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 
coverage for the requested items or services, but only when they are received from an in-network provider. You 
can find this information on pages 43 to 48 and on pages 68 and 69 of the Plan's 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. 
 
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 a microprocessor-controlled ankle foot system (L5973), energy storing foot (L5976), 
dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal 
(L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose 
functional level is 3 or above. An axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries 
whose functional level is 2 or above. A fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, 
L5614, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, 
L5856, L5857, L5858) is covered for beneficiaries whose functional level is 3 or above. 
 
Socket replacements are considered reasonable and necessary if there is adequate documentation of functional 
and/or physiological need. It is recognized that there are situations where the explanation includes but is not 
limited to: changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to 
excessive beneficiary weight or prosthetic demands of very active amputees. You can find this rule in Local 
Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
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 vacuum erection devices (L7900) and related supplies are considered Prosthetic Devices 
under the Prosthetic Devices benefit category (Social Security Act 1861(s)(8)). For dates of service on or after 
July 1, 2015, codes L7900 and L7902 are statutorily non-covered based on the Achieving a Better Life 
Experience (ABLE) Act of 2014 (see Social Security Act 1834(a)(1)(I)). You can find this information in 
Medicare's Local Coverage Determination (LCD): Vacuum Erection Devices (VED) (L34824) and Medicare's 
Local Coverage Article: Vacuum Erection Devices (VED) - Policy Article (A52712). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say effective for claims with dates of service July 1, 2007, and after, the non-Outpatient Prospective 
Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. This 
integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital claims, 
through a single integrated OCE eliminating the need to update two separate OCE software packages on a 
quarterly basis. You can find this rule in the Centers for Medicare and Medicare Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 4, Section 40.1. 
 
The rules say that the OCE will return to the provider any claim that reports a HCPCS code for a procedure 
assigned to a device-intensive APC, for which the procedure requires the implantation of a device that does not 
also report at least one device HCPCS code required for that procedure. If the claim is returned to the provider 
for failure to pass the edit, the hospital will need to modify the claim by either correcting the procedure code or 
ensuring that one of the required device codes is on the claim before resubmission. While all devices that have 
device HCPCS codes and that were used in a given procedure should be reported on the claim, only one of the 
possible device codes is required to be on the claim for payment to be made, unless otherwise specified. You 
can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
04, Medicare Claims Processing Manual Chapter 4, Section 61.2. 
 
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 Medicare would consider the low testosterone related symptoms from the nonspecific and 
specific groups described above to be documented in the chart along with two low testosterone levels drawn on 
two mornings and a single LH or FSH to demonstrate the need for testosterone therapy in the age related group 
of symptomatic androgen deficiency. Documentation of the symptoms, signs, physical examination and lab 
tests must be available in the chart if requested. You can find this rule at Local Coverage Determination (LCD) 
L36538: Treatment of Males with Low Testosterone (eff. 11/1/19). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, 30.2.2. 
 
The rules say Medicare Physician's Fee Schedule Database (MPFSDB) Status Code of P is defined as 
Bundled/excluded codes. There are no RVUs and no payment amounts for these services. No separate payment 
is made for them under the fee schedule. If the item or service is covered as incident to a physician service and 
is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident. 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 30.2.2. 
 
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, 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 Medicare will pay for durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers 
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment 
already available to an enrollee. You can find these rules in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(C). 
 
The rules also say that calf rest pads (E0955) are included in the allowance for a power wheelchair base when 
provided at the same time. You can find this rule in Local Coverage Article: Wheelchair Options/Accessories - 
Policy Article (A52504). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that CMS requires that surgical pathology, including gross and microscopic examination, of any 
and all submitted prostate needle biopsy specimens from a single patient be reported with one unit of service of 
HCPCS code G0416 rather than CPT code 88305. You can find this rule in the Centers for Medicare and 
Medicaid Services, National Correct Coding Initiative Policy Manual, Chapter 10 (L10). 
 
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 Plan 
contract includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. Unspecified removable prosthodontic procedure (D5899) is not included on 
this list and is not a covered supplemental benefit. You can find this information on pages 4-66 to 4-79 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. 
 
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 Q4 services are assigned to laboratory Healthcare Common Procedure Coding System 
(HCPCS) codes that appear on the Clinical Laboratory Fee Schedule (CLFS). Status indicator Q4 designates 
packaged ambulatory payment classification (APC) payment if billed on the same claim as a HCPCS code 
assigned status indicator J1, J2, S, T, V, Q1, Q2, or Q3. When a Q4 service is not billed on 
the same claim as another separately payable service then the Integrated Outpatient Code Editor (IOCE) 
automatically changes their status indicator to A and separate payment is made at the CLFS payment rate. 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 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 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 services but is limited to once every three plan years. You can find this information on pages 4-66 to 
4-67 of the Plan's 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.
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 you are covered by both Medicare and Medicaid. Medicare is the Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with end-stage renal disease (kidney failure). Medicaid is a joint Federal and state government program that helps with medical costs for certain people with limited incomes and resources. Medicaid coverage varies depending on the state and the type of Medicaid you have. Some people with Medicaid get help paying for their Medicare premiums and other costs. Other people also get coverage for additional services and drugs that are not covered by Medicare. You can see this on page 11 of the Plan's 2021 Evidence of Coverage.
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 date of service (DOS) policy for either a clinical laboratory test or the technical component of physician pathology service is as follows: General Rule: The DOS of the test/service must be the date the specimen was collected. Variation: If a specimen is collected over a period that spans two calendar days, then the DOS must be the date the collection ended. Exceptions: The following three exceptions apply to the DOS policy for either a clinical laboratory test or the technical component of physician pathology service: A. DOS for Tests/Services Performed on Stored Specimens: In the case of a test/service performed on a stored specimen, if a specimen was stored for less than or equal to 30 calendar days from the date it was collected, the DOS of the test/service must be the date the test/service was performed only if: - The test/service is ordered by the patient's physician at least 14 days following the date of the patient's discharge from the hospital; - The specimen was collected while the patient was undergoing a hospital surgical procedure; - It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted; - The results of the test/service do not guide treatment provided during the hospital stay; and - The test/service was reasonable and medically necessary for treatment of an illness. If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service must be the date the specimen was obtained from storage. You can find this in the Medicare Claims Processing Manual Chapter 16 under Laboratory Services, section 40.8, Date of Service (DOS) for Clinical Laboratory and Pathology Specimens. The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid information for all these elements may be returned as un-processable. You can find this rule in the Medicare Claims Processing Manual, Chapter 1, Section 80.3.1.
The rules state that when completing the 1500 claim form, providers must enter the correct Place of Service (POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. You can find this rule at Medicare Claims Processing Manual Ch. 26 Section 10.6.
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 Medicare grants contractors the authority to request any information necessary to determine 
the amounts due. This includes proof of delivery in order to verify that the beneficiary received the Durable 
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) item billed and thus to determine the 
amount due to the provider. For any items that do not have proof of delivery from the supplier, such claimed 
items shall be denied. The signature of the designee (defined as any person who can sign and accept the 
delivery on behalf of the beneficiary) should be legible. If the signature of the designee is not legible, the 
supplier/shipping service should note the name of the designee on the delivery slip. You can find these rules in 
Medicare Program Integrity Manual Chapter 4, Sections 4.7.3.1 and 4.7.3.1.1. 
 
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.