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 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 CFR 424.5.

The rules say 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 Centers for
Medicare & Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity
Manual, Chapter 3, Section 3.3.2.1.

The rules say that Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective
and otherwise reasonable and necessary for the patient. Food and Drug Administration (FDA) approved drugs
used for indications other than what is indicated on the official label may be covered if the use is determined to
be medically accepted, taking into consideration the major drug compendia, authoritative medical literature
and/or accepted standards of medical practice. 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, Sections
50.4.1 and 50.4.2

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 state that a peripheral nerve block injection (Current Procedural Terminology codes 64XXX) for 
postoperative pain management may be reported separately with an anesthesia 0XXXX code only if the mode 
of intraoperative anesthesia is general anesthesia, subarachnoid injection, or epidural injection, and the 
adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block injection. An epidural 
or peripheral nerve block injection (code numbers as identified above) administered preoperatively or 
intraoperatively is not separately reportable for postoperative pain management if the mode of anesthesia for 
the procedure is monitored anesthesia care, moderate conscious sedation, regional anesthesia by peripheral 
nerve block, or other type of anesthesia not identified above. If an epidural or peripheral nerve block injection 
(62320-62327 or 64400-64530 as identified above) for postoperative pain management is reported separately 
on the same date of service as an anesthesia 0XXXX code, modifier -59 or -XU may be appended to the 
epidural or peripheral nerve block injection code (62320-62327 or 64400-64530 as identified above) to indicate 
that it was administered for postoperative pain management. You can find this rule in the Centers for Medicare 
& Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, 
Chapter 2(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.
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 LTACH is a hospital that has an average inpatient length of stay of greater than 25 days. 
You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).  
 
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need 
medical care. You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, 
Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2. 
 
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 cosmetic surgery is performed to reshape and adjust normal structures of the body to enhance 
the visual appearance. Reconstructive surgery is performed to restore and improve function and correct any 
deformities or abnormal structures of the body that have been caused by congenital defects, developmental 
abnormalities, trauma, infection, tumors or disease. You can find this rule in the Local Coverage Determination 
(LCD) - Cosmetic and Reconstructive Surgery (L38914). 
 
The rules say that macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue 
relative to the general body habitus. Breast hypertrophy may adversely affect other body systems (e.g., 
musculoskeletal, respiratory, integumentary). At times, unilateral hypertrophy may result in symptoms 
following contralateral mastectomy. Considerable attention has been given to the amount of breast tissue 
removed in differentiating between cosmetic and medically reasonable and necessary reduction mammoplasty. 
Arbitrary minimum weight breast tissue removed criteria do not consistently reflect the consequences of 
mammary hypertrophy in individuals with a unique body habitus. There are wide variations in the range of 
height, weight and associated breast size that cause symptoms. The amount of tissue that must be removed to 
relieve symptoms will vary and depend upon these variations. You can find this rule in the Local Coverage 
Determination (LCD) - Cosmetic and Reconstructive Surgery (L38914). 
 
The rules say that the Schnur sliding scale is an evaluation method for physicians to use on individuals 
considering breast reduction surgery. If the individual's body surface area and weight of breast tissue removed 
fall above the 22nd percentile, then the surgery is considered medically reasonable and necessary with the 
appropriate criteria.5 The scale abbreviated below allows a rough estimate of the minimal amount of soft tissue 
to be removed to justify surgery to alleviate symptoms based on body surface area; breast tissue may be 
removed from the other breast in order to achieve symmetry. You can find this rule in the Local Coverage 
Determination (LCD) - Cosmetic and Reconstructive Surgery (L38914). 
 
