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 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 core 
buildup when meeting certain criteria. You can find this information in Chapter 4 on page 115 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 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 the treatments for symptomatic varicose tributaries are either compressive sclerotherapy or 
microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are > than 4 mm in diameter and if the patient 
remains symptomatic after a six-week trial of conservative therapy. You can find this information in the 
Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD): Varicose Veins of the 
Lower Extremity, Treatment of (L33575). 
 
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 osseous surgery and the bone replacement graft are not covered by the Plan's dental benefits. 
You can find this information on pages 71 to 74 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 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 an option/accessory that is beneficial primarily in allowing the beneficiary to perform leisure 
or recreational activities is non-covered. 
 
A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are 
not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or 
E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will 
be denied as non-covered. You can find this rule in Local Coverage Article Wheelchair Options/Accessories - 
Policy Article 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 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 if a procedure has a global period of 000 or 010 days, it is defined as a minor surgical 
procedure. (Osteopathic manipulative therapy and chiropractic manipulative therapy have global periods of  
000.) In general, E&M services on the same date of service as the minor surgical procedure are included in the 
payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for 
the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant 
and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is 
separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different 
diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M 
services apply. The fact that the patient is new to the provider/supplier is not sufficient alone to justify 
reporting an E&M service on the same date of service as a minor surgical procedure. The NCCI program 
contains many, but not all, possible edits based on these principles. You can find this information in Medicare's 
National Correct Coding Initiative Policy Manual, Chapter: XI Evaluation and Management Services CPT 
Codes 90000 - 99999, Section: U. Evaluation & Management (E&M) Services. 
 
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 Health Maintenance Organizations (HMOs) may offer a Point of Service (POS) option as a 
mandatory or optional supplemental benefit. The POS benefit provides coverage for some plan-covered 
services outside of the HMOs network. The HMO plan may either require or waive prior authorization rules 
for obtaining POS services. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), 
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 Plan 
contract also says that generally, a referral or approval in advance is needed for out-of-network services. You 
can find this information on page 36 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 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 if the bilateral surgery indicator is 1, a bilateral surgical procedure must be reported with 
1 unit of service and modifier 50 (bilateral modifier). A bilateral diagnostic procedure may be reported with 
1 unit of service and modifier 50 on 1 claim line, or 1 unit of service with modifier right (RT) on 1 claim 
line plus 1 unit of service and modifier left (LT) on a second claim line. You can find this information in 
Medicare's National Correct Coding Initiative Policy Manual, Chapter I: General Correct Coding Policies, 
Section: V. Medically Unlikely Edits (MUEs). 
 
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 specific 
dental procedure codes included in a dental benefits chart. Biologic materials to aid in soft and osseous tissue 
regeneration (D4265) is not listed as a covered dental benefit. You can find this information in the dental rider 
to 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 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 B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident.  
 
The rules say that Physician Fee Schedule Status Indicator T means that there are Relative Values (RVUs) and 
payment amounts for these services, but they are only paid if there are no other services payable under the 
physician fee schedule billed on the same date by the same provider. If any other services payable under the 
physician fee schedule are billed on the same date by the same provider, these services are bundled into the 
physician services for which payment is made. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
23, 30.2.2. 
 
The rules say that unique Test Identifier Requirement: "Because the available language in the current HIPAA 
compliant code sets used to describe the pathology and laboratory categories and the tests included in 
those categories are not specific to the actual test results provided, all MDT services must include an identifier 
as additional claim documentation. Test providers must receive an identifier specific to the applicable test and 
submit the test assigned identifier with the claim for reimbursement. The assigned identifier will provide a 
crosswalk between the test's associated detail information on file and the submitted claim detail line(s) required to adjudicate each test's claim. You can find this information in Medicare's Local Coverage Determination 
(LCD): MolDX: Molecular Diagnostic Tests (MDT) (L35025). 
 
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 Physician Fee Schedule Status Indicator T means that there are Relative Values (RVUs) and 
payment amounts for these services, but they are only paid if there are no other services payable under the 
physician fee schedule billed on the same date by the same provider. If any other services payable under the 
physician fee schedule are billed on the same date by the same provider, these services are bundled into the 
physician services for which payment is made. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
23, 30.2.2. 
 
The rules say that unique Test Identifier Requirement: "Because the available language in the current HIPAA 
compliant code sets used to describe the pathology and laboratory categories and the tests included in those 
categories are not specific to the actual test results provided, all MDT services must include an identifier as 
additional claim documentation. Test providers must receive an identifier specific to the applicable test and 
submit the test assigned identifier with the claim for reimbursement. The assigned identifier will provide a 
crosswalk between the test's associated detail information on file and the submitted claim detail line(s) required 
to adjudicate each test's claim. You can find this information in Medicare's Local Coverage Determination 
(LCD): MolDX: Molecular Diagnostic Tests (MDT) (L35025). 
 
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. 
 
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, care received from out-of-network providers will have higher cost-
sharing. 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 35 to 36 of the Plan's 
203 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, generally, items and services provided outside of the United States (US) are not covered. 
The only exceptions are emergency hospital services when the emergency occurred within the US, 
emergency/non-emergency hospital services when the foreign hospital is substantially closer or more 
accessible than the US hospital, or services provided on a ship docked at a US port or within US Territorial 
waters. You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 60. 
 
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 it provides coverage for services rendered outside of the United States for emergency or 
urgently needed care. Urgently needed services are non-emergency, unforeseen medical illness, injury, or 
condition that requires immediate medical care. You can find this on pages 3-8 to 3-9 of your Plan's 2022 
Evidence of Coverage.