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 suppliers must add a KX modifier to the code for the manual wheelchair base only if all of 
the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section of the related 
LCD have been met and evidence of such is retained in the suppliers files and available to the DME MAC 
upon request. 
 
Claim lines billed without a KX, GA, GY, or GZ modifier will be rejected as missing information. 
 
You can find this rule in the Local Coverage Article for Manual Wheelchair Bases - Policy Article, A52497 
 
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 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 the National Correct Coding Initiative (NCCI) was developed to prevent inappropriate 
payment of services that should not be reported together. NCCI edits are organized in a Column I/Column 2 
table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of an edit 
pair, only the Column 1 code is payable. For edits with a modifier indicator of 0, the Column 2 code cannot be 
paid regardless of whether a modifier is used. You can find this in the NCCI Manual, Chapter I. 
  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). 
 
The rules say that blepharoplasty may be considered reconstructive when performed for one of the following 
conditions that may affect both upper and lower eyelids. 
To correct visual impairment caused by: 
o Dermatochalasis, including symptomatic redundant skin weighing down on the upper eyelashes 
(i.e., pseudoptosis) and surgically induced dermatochalasis after ptosis repair. 
o Blepharochalasis. 
o Blepharoptosis, including dehiscence of the aponeurosis of the levator palpebrae superioris 
muscle after trauma or cataract extraction, causing ptosis that may obstruct the superior visual 
field as well as the visual axis in downgaze (reading position). 
o Brow ptosis. It is recognized that brow ptosis repair, in addition to blepharoplasty and/or 
blepharoptosis repair, may be necessary in some cases to provide an adequate functional result. 
 
Any procedure(s) involving blepharoplasty and billed to this contractor must be supported by documented 
patient complaints which justify functional surgery. This documentation must address the signs and symptoms 
commonly found in association with ptosis, pseudoptosis, blepharochalasis and/or dermatochalasis. These 
include (but are not limited to): 
o Significant interference with vision or superior or lateral visual field, (e.g., difficulty seeing 
objects approaching from the periphery); 
o Difficulty reading due to superior visual field loss; or, 
o Looking through the eyelashes or seeing the upper eyelid skin. The visual fields should demonstrate a significant loss of superior visual field and potential correction of the 
visual field by the proposed procedures(s). A minimum 12 degree or 30 percent loss of upper field of vision 
with upper lid skin and/or upper lid margin in repose and elevated (by taping of the lid) to demonstrate 
potential correction by the proposed procedure or procedures is required. Photographs should also demonstrate 
the eyelid abnormality(ies) necessitating the procedures(s). 
 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage Article 
(LCA): Blepharoplasty - Medical Policy Article (A52837). 
 
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 suppliers must add a KX modifier to the AFO/KAFO base and addition codes only if all of 
the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section in the related 
Local Coverage Determination have been met and evidence of such is retained in the suppliers files and 
available upon request. If all of the criteria in the Coverage Indications, Limitations, and/or Medical Necessity 
section of the related LCD have not been met, the GA or GZ modifier must be added to the code. Claim lines 
billed with codes without a KX, GA or GZ modifier will be rejected as missing information. You can find this 
rule in the Local Coverage Article for Ankle-Foot/Knee-Ankle-Foot Orthoses, A52457. 
 
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 when services are furnished in a mobile unit, they are often provided to serve an entity for 
which another Place of Service (POS) code exists. For example, a mobile unit may be sent to a physician's 
office or a skilled nursing facility. If the mobile unit is serving an entity for which another POS code already 
exists, providers should use the POS code for that entity. However, if the mobile unit is not serving an entity 
which could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15. 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, 10.5. 
 
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 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. 
 
