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 (CMS), Medicare National Correct Coding Initiative Policy 
Manual for Medicare Services, Chapter I(A). 
 
Add-on Codes (AOCs) are discussed in Chapter I, Section R (Add-on Codes). The CMS publishes a list of 
AOCs and their primary codes annually prior to January 1. CMS identifies AOCs and their primary codes 
based on CPT Manual instructions, CMS interpretation of HCPCS/CPT codes, and CMS coding instructions. 
 
The NCCI program includes 3 AOC Edit Tables, 1 table for each of 3 Types of AOC. Each table lists the 
AOC with its primary codes. An AOC is a HCPCS/CPT code that describes a service that, with rare exception, 
is performed in conjunction with another primary service by the same practitioner. An AOC is rarely eligible 
for payment if it is the only procedure reported by a practitioner. 
 
The Type I AOC Edit Table lists AOCs for which the CPT Manual or HCPCS tables define all acceptable 
primary codes. Claims processing contractors should not allow other primary codes with Type I AOCs. CPT 
code 99292 (Critical care, evaluation, and management of the critically ill or critically injured patient; each 
additional 30 minutes (List separately in addition to code for primary service)) is included as a Type I AOC 
since its only primary code is CPT code 99291 (Critical care, evaluation, and management of the critically ill or 
critically injured patient; first 30-74 minutes). For Medicare purposes, CPT code 99292 may be eligible for 
payment to a physician without CPT code 99291 if another physician of the same specialty and physician 
group reports and is paid for CPT code 99291. You can find this rule in the Centers for Medicare and Medicaid 
Services (CMS), Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 
I(W). 
 
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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 43-47 of the Plan's 2022 
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 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 pages 8 to 9 of the Plan's 2021 
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 some International Classification of Diseases, 10th Revision, Clinical Modification (ICD-
10-CM) codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If the 
side is not identified in the medical record, assign the code for the unspecified side. You can find this 
information in the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) 
Official Guidelines for Coding and Reporting, Section I.B.13. 
 
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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 the Plan will provide $150 allowance every 24 months that you can use to pay for 
eyewear. The allowance can be used to pay for the following items: 
eyeglass frames, eyeglass lenses, contact lenses, fitting, and dispensing. 
We will not provide the allowance if we have provided an allowance toward (or otherwise covered) lenses or 
frames within the same 24-month period. If the eyewear you purchase costs more than $150, you pay the 
difference. You can find this on page 75 of the Plan's 2022 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 417.414. 
The rules say that molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage when ALL 
of the following criteria are met: 
 Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are 
unavailable or results are clearly equivocal; AND 
 Availability of a clinically valid test, based on published peer reviewed medical literature; AND 
 Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed 
test) or LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) of 
analytical validity and clinical utility; AND 
 Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND 
 For testing panels, including but not limited to, multiple genes or multiple conditions, and in cases 
where a tiered approach/method is clinically available, testing would be covered ONLY for the number 
of genes or test that are reasonable and necessary to obtain necessary information for therapeutic 
decision making; AND 
 Individual has not previously received genetic testing for the disease/condition. (In general, diagnostic 
genetic testing for a disease should be performed once in a lifetime.) Exceptions include clinical 
scenarios whereby repeat testing of somatically-acquired mutations (for example, pre- and post- 
therapy) may be required to inform appropriate therapeutic decision-making. 
 Limitations: 
 Any procedures required prior to cell lysis should be reported separately and utilization must be clearly 
supported based on the application and clinical utility. Such claims may be subject to prepayment 
medical review.  The medically necessary interpretation and report of a molecular pathology test, written by a 
pathologist, which is above and beyond the report of standard laboratory results may not be reported by 
Non- physician practitioners (e.g., PhD, scientists etc.); only physicians are eligible to report this 
service. 
 Testing for quality assurance component of the service is not separately billable. 
You can find this rule at Local Coverage Determination (LCD) L35000: Molecular Pathology Procedures (eff. 
7/1/20). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays for up to 100 days of skilled care in a Skilled Nursing Facility (SNF) in each 
benefit period. A benefit period begins upon admission to a hospital or SNF and ends after 60 days in a row 
without the patient receiving hospital or skilled SNF services. You can find this rule in the Social Security Act, 
Section 1862(a)(18), at 42 CFR Sections 409.60(a) and (b) and Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, 
Chapter 3, 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. The Plan 
contract says that the Plan covers up to 100 days each benefit period for inpatient services in a Skilled Nursing 
Facility (SNF), in accordance with Medicare guidelines. A benefit period begins on the first day an enrollee 
goes into a covered inpatient hospital or Skilled Nursing Facility. The benefit period ends when the enrollee 
has not been an inpatient at any hospital or SNF for 60 days in a row. You can find this information in on pages 
90 and 91 of the Plan's 2022 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 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 in Chapter 3 of the Plan's 2021 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the medical effectiveness of the above therapies has not been verified by scientifically 
controlled studies. Accordingly, reimbursement for these modalities should be denied on the ground that they 
are not reasonable and necessary as required by 1862(a)(1) of the Act. You can find this rule at Centers for 
Medicare and Medicaid Services, National Coverage Determination (NCD), 150.7-Prolotherapy, Joint 
Sclerotherapy, and Ligamentous Injections with Sclerosing Agents. 
 
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). 
 
F05 (delirium due to known physiological condition): 
Acute or subacute brain syndrome, acute or subacute confusional state (nonalcoholic), acute or subacute 
infective psychosis, acute or subacute organic reaction, acute or subacute psycho-organic syndrome, delirium 
of mixed etiology, delirium superimposed on dementia, sundowning 
 
Code first: the underlying physiological condition 
Excludes1: delirium not otherwise specified (R41.0) 
Excludes2: delirium tremens alcohol-induced or unspecified (F10.231, F10.921) 
 
You can find this information in the Centers for Medicare and Medicaid Services, ICD-10-CM Tabular List of 
Diseases and Injuries. 
 
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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 8, and 30 of the Plan's 
2022 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b). 
 
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 health 
Plan contract says that the Plan covers only manual manipulation of the spine to correct subluxation. You can 
find this information on page 77 of the Plan's 2021 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 for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare 
Program Integrity Manual Chapter 3, Section 3.3.2.1. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 Code of Federal Regulations (CFR), Section 424.5. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
comprehensive oral evaluation (D0150) and is limited to one procedure every three plan years. You can find 
this information on page 4-159 of the Plans 2022 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. 
 
Medicare guidance says: Targeted genomic sequence analysis panel is non-covered by Medicare. You can find 
this Medicare guidance in: Medicare Local Coverage Article: Billing and Coding: MoIDX: Molecular 
Diagnostic Tests (MDT) (A57526) and Medicare Local Coverage Determination (LCD) MoIDX: Molecular 
Diagnostic Tests (MDT) (L35160). 
 
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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 Enhancements including but not limited to the following are NOT covered through the 
allowance but may be purchased by the member at an additional cost: Optional cosmetic processes; Anti-
reflective, mirror, color or scratch coating; Blended, cosmetic, laminated, oversize, UV protected or 
polycarbonate lenses; Photochromic lenses, tinted lenses except Pink #1 and Pink #2.; Progressive multifocal 
lenses; Certain limitations on low vision care; A frame that costs more than Plan allowance. You can find this 
on page 99 of the Plan's 2021 Evidence of Coverage.