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 item or service but is limited to one D0140 every six months. This benefit does not include D0364 or 
D0460. You can find this information on pages 51-52 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 to report a service for Molecular Syndromic Panels for Infectious Disease Pathogen 
Identification Testing, please submit the following claim information: 
- The appropriate procedure code 
~ If the panel being used does not have its own proprietary procedure code, select the appropriate 
code and follow the additional instructions for the given 'panel'. If no specific code exists for the 
test submitted, bill with code 87999. 
- Procedure codes that are not billed with the appropriate accompanying diagnosis codes will be denied. 
Tests with other indicated uses may therefore submit for a Z-code and undergo a Technical Assessment 
(TA) by MolDX. Tests using code 87999 will also require a Z-Code and a TA. 
- Tests that are Food & Drug Administration (FDA)-approved/cleared and performed in ways consistent 
with their intended use labeling directions do not require a Z-code when billed with an appropriate 
accompanying diagnosis code. However, the performance of multiple FDA-approved/cleared molecular 
Infectious Disease pathogen identification tests on the same date of service (DOS) for the same 
intended use on the same patient sample is considered as one distinct service and requires a Z-Code and 
a TA. If an existing code does not identify the service, it requires the use of code 87999. 
- Add modifier 59 for different species or strains reported by the same code, as allowed by the policy. 
- Enter 1 unit of service (UOS) 
- If applicable, enter the appropriate DEX Z-Code identifier adjacent to the procedure code in the 
comment/narrative field 
- Select the appropriate diagnosis code(s) 
 
You can find this rule in Local Coverage Article (LCA) Billing and Coding: MolDX: Molecular Syndromic 
Panels for Infectious Disease Pathogen Identification Testing (A58710). 
 If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare & 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 27-32 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 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 contractor 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. If an unassigned purchase claim does not specify whether the item was new or used, contractors 
develop the claim with the supplier. 
-NU New equipment 
-RR Rental (use the 'RR' modifier when DME is to be rented)  
 
You can find this rule in the Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 20, Section 130.9. 
 
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 the Medicare approved amount for procedures with a global surgical package includes 
payment for the following services related to the surgery when furnished by the physician who performs the 
surgery. 
- Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day 
before the day of surgery for major procedures and the day of surgery for minor procedures; 
- Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a 
surgical procedure; 
- Complications Following Surgery - All additional medical or surgical services required of the surgeon 
during the postoperative period of the surgery because of complications which do not require additional 
trips to the operating room; 
- Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to 
recovery from the surgery; 
- Postsurgical Pain Management - By the surgeon; 
- Supplies - Except for those identified as exclusions; and 
- Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative 
pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, 
irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal 
tubes; and changes and removal of tracheostomy tubes. 
 
You can find this rule in Medicare Claims Processing Manual Chapter 12, Section 40.1. 
 
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.
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 does not include 
D9944. You can find this information on pages 75-77 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 an add-on to convert a manual wheelchair to a joystick-controlled power mobility device 
(E0983) or to a tiller-controlled power mobility device (E0984) will be denied as not reasonable and necessary. 
You can find this information in the Local Coverage Determination (LCD) for Power Mobility Devices 
(L33789). 
 
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 15-21 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 a Medicare plan may not pay for services given by a physician or other practitioner who has 
opted out of Medicare. This rule does not apply to emergency or urgently needed services. A Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the 
Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 6, Section 60.2. 
 
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 items or services furnished by a provider who has opted-out of participation with Medicare 
are not covered. An opt-out provider cannot bill the Plan, nor can the Plan pay you for these services. You can 
find this information on page 109 of the Plan's 2023 Evidence of Coverage. 
 
The Plan contract also says enrollees must pay a $25 copayment per physician service with an out-of-network 
primary care physician (PCP). You can find this information on page 87 of the Plans 2023 Evidence of 
Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that consistent with Current Procedural Terminology (CPT) instruction, report CPT codes 93228 
and 93229 only once per 30 days. You can find this rule in the Billing and Coding Article: Ambulatory 
Electrocardiograph (AECG) Monitoring, A59270. 
 
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 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 Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and 
necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments 
(CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements 
are met: 
   a. Patient has: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, 
and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
You can find this in National Coverage Determination (NCD) Next Generation Sequencing (NGS) 90.2. 
 
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.