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 state that the Medicare approved amount for procedure with a global surgical packages includes 
payment for 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 these rules in Medicare Claims Processing Manual Chapter 12, Section 40.1(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 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 Outpatient diagnostic tests and therapeutic 
servicesand supplies.  You can find this information on page(s) 68 of the Plan's 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 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 $275 copayment for outpatient surgery.  You can find this information 
on page(s) 71 of the Plan's 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 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. This 
rule is found in Medicare 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 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 $295 copayment for outpatient surgery, including services provided 
athospital outpatient facilities and ambulatory surgicalcenters.  You can find this information on page(s) 92 of 
the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $295 copayment for inpatient hospital care. The enrollee must pay a 
$295 copayment per day for days 1-6. You can find this information on page(s) 67 of the Plan's 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 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 40% coinsurance for outpatient surgery and other medical services 
provided at hospital outpatient facilities and ambulatory surgical centers.  You can find this information on 
page(s) 85 to 87 of the Plan's 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 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 $20 copayment for outpatient rehabilitation services.  You can find this 
information on page(s) 64 of the Plan's 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 say that neurogenic disorders can be distinguishable from myopathic disorders by a carefully 
performed electromyography (EMG). Below is a list of common disorders where an EMG, in tandem with a 
properly conducted nerve conduction study (NCS), will be helpful in diagnosis: 
1. Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions. 
2. Radiculopathy - cervical, lumbosacral. 
3. Mono/polyneuropathy - metabolic, degenerative, hereditary. 
4. Myopathy - including poly-and dermatomyositis, myotonic and congenital myopathies. 
5. Plexopathy - idiopathic, trauma, infiltration. 
6. Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG is of special value here. 
7. At times, immediately prior to botulinum toxin injection, for localization. 
8. At times, immediately prior to injection of phenol or other substances for nerve blocking or 
chemodenervation. 
 
There may be other instances, not detailed here, where EMG may be of use. 
 
The necessity and reasonableness of the following uses of EMG studies have not been established: 
1. exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions 
2. definitive diagnostic conclusions based on paraspinal EMG in regions bearing scars of past surgeries 
(e.g., previous laminectomies) 3. pattern-setting limited limb muscle examinations, without paraspinal muscle testing for a diagnosis of 
radiculopathy 
4. EMG testing shortly after trauma, before EMG abnormalities would have reasonably had time to 
develop 
5. surface and macro EMGs 
6. multiple uses of EMG in the same patient at the same location of the same limb for the purpose of 
optimizing botulinum toxin injections. 
 
You can find this information in the Local Coverage Determination (LCD): Nerve Conduction Studies and 
Electromyography (L35048). 
 
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that anesthesia procedures listed in the CPT/HCPCS Codes section of the related Local 
Coverage Article Billing and Coding: Monitored Anesthesia Care (A57361), are examples of those that are 
usually provided by the attending surgeon and are included in the global fee and are not separately billable. In 
certain instances, MAC provided by anesthesia personnel may be reasonable and necessary for procedures that 
are generally provided by the attending surgeon if certain conditions or situations are present. In these 
situations, MAC may be necessary for these active and serious accompanying situations or conditions to ensure 
smooth anesthesia (and surgery) by the prevention of adverse physiologic complications. Refer to the related 
billing and coding article for diagnoses that support the use of MAC in these situations. Special conditions or 
criteria must be supported by documentation in the medical record. 
 
For procedures that do not usually require anesthesia services, MAC could be covered when the patients 
condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to 
the physician performing the procedure, and is so documented in the patients medical record. 
 
The  presence of an underlying condition alone may not be sufficient evidence that MAC is necessary. The 
medical condition must be significant enough to impact on the need to provide MAC such as the patient being 
on medication or being symptomatic, etc. The presence of a stable, treated condition, of itself, is not necessarily 
sufficient. 
 
You can find this rule in the Local Coverage Determination for Monitored Anesthesia Care, L35049. 
 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 & 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 
D6192. You can find this information on pages 88-100 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 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.

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 page 14 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 that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $50 copayment for Physician/Practitioner services/specialist.  You can 
find this information on page(s) 107 of the Plan's 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 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 & 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 P indicates a bundled/excluded code. There are 
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 (an example 
is an elastic bandage furnished by a physician incident to a physician service). If the item or service is covered 
as other than incident to a physician service, it is excluded from the fee schedule (for example, colostomy 
supplies) and is paid under the other payment provision of the Act. You can find this information in the Centers 
for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).   
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says covered services include manual manipulation of the spine to correct subluxation (when one or 
more of the bones of your spine move out of position. You can find this information on pages 45 to 46 of the 
Plan's 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 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 & 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 one D0330 every 
three years. This benefit does not include D9610, D7960, D7310, D9222, or D9223. You can find this 
information on pages 113-115 of the Plan's 2023 Evidence of Coverage (EOC).