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 the 
requested item or service but is limited to one D0150 every three Plan years. You can find this information on 
page 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 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 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 National Correct Coding Initiative (NCCI) was developed to prevent inappropriate 
payment of services that should not be reported together. NCCI edits are organized in a Column One/Column 
Two table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of 
an edit pair, only the Column One code is payable. For edits with a modifier indicator of 0, the Column Two 
code cannot be paid regardless of whether a modifier is used. You can find this in the NCCI Manual, Chapter I. 
 
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 Centers for Medicare & Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. MUEs for codes with an MAI of 3 are per day edits based on clinical 
benchmarks. Codes with an MAI of 3 are based on criteria combined with data such that it would be 
possible, but medically unlikely, that higher values would represent correctly reported medically necessary 
services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, 
were correctly coded, and were medically necessary. 
 
You can find this rule in the Centers for Medicare & Medicaid Services, Medicare National Correct Coding 
Initiative Policy Manual for Medicare Services, Chapter I(V). 
 
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 claims for services furnished on or after January 1, 2010, must be filed no later than the close 
of the period ending 1 calendar year after the date of service. You can find this rule at 42 CFR Section 
424.44(a). 
 
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 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 & 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 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 20% coinsurance for Medicare Part B prescription drugs.  You can find 
this information on page(s) 21 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 the Centers for Medicare & Medicaid Services (CMS) issued replacement files for National 
Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edits for the October 1, 2023, files. Effective 
July 1, 2023, CMS implemented NCCI PTP edits between Column One codes 80305, 80306, and 80307 for 
presumptive test(s), and Column Two codes G0480  G0483, and G0659 for definitive test(s). CMS will 
withdraw these edits retroactive to July 1, 2023, in a replacement file for the 4th quarter of 2023. Claims with 
dates of service between July 1, 2023, and October 1, 2023, should be adjusted to allow payment as appropriate 
under existing payment and coverage policies. You can find this rule at Centers for Medicare & Medicaid 
Services National Correct Coding Initiative Edits bulletin published on the www.cms.gov website. 
 
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 code K0108 must not be used for any component or feature of an expandable controller at 
the time of initial issue. The reimbursement for any type of complete expandable controller is included in the 
allowance for codes E2377/E2376 plus E2313. However, if individual components of the harness are replaced, 
code K0108 should be used. You can find this rule in the Local Coverage Article (LCA) for 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 state that the Centers for Medicare & Medicaid Services (CMS) changed the National Correct Coding 
Initiative (NCCI) Correct Coding Modifier Indicator (CCMI) Procedure-to-Procedure (PTP) edit for CPT 
code pair 81455 (Column 1 code) and 81456 (Column 2 code) from 0 to 1, effective with the implementation 
of the October 1, 2023, PTP edit files and retroactive to January 1, 2023. You can find this rule at Palmetto 
GBA bulleting entitled "RESOLVED: Revision to National Correct Coding Initiative (NCCI) Procedure-to-
Procedure Correct Coding Modifier Indicator." 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that for qualifying wounds and ulcers, once placed on a negative pressure wound therapy 
(NPWT) pump and supplies, in order for coverage to continue, a licensed medical professional must do the 
following: 
1. On a regular basis, 
a. Directly assess the wound(s) being treated with the NPWT pump, and 
b. Supervise or directly perform the NPWT dressing changes, and 
2. On at least a monthly basis, document changes in the ulcers dimensions and characteristics. 
 
If criteria 1 and 2 are not fulfilled, continued coverage of the NPWT pump and supplies will be denied as not 
reasonable and necessary. For qualifying wounds and ulcers, a NPWT pump and supplies will be denied as not 
reasonable and necessary with any of the following, whichever occurs earliest: 
A. Criteria 1 and 2 cease to occur, 
B. In the judgment of the treating practitioner, adequate wound healing has occurred to the degree that 
NPWT may be discontinued, 
C. Any measurable degree of wound healing has failed to occur over the prior month. Wound healing is 
defined as improvement occurring in either surface area (length times width) or depth of the wound 
D. 4 months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) 
have elapsed using a NPWT pump in the treatment of the most recent wound 
E. Once equipment or supplies are no longer being used for the beneficiary, whether or not by the treating 
practitioners order 
 
You can find these rules in Local Coverage Determination (LCD) Negative Pressure Wound Therapy Pumps 
(L33821). 
 
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 25% coinsurance for out-of-network durable medical equipment 
provider. You can find this information on page 53 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 for home health periods of care, the distinct 5-position, alphanumeric home health Health 
Insurance Prospective Payment System (HIPPS) codes are created as follows: 
 The first position represents a combination of the referral source (community or institutional) and the period 
timing (early or late). 
 The second and third positions represent the clinical and functional domains of the HHRG coding system. 
 The fourth position represents the co-morbidity category that applies to the patient. 
 The fifth position is a placeholder for future use, required only because the field used to report HIPPS codes 
requires five positions. 
Position 3 indicates the Functional Level with A for Low, B for Medium, and C for High. 
 
You can find these rules in the Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.1.9. 
 
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 state that genetic testing procedures submitted under code 81541 is unlikely to impact therapeutic 
decision-making in the clinical management of the patient and will be denied automatically as not medically 
necessary. You can find this information in Local Coverage Article (LCA): Billing and Coding: Molecular 
Pathology Procedures (A56199).  
 
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 
prefabricated abutment and abutment supported crown when certain criteria is met. You can find this 
information in Chapter 4 on page 62 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 for any durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item to be 
covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's 
medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency 
of use or replacement (if applicable). The information should include the patient's diagnosis and other pertinent 
information including, but not limited to, duration of the patient's condition, clinical course (worsening or 
improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and 
results, past experience with related items, etc. If an item requires a certificate of medical necessity (CMN) or 
DME information form (DIF), it is recommended that a copy of the completed CMN or DIF be kept in the 
patient's record. However, neither a physician's order, nor a CMN, nor a DIF, nor a supplier prepared 
statement, nor a physician attestation by itself provides sufficient documentation of medical necessity, even 
though it is signed by the treating physician or supplier. There must be information in the patient's medical 
record that supports the medical necessity for the item and substantiates the answers on the CMN (if 
applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if 
applicable). You can find this information in the Centers for Medicare & Medicaid Service, Internet-Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5  Items and Services Having 
Special DME Review Considerations, Section 5.9  Documentation in the Patients Medical Record. 
 
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. However, gradient compression 
stockings described by codes A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, A6541, 
A6544, and A6549 are noncovered because they do not meet the statutory definition of a dressing.  
 
The rules say that the following are examples of wound care items which are non-covered under the surgical 
dressing benefit because they do not meet the statutory definition of a dressing (not all-inclusive): non-elastic 
binder for an extremity. You can find these rules in the Local Coverage Determination (LCD): Surgical 
Dressings L33831 and Local Coverage Article: Surgical Dressings-Policy Article A54563. 
 
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 a sequela is the residual effect (condition produced) after the acute phase of an illness or 
injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent 
early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. 
Examples of sequela include scar formation resulting from a burn, deviated septum due to a nasal fracture, and 
infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes 
sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is 
sequenced second. You can find this rule in the 2023 international classification of diseases, tenth edition, 
clinical modification (ICD-10-CM) Diagnosis Codebook, Section I.B(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.