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 state that a diagnostic mammography is a radiologic procedure furnished to a man or woman with 
signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy - 
proven benign breast disease and includes a physician's interpretation of the results of the procedure. 
A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of 
breast disease, for the purpose of early detection of breast cancer, and includes a physicians interpretation of 
the results of the procedure. A screening mammography has limitations as it must be, at a minimum a two-view 
exposure (cranio-caudal and a medial lateral oblique view) of each breast. 
Indications and Limitations of Coverage 
 
A diagnostic mammography is a covered service if it is ordered by a doctor of medicine or osteopathy as 
defined in 1861(r)(1) of the Act.  
Payment may not be made for a screening mammography performed on a woman under age 35. Payment may 
be made for only one screening mammography performed on a woman over age 34, but under age 40. For an 
asymptomatic woman over age 39, payment may be made for a screening mammography performed after at 
least 11 months have passed following the month in which the last screening mammography was performed. 
A radiological mammogram is a covered diagnostic test under the following conditions:  A patient has distinct signs and symptoms for which a mammogram is indicated; 
 A patient has a history of breast cancer; or 
 A patient is asymptomatic but, on the basis of the patients history and other factors the physician 
considers significant, the physician's judgment is that a mammogram is appropriate. 
Use of mammograms in routine screening of: (1) asymptomatic women aged 50 and over, and (2) 
asymptomatic women aged 40 or over whose mothers or sisters have had the disease, is considered medically 
appropriate, but would not be covered for Medicare purposes. 
You can find this rule at the Medicare National Coverage Determination (NCD) 220.4: Mammograms. 
 
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 group 2 support surface is covered if the beneficiary meets at least one of the following 
three criteria (1, 2, or 3): 
 
1. The beneficiary has multiple stage II pressure ulcers located on The rules say that a group 2 support surface 
is covered if the beneficiary meets at least one of the following three criteria (1, 2, or 3): 
 
1. The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis which have failed to 
improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment 
program including each of the following: 
 
a. Use of an appropriate group 1 support surface 
b. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and 
c. Appropriate turning and positioning, and 
d. Appropriate wound care 
e. Appropriate management of moisture/incontinence, and 
f. Nutritional assessment and intervention consistent with the overall plan of care 
 
2. The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis 
 
3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the 
past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses), 
and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing 
facility within the past 30 days 
 
You can find this rule in Local Coverage Determination (LCD): Pressure Reducing Support Surfaces - Group 2 
(L33642) - Effective January 1, 2020. 
 
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(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 36 of the Plan's 
2023 Evidence of Coverage. 
 
The Plan contract says that outpatient diagnostic tests include laboratory tests. Authorization may be required. 
You can find this information on page 79 of the Plans 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 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 if the expense for repairs exceeds the estimated expense of purchasing or renting another 
item of equipment for the remaining period of medical need, no payment can be made for the amount of excess. 
You can find this rule in the C enters for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2. 
 
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 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 $30 copayment for physician/practitioner services, including doctors 
office visits.  You can find this information on page(s) 75 to 76 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 state that when reviewing medical records, if it is determined that a valid signature is missing, the 
reviewer shall contact the person or organization that billed the claim and ask if the billing entity would like to 
submit an attestation statement or signature log within 20 calendar days. The 20-day timeframe begins on the 
date of the telephone contact with the provider or on the date the request letter is received by the provider. If 
the biller submits a signature log or attestation, the reviewer shall consider the contents of the medical record 
entry. In cases where a reviewer has requested a signature attestation or log, the time for completing the review 
is extended by 15 days. This extension starts upon receipt of the signature attestation or log. You can find this 
information in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-08, 
Medicare Program Integrity Manual, Chapter 3, 3.3.2.4. 
 
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.
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules state that STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. You 
can find this rule at Centers for Medicare & Medicaid Services, Internet-Only Publication 100-04, Medicare 
Claims Processing Manual, Chapter 4, Section 10.4.(C)(2). 
 
The rules say that if a claim contains services that result in an Ambulatory payment classifications (APCs) 
payment but also contains packaged services, separate payment for the packaged services is not made since 
payment is included in the APC. Unconditionally packaged services are services for which separate payment is 
never made because the payment for the service is always packaged into the payment for other services. 
Unconditionally packaged services are identified in the Outpatient Prospective Payment System (OPPS) 
Addendum B with status indicator of N. You can find this rule in the Centers for Medicare & Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 4, 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.
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 health plans, physicians, hospitals, and other health care providers must comply with the 
Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding 
Guidelines. You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 10. 
 
