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 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 specific 
dental procedure codes included in a dental benefits chart. Treatment of root canal obstruction (D3331) is not 
listed as a covered dental benefit. You can find this information on pages 119-121 of the Plans 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 routine 
preventive and comprehensive dental care, but services must be performed by a general dentist or periodontist. 
You can find this information on page 63 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 state that if an independent lab bills for services, the place where the sample was taken is reported as 
the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of 
service. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.6. 
 
The rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other 
supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two 
exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or 
outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You 
can find this information in the MLN Matters article number MM7631, Revised and Clarified Place of Service 
(POS) Coding Instructions. 
 
The rules say that a laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
The rules say that Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
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 280.3(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, 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 in Chapter 3 on page 39 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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules also say that Medicare plans must make reasonable and diligent efforts to gather and forward 
information to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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 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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
A panniculectomy is considered medically necessary when the panniculus hangs below the level of the pubis, 
and the medical records document that the panniculus causes chronic intertrigo (dermatitis occurring on 
opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over 3 months while 
receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of 3 
months. 
 
If the procedure is being performed following significant weight loss, in addition to meeting the criteria noted 
above, there should be evidence that the individual has maintained a stable weight for at least 3 to 6 months. If 
the weight loss is the result of bariatric surgery, abdominoplasty/panniculectomy should generally not be 
performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the 
most recent 3 to 6 months. 
 
The Plan does not cover abdominoplasty or panniculectomy when performed primarily for any of the following 
indications, because it is considered not medically necessary (this list may not be all-inclusive): 
 Treatment of neck or back pain 
 Improving appearance (i.e., cosmesis) 
 Repairing abdominal wall laxity or diastasis recti 
 Treating psychological symptomatology or psychosocial complaints  When performed in conjunction with abdominal or gynecological procedures (e.g., abdominal hernia 
repair, hysterectomy, obesity surgery) unless criteria for panniculectomy and abdominoplasty are met 
separately 
Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L33428). 
 
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 a heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets 
one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does 
not exceed 600 pounds. 
 
An extra heavy-duty hospital bed (E0302, E0304) is covered if the beneficiary meets one of the criteria for a 
hospital bed and the beneficiary's weight exceeds 600 pounds. 
 
These rules are found in Local Coverage Determination (LCD): Hospital Beds And Accessories (L33820). 
 
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 the Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 30.2.2. 
 
The rules also say that the global surgery package of a minor procedure with a 0- or 10-day global period 
includes preoperative evaluation and management (EM) services on the day of surgery. Visits by the same 
physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, 
unless a significant, separately identifiable service is also performed. Modifier "-25" is used to facilitate billing 
of evaluation and management services on the day of a procedure for which separate payment may be made. 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication Number 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40. 
 
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 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 in Chapter 4 on pages 57 to 58 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 modifiers were established to simplify billing for visits and other procedures which are 
furnished during the postoperative period of a surgical procedure, but which are not included in the payment 
for the surgical procedure. Modifier -24 is used to report an unrelated evaluation and management service by 
same physician during a postoperative period. The physician may need to indicate that an evaluation and 
management service was performed during the postoperative period of an unrelated procedure. This 
circumstance is reported by adding the modifier -24 to the appropriate level of evaluation and management 
service. Services submitted with the -24 modifier must be sufficiently documented to establish that 
the visit was unrelated to the surgery. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.2. 
 
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 state that to report a service for molecular syndromic panels for infectious disease pathogen 
identification testing, please submit the following claim information: 
- The appropriate procedure code 
- The appropriate accompanying diagnosis code. Tests with other indicated uses may therefore submit a 
Z-Code and undergo a Technical Assessment (TA) by MolDX. 
- Tests that are Food & Drug Administration (FDA) approved/cleared and performed in ways consistent 
with their intended use labelling directions do not require a Z-code when billed with the appropriate 
diagnosis code. However, the performance of multiple molecular infectious disease pathogen 
identification tests on the same date of service for the same intended use on the same patient sampel is 
considered as one distinct service. As such, it would require the use of code 87999. Tests using code 
87999 will require a Z-Code and a Technical Assessment (TA). 
- Add modifier -59 for different species or strains reported by the same code. 
- 1 unit of service 
- The appropriate DEX Z-Code 
 
You can find these rules in Local Coverage Article (LCA) Billing and Coding: MolDX: Molecular Syndromic 
Panels for Infectious Disease Pathogen Identification Testing (A58720). 
 
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 covers services in an emergency department only if the emergency clinic is 
affiliated with a hospital. You can find this rule at Social Security Act, Section 1861, 42 CFR Section 489.24, 
and 42 CFR Section 413.65. 
 
The rules say that Medicare is creating additional flexibilities to allow licensed independent freestanding 
emergency departments (EDs) to participate in Medicare and Medicaid to help address the urgent need to 
increase hospital capacity to provide care to patients. The ways to participate include the following: 
1. Becoming affiliated with a Medicare/Medicaid-certified hospital under the temporary expansion 1135 
emergency waiver. 
2. Participating in Medicaid under the clinic benefit if permitted by the State, or 
3. Enrolling temporarily as a Medicare/Medicaid-certified hospital to provide hospital services. You can 
find this information in The Centers for Medicare and Medicaid Services (CMS) Guidance for Licensed 
Independent Freestanding Emergency Departments (EDs) to Participate in Medicare and Medicaid during the 
COVID-19 Public Health Emergency (PHE). 
 
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 claims or claim lines that have been determined to be exact duplicates of another claim or 
claim line are denied. However, such denials may be appealed. An exact duplicate for physician and other 
supplier claims is a claim that exactly matches another claim or claim line with respect to, among other items, 
provider number, date of service, procedure code, place of services, and billed amount. You can find this rule 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 1, Section 120.2. 
 
The rules say that "Physicians in the same group practice who are in the same specialty must bill and be paid as 
though they were a single physician. If more than one evaluation and management (face-to-face) service is 
provided on the same day to the same patient by the same physician or more than one physician in the same 
specialty in the same group, only one evaluation and management service may be reported unless the 
evaluation and management services are for unrelated problems. Instead of billing separately, the physicians 
should select a level of service representative of the combined visits and submit the appropriate code for that 
level. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.5. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $0 copayment for virtual visit services provided by an in-network 
provider. You have the option of getting these services through an in-person visit or by telehealth. If you 
choose to get one of these services by telehealth, you must use a network provider who offers the service by 
telehealth. You can find this information on page 98 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 state that panels with greater than 5 respiratory pathogens performed in the Part B outpatient setting 
are considered not medically reasonable and necessary. You can find this information in Local Coverage 
Determination (LCD): Respiratory Pathogen Panel Testing (L38918). 
 
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.