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 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 Botulinum toxin type A and botulinum toxin type B have many similarities and as 
experience has been gained, medical consensus has gradually developed that the two toxins have similar, but 
not identical, properties. Each botulinum toxin product is pharmacologically and clinically distinct, and 
therefore, not interchangeable with any other botulinum toxin product. As a result, approved indications for the 
two toxins differ. This A/B MAC has determined that the separate accepted indications for the four toxins will 
be combined into a single list of covered indications in this Local Coverage Determination (LCD) policy. 
However, it is the responsibility of providers to use each drug in accordance with the FDA approved 
indications unless there are valid and documented reasons stating why the unapproved/off label form is used, 
Providers should consult the package insert of each neurotoxin to identify the FDA approved indications for 
each product. You can find this information in the Local Coverage Determination (LCD) L35172:  Botulinum 
Toxin Types 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.
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 may cover the use of a Food and Drug Administration-approved (FDA) drug or 
biological if it is safe and effective and otherwise reasonable and necessary for the patient. FDA-approved 
drugs used for indications other than what is indicated on the official label may be covered if the use is 
determined to be medically accepted, taking into consideration the major drug compendia, authoritative 
medical literature and/or accepted standards of medical practice. You can find this rule in Medicare Benefit 
Policy Manual Chapter 15, Sections 50.4.1 and 50.4.2. 
 
The rules say that Medicare has approved intravenous immune globulin (IVIG) for the following off-label uses: 
- Stiff-person syndrome 
- Autoimmune retinopathy (AIR) 
- Pure red cell aplasia 
- Hematopoetic stem cell transplantation (HSCT) 
- Secondary hypogammaglobulinemia 
- Chronic graft versus host disease (GVHD) 
- Hypogammaglobulinemia for graft vs. host disease 
- Systemic lupus erythematosus 
- Scleromyxedema 
- Systemic capillary leak syndrome (SCLS) or Clarksons Disease 
- Immune-mediated necrotizing myositis 
 
You can find these rules in Local Coverage Determination (LCD) Off-Label Uses of Intravenous Immune 
Globulin (IVIG) (L39314). 
 
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 exercise equipment is not covered because it is not primarily medical in nature. You can find 
this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, 
Medicare National Coverage Determinations Manual, Section 280.1.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit does not include 
D9630, D4381, D4921, or D2950. You can find this information on pages 74-77 of the Plans 2023 Evidence 
of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that: 
 
Nationally Covered Indications 
 
The CologuardTM  Multi-target Stool DNA (sDNA) Test (effective October 9, 2014) 
Screening stool or fecal DNA (deoxyribonucleic acid, sDNA) testing detects molecular markers of altered 
DNA that are contained in the cells shed by colorectal cancer and pre-malignant colorectal epithelial neoplasia 
into the lumen of the large bowel. Through the use of selective enrichment and amplification techniques, sDNA 
tests are designed to detect very small amounts of DNA markers to identify colorectal cancer or pre-malignant 
colorectal neoplasia. The CologuardTM  multi-target sDNA test is a proprietary in vitro diagnostic device that 
incorporates both sDNA and fecal immunochemical test techniques and is designed to analyze patients stool 
samples for markers associated with the presence of colorectal cancer and pre-malignant colorectal neoplasia. 
Effective for dates of service on or after October 9, 2014, The CologuardTM test is covered once every three 
years for Medicare beneficiaries that meet all of the following criteria: 
 Age 50 to 85 years, and, 
 Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower 
gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test (gFOBT) or fecal 
immunochemical test (iFOBT)), and, 
 At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal 
cancer, or inflammatory bowel disease, including Crohns Disease and ulcerative colitis; no family 
history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary 
nonpolyposis colorectal cancer). 
You can find this rule at the Medicare National Coverage Determination (NCD) 210.3: Colorectal Cancer 
Screening Tests. 
 
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 20% coinsurance for Medicare Part B chemotherapy drugs. You can find 
this information on page 90 of the Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay 20% coinsurance for radiation therapy. You can find this 
information on page 95 of the Plans 2023 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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. 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 50.4.1. 
 
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 107-108 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 & 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 & Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules say that certain modifiers can be appended to a code that would typically not be separately paid due 
to National Correct Coding Initiative (NCCI) edits if the service at issue is separate. The XU modifier is to be 
used to indicate that a service is distinct because it does not overlap usual components of the main service. You 
can find this rule at Centers for Medicare and Medicaid Services, Medicare Learning Network (MLN) Fact 
Sheet entitled Proper Use of Modifiers 59, XE, XP, XS, and XU. 
  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
pontic (D6245) and retainer crown (D6740) but is limited to one procedure code each, every five years. You 
can find this information on page 84 of the Plan's 2023 Evidence of Coverage (EOC).  
 
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 specific 
dental procedures included in a dental benefits chart. Maxillary partial denture (D5213), mandibular partial 
denture (D5214) and core buildup (D2950) are not listed as covered dental benefits. You can find this 
information on pages 82-84 of the Plan's 2023 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 painful, debilitating, osteoporotic vertebral collapse/compression fractures, that have not 
responded to non-surgical management (e.g. narcotic and/or non-narcotic medication, physical therapy 
modalities) with or without methods of immobility (e.g. bed rest, bracing). Both percutaneous 
vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA or kyphoplasty) will be considered 
reasonable and necessary for osteoporotic conditions when all of the following criteria are met: 
 
1. Acute (less than 6 weeks) or subacute (6 to 12 weeks) osteoporotic vertebral compression fracture 
(VCF) based on symptom onset, and documented by recent (within 30 days) advanced imaging (bone 
marrow edema on MRI or bone-scan/SPECT/CT uptake) and 
2. The beneficiary is symptomatic and is hospitalized with severe pain or is non-hospitalized with 
moderate to severe pain (NRS or VAS  5) despite optimal non-surgical management (NSM)
 
with one 
of the following: 
a. Worsening pain or 
b. Stable to improved pain when 2 or more of the following are present: 
- Progression of vertebral body height loss 
- More than 25% vertebral body height reduction 
- Kyphotic deformity 
- Severe impact of VCF on daily functioning  
- Steroid-induced fractures 
- Reinforcement or stabilization of vertebral body prior to surgery 
You can find this information in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L38213). 
 
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 $25 - $195 copayment for each Medicare-covered diagnostic radiology
service including a $75 copayment for Medicare-covered MRI, MRA, and Angiogram at a freestanding
provider. You can find this information on pages 84-85 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 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).

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 indicator 8 identifies the professional component of clinical laboratory codes for which 
separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. This 
applies only to code 85060. No technical component (TC) billing is recognized because payment for the 
underlying clinical laboratory test is made to the hospital, generally through the Prospective Payment System 
(PPS) rate. No payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. 
The physician interpretation is paid through the clinical laboratory fee schedule payment for the clinical 
laboratory test. 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 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 the Centers for Medicare & 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. 
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. MUEs for codes with an MAI of 3 are per day edits based on clinical 
benchmarks. 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 & Medicaid Services, Medicare National Correct Coding 
Initiative Policy Manual for Medicare Services, Chapter I(V). 
 
The rules say that CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle 
placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a 
single patient encounter regardless of the number of needle placements performed. The unit of service for these 
codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of 
injections, or number of localizations. You can find this rule in the Centers for Medicare & Medicaid Services, 
Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter IX(G-4). 
 
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.