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 L5781 describes a complete device that is an addition to a lower limb prosthesis. The 
primary function of the vacuum pump is to suspend the prosthetic limb. Additionally, products coded L5781 
provide residual limb volume management and moisture evacuation. The pump mechanism evacuates air and 
accumulated moisture between the limb and socket walls. The pump mechanism can be actuated by either 
external power and/or mechanical system(s). 
 
L5782 describes a complete device that is an addition to a lower limb prosthesis. The primary function of the 
vacuum pump is to suspend the prosthetic limb. It also provides residual limb volume management and 
moisture evacuation. The pump mechanism evacuates air and accumulated moisture between the limb and 
socket walls. The pump mechanism can be actuated by either external power and/or mechanical system(s). 
Products described by this code would have components built to withstand higher prosthetic limb forces than 
L5781. 
 
L5988 describes an endoskeletal pylon device that allows vertical shock reduction between the foot and pelvis 
during ambulation. The vertical shock reducing pylon feature of L5988 is a separate function from other 
products which use a piston/telescoping mechanism such as products described by L5781 or L5782. The 
predicate product is the Total Shock that was manufactured by Century XXII International, Inc. 
 
You can find these rules in the Local Coverage Article Lower Limb Prostheses - Policy Article A52496. 
 
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 34-40 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 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 the use of HBO therapy is covered as adjunctive therapy only after there are no measurable 
signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to 
standard wound care. Standard wound care in patients with diabetic wounds includes assessment of a patients 
vascular status and correction of any vascular problems in the affected limb, if possible, optimization of 
nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, 
maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-
loading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard 
wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds 
must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO 
therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of 
treatment. You an find the rules in National Coverage Determination (NCD) Hyperbaric Oxygen Therapy 
20.29. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. The only exception is as 
follows:  
 
For the same date of service only one physician of the same specialty in the group practice may report code 
99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care 
services with CPT code 99292. 
 
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 20.9. 
 
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 Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the code pair to bypass the edit. 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 20.9. 
 
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 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).   
 
The rules say subluxation may be shown by x-ray or physical exam. 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, Section 240.1.2. 
 
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 states that along with Medicare-covered chiropractic services, the Plan offers coverage of routine 
chiropractic services. You may self-refer to a network chiropractor for 10 visits per calendar year. You can find 
this information on page 67 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 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 the basic requirement for all forms of PBT treatment delivery is that the technology must 
accurately produce the calculated dose distribution described by the PBT plan. PBT dose distributions are 
sensitive to changes in target depth and shape and thus, changes in patient anatomy during treatment may 
require repeat planning. Such a change must be documented. 
 
Precise delivery is vital for proper treatment. Therefore, imaging techniques such as stereoscopic X-ray or CT 
scan (collectively referred to as Image Guided Radiation Therapy or IGRT) should be utilized to verify 
accurate and consistent patient and target setup for every treatment fraction. You can find this rule in the Local 
Coverage Determination (LCD) Proton Beam Therapy L35075. 
 
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 coverage is denied for all cardiovascular (CV) risk assessment panels, except the basic lipid 
panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because 
panel testing is not specific to a given patients lipid abnormality or disease. The policy indicates the medical 
indication(s) based on published scientific articles and consensus guidelines for individual lipid biomarkers that 
may be covered to characterize a given lipid abnormality or disease, to determine a treatment plan or to assist 
with intensification of therapy. Each individual lipid biomarkers must be specifically ordered and the reason for 
the test order documented in the patients medical record. The policy denies coverage for all non-lipid 
biomarkers when used for CV risk assessment including but not limited to, biochemical, immunologic, and 
hematologic, and genetic biomarkers for CV risk assessment regardless of whether ordered in a panel or 
individually. You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD): MolDX: Biomarkers in Cardiovascular Risk Assessment (L36362) 
 
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 claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing 
information. This information is found in Local Coverage Article 
Knee Orthoses - Policy Article (A52465). 
 
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 only the 
items and services listed in the dental rider. An endosteal implant (D6010) and guided tissue regeneration 
(D4266) are not covered by the Plan's dental benefits. You can find this information on pages 103-109 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 the global surgery package of procedure with a global period of 10 days includes all 
additional medical or surgical services required of the surgeon during the postoperative period of the 
surgery. The initial evaluation is always included in the allowance for a minor surgical procedure. Services not 
included in the global surgery payment are those such as treatment for the underlying condition or an added 
course of treatment which is not part of normal recovery from surgery, Critical care services (CPT codes 99291 
and 99292) unrelated to the surgery, for example, where a seriously injured or burned patient is critically ill and 
requires constant attendance of the physician. You can find this in the Centers for Medicare and Medicaid 
Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 
40.1 (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 items and services furnished outside the United States are excluded from coverage except for 
the following services, and certain services rendered on board a ship: 
- Emergency inpatient hospital services where the emergency occurred: 
~ While the beneficiary was physically present in the United States; or 
~ In Canada while the beneficiary was traveling without reasonable delay and by the most direct 
route between Alaska and another State. 
- Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the 
United States, if the hospital was closer to, or substantially more accessible from, the beneficiary's 
United States residence than the nearest participating United States hospital which was adequately 
equipped to deal with and available to provide treatment of the illness or injury; 
- Physician and ambulance services furnished in connection with a covered foreign hospitalization. 
Program payment may not be made for any other Part B medical and other health services, including 
outpatient services furnished outside the United States; 
- Services rendered on board a ship in a United States port, or within 6 hours of when the ship arrived at, 
or departed from, a United States port, are considered to have been furnished in United States territorial 
waters. Services not furnished in a United States port, or within 6 hours of when the ship arrived at, or 
departed from, a United States port, are considered to have been furnished outside United States 
territorial waters, even if the ship is of United States registry; and 
- The term "United States" means the 50 States, the District of Columbia, the Commonwealth of Puerto 
Rico, the Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of 
services rendered on a ship, includes the territorial waters adjoining the land areas of the United States. 
 
You can find these rules in Medicare Benefit Policy Manual Chapter 16, Section 60. 
 
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 
provider worldwide coverage for emergency department services. This includes emergency or urgently needed 
care and emergency ambulance transportation from the scene of an emergency to the nearest medical treatment 
facility. Transportation back to the United States from another country is not covered. You can find this 
information in Chapter 4 on pages 4-20 to 4-22 of the Plans 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 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 a list of 
covered dental services including frequency and limitations. Intraoral-periapical each additional radiographic 
image (D0230) is limited to one procedure code per calendar year. 2D oral/facial photographic images 
(D0350), oral hygiene instructions (D1330), localized delivery of antimicrobial agents into diseased crevicular 
tissue (D4381), and core buildup, including any pins when required (D2950) are not among the services 
covered by the Plan's dental benefit. You can find this information in Chapter 4 on pages 84 to 86 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 beginning January 1, 2022, home health agencies (HHAs) will no longer submit Requests for 
Anticipated Payment (RAPs). Instead, for each admission to home health the HHA notifies Medicare systems 
via submission of a Notice of Admission (NOA). The NOA is a one-time submission to establish that the 
beneficiary is under a home health period of care and trigger home health consolidated billing edits. The NOA 
covers contiguous 30-day periods of care until the individuals is discharged from Medicare home health 
services.  
 
The admission date on the NOA must always match the from date. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-02, Medicare Benefit Policy 
Manual, Chapter 7, Sections 10.4 and 40.1 (Rev. 11447, Issued: 06-06-22, Effective: 01-01-22, 
Implementation: 05-26-22). 
 
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 page 1-8 of the 2023 Evidence 
of Coverage.