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 B-type Natriuretic Peptide (BNP) measurements may be considered reasonable and 
necessary when used in combination with other medical data such as medical history, physical examination, 
laboratory studies, and chest x-ray.  
        to diagnose or to differentiate heart failure from other potential clinical conditions if the patients signs 
and/or symptoms are consistent with both heart failure and one or more other conditions, e.g., acute dyspnea in 
a patient with known or suspected pulmonary disease. 
        to diagnose or differentiate worsening heart failure if use of the test replaces other diagnostic tests, such as 
chest film; and/or to confirm the diagnosis when other diagnostic tests are equivocal. 
 
 Limitations: 
 
        BNP measurements must be assessed in conjunction with standard diagnostic tests, medical history and 
clinical findings. The efficacy of BNP measurement as a stand-alone test has not been established yet. 
        BNP measurements for monitoring and management of CHF are non-covered. Treatment guided by BNP 
has not been shown to be superior to symptom-guided treatment in either clinical or quality-of-life outcomes. 
        The efficacy but not the utility of BNP as a risk stratification tool (to assess risk of death, myocardial 
infarction or congestive heart failure) among patients with acute coronary syndrome (myocardial infarction 
with or without T-wave elevation and unstable angina) has been established. However, the assessment of BNP 
level has not been shown to alter patient management. The BNP is not sufficiently sensitive to either preclude 
or necessitate any other evaluation or treatment in this group of patients. 
 
        Screening examinations are statutorily non-covered. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): B-type Natriuretic Peptide 
(BNP) Testing (L34038). 
 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 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 effective for claims with dates of service July 1, 2007 and after, the non-Outpatient 
Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. 
This integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital 
claims, through a single integrated OCE eliminating the need to update two separate OCE software packages 
on a quarterly basis. The integrated OCE does not change the current logic that is applied to outpatient bill 
types that already pass through the OPPS OCE software. It merely expands the software usage to include non-
OPPS hospitals. This new software product will be referred to as the Integrated OCE (I/OCE). The I/OCE 
instructions and specifications are provided via Recurring Update Notifications. They are also posted on the 
Web at the following address 
https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs.  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 40.1. 
 
The rules say that Edit 8 is invoked when the sex of the patient does not match the sex designated for the 
procedure code reported. This edit is bypassed if condition code 45 is present on the claim. The disposition for 
this edit is "return to provider" (RTP), which means that there is one or more edits present which cause the 
entire claim to be denied and returned to the provider. A claim returned to the provider means that the provider 
can resubmit the claim once the problems are corrected. You can find this information in the Integrated OCE 
Centers for Medicare and Medicaid Services (CMS) Specifications V23.3 Effective October 1, 2022. 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, 30.2.2. 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that thyroid testing is only covered for certain diagnosis codes. You can find this list of 
diagnosis codes in the National Coverage Determination (NCD) for Thyroid Testing (190.22). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. You can find this rule at 42 CFR Section 422.111(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. The Plan 
contract also says that members are eligible to receive the following diabetic meters, and the associated test 
strips: FreeStyle test strips, FreeStyle Lite meters and test strips, FreeStyle Freedom Lite meters, Precision Xtra 
meters and test strips, Precision Xtra Beta Ketone test strips, FreeStyle Precision Neo test strips, and FreeStyle 
Precision Neo meter. You can find this information on page 56 of the Plan's 2023 Evidence of Coverage 
(EOC).