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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
 
2. The services require the skills or direct supervision of a therapist,  
 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2. 
 
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 rules also say that for outpatient therapy to be considered reasonable and necessary, the services must meet 
Medicare guidelines. The guidelines for coverage of outpatient therapies have basic requirements in common. 
In the case of rehabilitative therapy, the patients condition has the potential to improve or is improving in 
response to therapy. A therapy plan of care is developed either by the physician/ non-physician practitioner 
(NPP), or by the physical therapist who will provide the physical therapy services. All services provided are to 
be specific and effective treatments for the patients condition according to accepted standards of medical 
practice; and the amount, frequency, and duration of the services must be reasonable. The services that are provided must meet the description of skilled therapy. You can find this information in Local Coverage 
Determination (LCD) L33631: Outpatient Physical and Occupational Therapy Services.
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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers 60 one-way transportation trips when each one-way trip does not exceed 50 miles. You can find this 
information on pages 112-113 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). 
 
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 must report services correctly. Procedures should be reported with the CPT code
that describes the services performed. The rules also say that modifiers may be appended to HCPCS/CPT codes
only if the clinical circumstances justify the use of the modifier. A modifier shall not be appended to a
HCPCS/CPT code solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use. You
can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I.

The rules say that the CPT Manual defines modifier 25 as a "significant, separately identifiable evaluation and
management service by the same physician or other qualified health care professional on the same day of the
procedure or other service". Modifier 25 may be appended to an evaluation and management (E&M) CPT code
to indicate that the E&M service is significant and separately identifiable from other services reported on the
same date of service. The E&M service may be related to the same or different diagnosis as the other
procedure(s). You can find this information in the CPT Coding Manual.

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 current accepted diagnoses and indications for Mohs Micrographic Surgery include basal 
cell carcinomas (BCC), squamous cell carcinomas (SCC), or basalosquamous/basosquamous cell carcinomas 
that are in anatomic locations H, M, and L (trunk and extremities) regardless of subtype, size or depth arising in 
prior radiated skin, a traumatic scar, an area of osteomyelitis, an area of chronic inflammation/ulceration, and 
in patients with genetic syndromes. The rules also say that BCC located in Area L (trunk and extremities) is not 
considered medically necessary for recurrent superficial BCC of any size, for primary superficial BCC of any 
size, for primary nodular BCC less than or equal to 2 centimeters (cm), or for primary nodular BCC less than or 
equal to 1 cm. You can find this information in the Local Coverage Determination (LCD): Mohs Micrographic 
Surgery (MMS) (L33689). 
 
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. 
 
A knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a 
knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation 
  
  control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a surgical 
procedure on the knee(s). Refer to the diagnoses listed in the Groups 2 or 4 ICD-10 Codes in the LCD-related 
Policy Article. 
 
Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is 
ambulatory and has knee instability due to a condition specified in the Group 4 ICD-10 Codes in the LCD-
related Policy Article. 
 
For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by 
examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, 
anterior/posterior Drawer test). 
 
Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and 
necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied 
if only pain or a subjective description of joint instability is documented. 
 
You can find this information in the Local Coverage Determination (LCD) Knee Orthoses L33318. 
 
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 that the only covered chiropractic service is manual manipulation of the spine to correct 
subluxation. You can find this information on page 62 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 and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for specific dental items/services stated in the Plans contract. An oral exam is covered every six 
months. A 2D oral/facial photographic image (D0350) is not covered. You can find this information on pages 
61-62 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 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. 
 
The rules say that a series is defined as a set of injections for each joint and each treatment. The EJ modifier 
must be used with the Healthcare Common Procedure Coding System (HCPCS) code for the drug administered 
to indicate subsequent injections of a series. The modifier is not to be used with the first injection of each 
series. 
 
Effective 01/01/2017, per CR 9603, when billing for Part B drugs and biologicals (except those provided under 
community-acquired pneumonia (CAP)), the use of the JW modifier to identify unused drugs or biologicals 
from single use vials or single use packages that are appropriately discarded is required. The discarded amount 
shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded 
drug or biological in the patient's medical record. You can find these rules in the Local Coverage Article: 
Billing and Coding: Intraarticular Knee Injections of Hyaluronan A56157. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Medicare pays for the least expensive option of repair vs. replacement of durable medical 
equipment (DME). The repair is covered when the DME is being purchased or is already owned by the patient 
and repair is necessary to make the equipment serviceable. Do not pay for repair of previously denied 
equipment or equipment in the frequent and substantial servicing or oxygen equipment payment categories. 
Routine periodic servicing, such as testing, cleaning, regulating, and checking of the beneficiarys equipment, 
is not covered.  In no case can the reasonable useful lifetime of DME be less than 5 years. Replacement due to 
wear is not covered during the reasonable useful lifetime of the equipment. During the reasonable useful 
lifetime, 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 at Medicare Benefit Policy Manual Chapter 15  Covered Medical and Other 
Health Services, Section 110.2 - Repairs, Maintenance, Replacement, and Delivery and Medicare Claims 
Processing Manual Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), 
Section 10.2 - Coverage Table for DME Claims. 
 
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 and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that a professional component (PC)/technical component (TC) indicator of 3 identifies technical 
component only stand alone codes that describe the technical component (i.e., staff and equipment costs) of 
selected diagnostic tests for which there is an associated code that describes the professional component of the 
diagnostic tests only. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 50.6. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 if one laboratory procedure evaluates multiple genes using a next generation sequencing 
procedure, the lab shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 
If no CPT code accurately describes the procedure performed, the lab may report CPT code 81479 with one 
unit of service. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be 
reported for the procedure. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare 
National Correct Coding Initiative Manual, Chapter X(F). 
 
The rules say that 2 or more codes describing a genetic test billed on the same beneficiary on the same date 
may constitute a panel, and if so, the service must be billed as a single procedural service. When 2 or more 
codes are submitted for the same beneficiary on the same date of service, the claims processing system will 
reject every code submitted after the first service. You can find this rule in the Local Coverage Article for the 
Billing and Coding of Molecular Diagnostics (MolDX): Testing of Multiple Genes, A58120. 
 
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 
a retainer crown coded (D6750) and pontic. You can find this information on pages 82-85 of the Plans 2023 
Evidence of Coverage (EOC) and in the schedule of covered benefits.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for only those items and services specifically listed in your Plan contract. Limited oral evaluation  - 
problem focused (D0140 is not listed as a covered benefit. You can find this information on pages 72-75 of the 
Plans 2023 Evidence of Coverage (EOC). 
 
This benefit does include coverage for intraoral x-ray services. However, coverage for intraoral x-ray services 
is limited to 1 procedure code per calendar year. You can find this information on pages 72 to 75 of the Plans 
2023 EOC.