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 Following Breath Test is Covered: 
 
    - Lactose breath hydrogen to detect lactose malabsorption. 
 
The rules also say that the Following Breath Tests are Excluded from Coverage: 
 
    - Lactulose breath hydrogen for diagnosing small bowel bacterial overgrowth and measuring small bowel 
transit time. 
    - Carbon dioxide (CO2) for diagnosing bile acid malabsorption. 
    - CO2 for diagnosing fat malabsorption. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-03, National Coverage Determination (NCD) for Diagnostic Breath Analyses (100.5). 
 
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 replacement refers to the provision of an identical or nearly identical item. Equipment which 
the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. 
Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot 
be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful 
lifetime (RUL) of the equipment. In the absence of program instructions, Medicare contractors may determine 
the RUL of equipment, but in no case can it be less than 5 years. Replacement due to wear is not covered 
during the RUL of the equipment. During the RUL, Medicare does cover repair up to the cost of replacement 
(but not actual replacement) for medically necessary equipment owned by the beneficiary. You can find this 
information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 15, Section 110.2. 
 
Medicare rules state that products reviewed by the Pricing, Data Analysis, and Coding (PDAC) which do not 
meet the Durable Medical Equipment (DME) benefit category requirements must be coded as A9276, A9277, 
A9278, or A9279 and will be denied as non-covered. You can find this rule in Local Coverage Article (LCA) 
Glucose Monitor Policy Article (A52464). 
 
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 $15 copayment for chiropractic services. You can find this information 
on page 63 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 vascular stents are used to enhance primary patency in arteries and veins, usually at the site 
of stenotic or occlusive lesions. Stents also may be used as an adjunct to technically inadequate Percutaneous 
Transluminal Angioplasty (PTA) or in cases where PTA alone will not be expected to provide a durable result. 
Peripheral vascular stenting may be indicated for patients with symptomatic arterial and venous disease 
resulting from an occlusive process. 
 
PTA and stenting of vessels is covered only when all of the following conditions are met: 
- The patient has undergone prior thorough medical evaluation and management of symptoms. 
- Surgical intervention would otherwise be considered as an alternative treatment for the patient. 
- A stent may be placed as a planned adjunct to PTA rather than in response to a suboptimal or failed PTA (so-
called primary stent deployment). Primary stenting is justified for situations where PTA alone is not expected 
to provide a durable result, such as arterial or venous occlusions that carry a high risk for distal embolization or 
rapid recurrence OR occlusive lesions known to be unfavorable for PTA alone such as significantly calcified 
lesions, eccentric lesions, lesions related to external compression, or ostial renal artery stenosis. 
PTA and stent placement in infra-popliteal vessels is not expected to be often indicated and in those cases the 
rationale for stent placement must be thoroughly explained in the record. 
 
PTA and stenting for critical limb ischemia is considered appropriate when there is evidence of limb 
threatening lower extremity ischemia. 
 
PTA and stenting for claudication may be appropriate for individuals who have failed medical management and 
home exercise program and continue to have significant activity limiting disease, with an anatomically suitable 
lesion for intervention. Medical management of peripheral artery disease (PAD) should include Class I 
recommendations for antiplatelet therapy, statins, home exercise program, smoking cessation including 
planning, counseling or behavior modification and pharmacotherapy if needed. 
 
You can find this information in the Local Coverage Determination (LCD): Non-Coronary Vascular Stents 
(L35998). 
 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).  
 
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 there is a $750 deductible which applies to certain items and services. The Plan deductible 
applies to all services besides covered services received from an in-network provider, ambulance services, 
emergency room services, and urgently needed services at urgent care centers. You can find this information on 
pages 61 and 62 of the Plan's 2022 Evidence of Coverage (EOC), and pages 48 and 49 of the Plan's 2023 EOC. 
 
The Plan contract says that enrollees must pay a 50% coinsurance of the total cost for out-of-network Medicare 
Part B chemo drugs, and other Medicare Part B drugs. You can find this information on pages 85 and 86 of the 
Plan's 2022 EOC. 
 
The Plan contract also says that enrollees must pay a $65 copayment for out-of-network Medicare-covered 
physician specialist services. You can find this information on page 96 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 Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
preventive and comprehensive services. The requested service is excluded from this benefit. You can find this 
information on pages 60, 115-134, and 136 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 state that to repair means to fix or mend and to put the equipment back in good condition after 
damage or wear. 
 
Repairs to equipment which a beneficiary owns are covered when necessary to make the equipment 
serviceable. However, do not pay for repair of previously denied equipment or equipment in the frequent 
and substantial servicing or oxygen equipment payment categories. If the expense for repairs exceeds the 
estimated expense of purchasing or renting another item of equipment for the remaining period of medical 
need, no payment can be made for the amount of the excess. (See subsection C where claims for repairs 
suggest malicious damage or culpable neglect). You can find this rule in the Medicare Benefit Policy Manual 
Chapter 15, Section 110.2. 
 
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 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 says that the enrollee is responsible for a $50 office visit copay, 50% coinsurance for major restorative 
services and a $50 annual deductible applies. You can find this information in Chapter 4 on page 62 in 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 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 carriers must pay a set-up component for each radiologic procedure (other than retakes of the 
same procedure) during both single patient and multiple patient trips under Level II HCPCS code Q0092. 
Carriers do not make the set-up payment for EKG services furnished by the portable x-ray supplier. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 13, Section 90.4. 
 
The rules say that the Centers for Medicare and 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. 
 
CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between types of MUEs. 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 and 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 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 $35 copayment for outpatient diagnostic tests/X-rays. You can find this 
information on page 96 of the Plan's 2023 Evidence of Coverage (EOC). Also, a $45 copayment for 
physician/practitioner services/Medicare-covered visit with a specialist. You can find this information on page 
105 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. If the Plan determines a less 
expensive alternate procedure, service or course of treatment can be performed in place of the proposed 
treatment to correct a dental condition; and the alternate treatment will produce a professional satisfactory 
result; then the maximum the plan will allow will be the charge for less expensive treatment. You can find this 
information on page 78 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 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 there are exceptions to the date of service (DOS) policy for either a clinical laboratory test or 
the technical component of physician pathology service. 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 rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
16, Section 40.8(A). 
 
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 a laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
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 complex cataract surgery will be considered medically reasonable and necessary when there 
is one of the following: 
 
1. A miotic pupil that will not dilate sufficiently requiring the use of a mechanical iris expansion device (Iris  
retractors through four additional incisions, Beehler expansion device, or Malyugin ring) to adequately 
visualize the lens in the posterior chamber of the eye.  
2. Pre-existing zonular weakness requiring use of capsular tension rings or segments or intraocular suturing of 
the intraocular lens. 
3. Pediatric cataract surgery, intraoperatively difficult because of an anterior capsule that is more difficult to 
tear, cortex that is more difficult to remove needing a primary posterior capsulotomy or capsulorrhexis. 
4. Mature cataract requiring dye for visualization of capsulorrhexis. 
 
You can find this information at Local Coverage Determination (LCD)-Cataract Extraction (including 
Complex Cataract Surgery) (L35091). 
 
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 $250 copayment for inpatient hospital care. The enrollee must pay a 
$250 copayment per day, for days one to six, per inpatient admission. There is a $1,500 maximum copayment 
per admission. You can find this information on page(s) 76 of the Plan's 2023 Evidence of Coverage.