with stress, is performed in place of, but not in addition to, a single 
photon emission computed tomography; or the PET scan, whether at rest alone or rest with stress, is used 
following a SPECT that was found to be inconclusive. In these cases, the PET scan must have been considered 
necessary in order to determine what medical or surgical intervention is required to treat the patient. 
 
PET scans performed at rest or with pharmacological stress used for noninvasive imaging of the perfusion of 
the heart for the diagnosis and management of patients with known or suspected coronary artery disease using 
the FDA-approved radiopharmaceutical ammonia N-13 are covered, provided the requirements below are met: 
 
The PET scan, whether at rest alone, or rest with stress, is performed in place of, but not in addition to, a 
SPECT; or the PET scan, whether at rest alone or rest with stress, is used following a SPECT that was found to 
be inconclusive. In these cases, the PET scan must have been considered necessary in order to determine what 
medical or surgical intervention is required to treat the patient. You can find this rule in the National Coverage 
Determination (NCD) 220.6.1: PET for Perfusion of the Heart. 
 
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 For claims submitted on or after March 1, 2023 suppliers must add the KX modifier to claim 
lines billed for the external infusion pump, drugs and supplies for dates of service on or after January 1, 2023, 
only if all of the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section 
in the related LCD have been met. Evidence supporting the use of the KX modifier must be retained in the 
suppliers files and available to the DME MAC upon request. You can find this rule in the Local Coverage 
Article for External Infusion Pumps - Policy Article, A52507. 
 
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 Physician Fee Schedule Status Indicator X means 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 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 information 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 state that physicians in the same group practice who are in the same specialty must bill and be paid as 
though they were a single physician. If more than one evaluation and management (face-to-face) service is 
provided on the same day to the same patient by the same physician or more than one physician in the same 
specialty in the same group, only one evaluation and management service may be reported unless the 
evaluation and management services are for unrelated problems. You can find this information at the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 12, Section 30.6.5. 
 
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 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. This benefit includes
panoramic x-rays but are limited to 1 procedure code per 5 calendar years. Additionally, this benefit does not
include 2D oral/facial photographic images. You can find this information on pages 72-76 and 85-87 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 the Tempus xF testing is non-covered. You can find this rule in the DEXTM Diagnostics 
Exchange Registry. 
 
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 global surgery package of procedures with a global period of 10 or 90 days includes all 
additional medical or surgical services required of the surgeon during the postoperative period of the surgery 
because of complications which do not require additional trips to the operating room, follow-up visits during 
the postoperative period of the surgery that are related to recovery from the surgery, among other related 
services. Evaluation and management services provided on the day before major surgery or on the day of major 
surgery that result sin the initial decision to perform the surgery are not included in the global surgery payment 
for the major surgery and, therefore, may be billed separately. In addition to the evaluation and management 
code, modifier -57 (decision for surgery) is used to identify a visit which results in the initial decision to 
perform a surgery. 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.