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 & Medicaid Services (CMS) covers autologous treatment for 
cancer with T lymphocytes (T-cells) expressing at least one chimeric antigen receptor (CAR) when 
administered at healthcare facilities enrolled in the Food and Drug Administration (FDA) risk evaluation and 
mitigation strategies (REMS) and used for a medically accepted indication as defined at Social Security Act 
section 1861(t)(2) -i.e., is used for either an FDA-approved indication (according to the FDA-approved label 
for that product), or for other uses when the product has been FDA-approved and the use is supported in one or 
more CMS-approved compendia. You can find this rule in the Centers for Medicare & Medicaid Services, 
Internet Only Manual, Publication 100-03, Medicare National Coverage Determination for Chimeric Antigen 
Receptor (CAR) T-cell Therapy, 110.24. 
 
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that health plans, physicians, hospitals, and other health care providers must comply with the 
Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding 
Guidelines. You can find this rule in the Medicare Claims Processing Manual, Chapter 23, Section 10. 
 
The rules also say that it is the provider's responsibility to select codes carried out to the highest level of 
specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is 
rendered for the claim(s) submitted. Use ICD-10-CM code Z01.810 for those tests which were performed to 
evaluate pre-operative risk (see Indications section in L35083, Cardiovascular Nuclear Medicine) but for whom 
the test was negative. Medicare is establishing the following limited coverage for Myocardial Perfusion with or 
without Functional Studies as defined in CPT/HCPCS codes 78451, 78452, 78453, 78454, 78472, 78473, 
78481, and 78483: There is a list of diagnoses which support medical necessity. You can find this rule in the 
Local Coverage Determination (LCD): Cardiovascular Nuclear Medicine (L35083) and the Local Coverage 
Article (A56423). 
 
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 is the secondary payer to certain primary plans. When Medicare is the secondary 
payer, the provider or enrollee must first submit the claim to the primary payer. If the primary payer does not 
pay in full for the services, Medicare secondary benefits may be paid. The enrollee must file a claim with the 
primary payer or cooperate fully with the provider so that the provider can file the necessary claim. You can 
find these rules in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-05, 
Medicare Secondary Payer Manual, Chapter 1, Section 20 and Chapter 3, Section 10.8.  
 
The rules say that plans must identify payers that are primary to Medicare, identify the amounts payable by the 
primary payer, and coordinate benefits to Medicare enrollees with the benefits of the primary payer. You can 
find this rule at 42 CFR Section 422.108. 
 
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 routine physical checkups, eyeglasses, contact lenses, eye examinations for the purposes of 
prescribing, fitting, or changing eyeglasses, eye refractions, hearing aids and hearing aid examinations, and 
immunizations are not covered. The routine physical checkup exclusion applies to 
a. Examinations performed without relationship to treatment or diagnosis for a specific illness, symptoms, 
complaint, or injury 
b. Examinations required by third parties such as insurance companies, business establishments, or 
government agencies 
 
The routine physical checkup exclusion does not apply to the following services (as noted in section 42 CFR 
411.15(a)(1)): 
- Screening mammography, 
- Colorectal cancer screening tests, 
- Screening pelvic exams, 
- Prostate cancer screening tests, 
- Glaucoma screening exams, 
- Ultrasound screening for abdominal aortic aneurysms (AAA), 
- cardiovascular disease screening tests, 
- diabetes screening tests, 
- screening electrocardiogram, 
- Initial preventive physical examinations, 
- Annual wellness visits providing personalized prevention plan services, and 
- Additional preventive services that meet the criteria specified in 42 CFR 410.64. 
 
You can find these rules in Medicare Benefit Policy Manual Chapter 16, Section 90. 
 
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 $475 copayment for Outpatient diagnostic tests and therapeutic services 
and supplies.  You can find this information on page(s) 61-63 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 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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that the Current Procedural Terminology (CPT

) codebook contains the following information 
and direction for the Chemotherapy and Other Highly Complex Drug or Highly Complex Biological Agent 
Administration CPT codes: Chemotherapy administration codes 96401-96549 apply to parenteral 
administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for 
treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such 
as certain monoclonal antibody agents, and other biologic response modifiers.  
 
The administration of golimumab (Simponi Aria) should not be billed using a chemotherapy administration 
code. The IV administration of the drugs below should be billed with the appropriate IV injection/infusion CPT 
code listed under Therapeutic, Prophylactic, and Diagnostic Injections and Infusions in the CPT

 codebook. 
 
You can find this rule in the Local Coverage Article for the Billing and Coding of Complex Drug 
Administration Coding, A59073. 
 
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.