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 for periods beginning on or after January 1, 2021, through December 31, 2021, all home 
health agencies (HHAs) must submit a request for anticipated payment (RAP) within 5 calendar days after the 
start of care date for initial 30-day periods and within 5 calendar days after the from date for each subsequent 
30-day period of care, which is set at 0 percent at the beginning of every 30-day period. HHAs receive a single 
payment for a 30-day period of care after the final claim is submitted. You can find this rule at 42 CFR, Section 
484.205(g)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 codes that are listed on the dental 
benefit chart. The deep sedation is not covered by the Plan's dental benefits. You can find this information on 
pages 107 to 121 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 MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers, as long as the following conditions are met (42 CFR 422.100(l)):

- The MA plan provides all categories of DME covered under original Medicare Part B;
- The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME products or brands;
- The MA plan's contracted suppliers provide access to all preferred DME brands;
- During an enrollee's first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and repairs, as applicable) non-preferred DME brands furnished in the previous year;
- Although the MA plan may add brands to its preferred formulary during the year, it may not remove any brands mid-year;
- The MA plan treats denials of non-preferred DME products or brands as organization determinations;
- The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred DME product or brand with the Evidence of Coverage and Annual Notice of Change and on its website; and
- The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or subcategories annually determined by CMS to require full coverage.

You can find this information in the Centers for Medicare and Medicaid Services (CMS) Medicare Managed Care Manual Chapter 4, Section 10.12.2- Specifying Brands or Manufacturers of DME.

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 Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 pages 36 to 37 of the Plan's 
2023 Member Handbook.
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 a type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An 
Excludes1 note indicates that the code excluded should never be used at the same time as the code above the 
Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form 
versus an acquired form of the same condition. You can find this rule in the 2022 international classification of 
diseases, tenth edition, clinical modification (ICD-10-CM) Diagnosis Codebook, Section I.A(12). 
 
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 elastic stockings are not covered because they are non-reusable supply items. Elastic 
stockings are not durable medical equipment. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, 
Chapter 1, Section 280.1.   
  
The rules say that gradient pressure garments may be covered when used as dressings following burn injuries. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 270.5.  
 
The rules also say that compression bandages, multi-layer systems, and gradient compression wraps are 
covered only when they are used as dressings over a qualifying wound. A qualifying wound is either a wound 
caused or treated by surgery or a wound that must be debrided. A gradient compression stocking or wrap 
described by codes A6531, A6532, or A6545 is only covered when it is used in the treatment of an open 
venous stasis ulcer. Gradient compression stockings and wraps identified with codes A6531, A6532, and 
A6545 are not covered when they are used to treat the following conditions: 
 
Venous insufficiency without stasis ulcers; 
Prevention of stasis ulcers; 
Prevention of the reoccurrence of stasis ulcers that have healed; 
Treatment of lymphedema in the absence of ulcers. 
 
You can find these rules in Local Coverage Determination (LCD): Surgical Dressings L33831 and Local 
Coverage Article: Surgical Dressings-Policy Article A54563, effective for services performed on or after July 
24, 2017. 
 
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. The contract also says that 
enrollees may be billed by the out-of-network provider for any charged amount greater than the payment made 
by the Plan. You can find this information on pages 115 to 118 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 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 say that the Physician Fee Schedule Status Indicator I means that this code is not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment for, these 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 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 state that providers must bill the appropriate Place of Service (POS) code for services. POS code 21 
indicates that the services were performed in an inpatient hospital setting. POS code 22 indicates that the 
services were performed in an outpatient hospital setting. You can find this rule at Centers for Medicare and 
Medicaid Services, Internet-Only Publication 100-04, Medicare Claims Processing Manual Chapter 26, Section 
10.5. 
 
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. 
 
An ultrasonic osteogenesis stimulator (E0760) is covered only if all of the following criteria are met: 
 
1. Nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to starting 
treatment with the osteogenesis stimulator, separated by a minimum of 90 days. Each radiograph set must 
include multiple views of the fracture site accompanied by a written interpretation by a treating practitioner 
stating that there has been no clinically significant evidence of fracture healing between the two sets of 
radiographs; and 
2. The fracture is not of the skull or vertebrae; and 
3. The fracture is not tumor related. 
An ultrasonic osteogenesis stimulator will be denied as not medically necessary if any of the criteria above are 
not met. 
 
Use of an ultrasonic osteogenesis stimulator for the treatment of a fresh fracture or delayed union will be 
denied as not medically necessary. 
 
You can find this information in the Medicare Local Coverage Determination (LCD): Osteogenesis Stimulators 
(L33796). 
 
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 20% coinsurance for Medicare part B prescription drugs. You can find 
this information on page 63 of the Plan's 2023 Evidence of Coverage (EOC). Also, a 20% coinsurance for 
services to treat kidney disease/dialysis treatment. You can find this information on page 85 of the Plan's 2023 
Evidence of Coverage (EOC). Also, a $800 out-of-pocket maximum. You can find this information on page 39 
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 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 claims must specify whether equipment is rented or purchased. For purchased equipment, the 
itemized bill or claim must also indicate whether equipment is new or used. If the provider or supplier fails to 
indicate on an assigned claim whether equipment was new or used, the MAC processing the claims assumes 
purchased equipment is used and process the claim accordingly, i.e., they pay on the basis of the used purchase 
fee. The following table indicates the HCPCS modifiers which are added to the equipment code to indicate its 
status: Modifier: KH- DMEPOS item, initial claim, purchase or first month rental; Modifier: KI -DMEPOS 
item, second- or third-month rental; Modifier: KJ- DMEPOS item, PEN pump or capped rental months four to 
fifteen. You can find this in Medicare Claims Processing Manual Chapter 20 Durable Medical Equipment, 
Prosthetics, Orthotics, and Supplies (DMEPOS) Section 130. 
 
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
 
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 65 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 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. Dental code D7286 is not listed and therefore not 
covered by the Plan's dental benefit. You can find this information in Chapter 4 on pages 90 to 102 of the 
Plans 2023 Evidence of Coverage (EOC).