The rules say that Thermal destruction of the intraosseous BVN will be considered medically reasonable and 
necessary for the treatment of cLBP in patients who meet ALL the following criteria: 
1. Chronic lumbar back pain of 6 months duration that causes functional deficit measured on a pain or 
disability scale*, AND 
2. Documented failure to respond to 6 months of non-surgical management**, AND 
3. Absence of non-vertebrogenic pathology per clinical assessment or radiology studies that could explain 
the source of the patients pain, including but not limited to fracture, tumor, infection, or significant 
deformity, AND 
4. Evidence of Type 1 or Type 2 Modic changes on MRI, such as inflammation, edema, vertebral endplate 
changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent 
marrow, hypotensive signals (Type 1 Modic change), and changes to the vertebral body marrow 
including replacement of normal bone marrow by fat, and hypertensive signals (Type 2 Modic change), 
in 1 or more vertebrae from L3-S1. 
You can find this information in the Local Coverage Determination (LCD): Thermal Destruction of the 
Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain (L39420). 
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 commode is covered when the beneficiary is physically incapable of utilizing regular toilet 
facilities. This would occur in the following situations: 
1. The beneficiary is confined to a single room, or 
2. The beneficiary is confined to one level of the home environment and there is no toilet on that level, or 
3. The beneficiary is confined to the home and there are no toilet facilities in the home. 
You can find this information in the Local Coverage Determination (LCD): Commodes (L33736). 
 
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 a fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, 
L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, 
L5858) is covered for beneficiaries whose functional level is 3 or above. 
 
A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot 
with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot 
system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. 
 
You can find this rule in the Local Coverage Determination (LCD) for 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 state that certain cardiac event monitors capture electrical activity with a single electrode attached to 
the skin. Other devices may employ multiple electrodes in order to record more complex EKG tracings. 
Additionally, devices may be individually programmed to detect patient-specific factors, electrode malfunction, 
or other factors. Cardiac event monitors can be further categorized as either pre-event or post-event 
recorders, based on their memory capabilities: 
 
    Pre-symptom Memory Loop Recorder (MLR) 
 
    Upon detecting symptoms, the wearer presses a button, which activates the recorder to save (i.e., memorize) 
an interval of pre-symptom EKG data along with data during and subsequent to the symptomatic event. Self-
sensing recorders (also known as event-activated or automatic trigger) do not require patient input to capture 
these data. Single or multiple events may be recorded. The device is worn at all times, usually for up to 30 
days. 
        Implantable (or Insertable Loop) Recorder (ILR) 
 
    Another type of pre-symptom MLR, it is implanted subcutaneously in a patients upper left chest and may 
remain implanted for many months. An ILR is used when syncope is thought to be cardiac-related, but is too 
infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom MLR. 
 
You can find this information in the National Coverage Determination (NCD Electrocardiographic Services 
20.15. 
 
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 codes that can be billed under the ambulatory surgical center (ASC) payment system are 
assigned a payment indicator (PI) that defines the code as a payable, non-payable, or packaged service. For 
payable services, the PI description details how payment is calculated. The PI can change if the payment 
methodology applicable to the HCPCS code changes. This edit identifies a HCPCS code with an ASC payment 
indicator of N1 (packaged service/item; no separate payment made). You can find this information in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 14, Sections 20 and 60.3. 
 
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.
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 repetitive transcranial magnetic stimulation (rTMS) is only considered medically necessary 
in adults who have a confirmed diagnosis of major depressive disorder (MDD), single or recurrent episode and 
meet the following criteria: 
- One or more of the following: 
~ Resistance to treatment with psychopharmacologic agents as evidenced by a lack of a clinically 
significant response to one trial of psychopharmacologic agents in the current depressive 
episode from at least two different agent classes. Each agent in the treatment trial must have 
been administered at an adequate course of mono- or poly-drug therapy; or 
~ Inability to tolerate psychopharmacologic agents as evidenced by two trials of 
psychopharmacologic agents from at least two different agent classes, with distinct side effects; 
or 
~ History of response to rTMS in a previous depressive episode; or 
~ If patient is currently receiving electro-convulsive therapy, rTMS may be considered reasonable 
and necessary as a less invasive treatment option. 
- A trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an 
adequate frequency and duration without significant improvement in depressive symptoms as 
documented by standardized rating scales that reliably measure depressive symptoms. 
- The order for treatment (or retreatment) is written by a psychiatrist (MD or DO) who has examined the 
patient and reviewed the record. The physician will have experience in administering TMS therapy. The 
treatment shall be given under direct supervision of this physician (physician present in the area but 
does not necessarily personally provide the treatment). 
- Non-physician practitioners (NPPs) providers may order treatment (or retreatment) if it is within the 
scope of practice of the NPP in the State they are licensed. It is expected that the NPP has examined the 
patient, reviewed the record and has experience administering TMS therapy. The treatment shall be 
given under direct supervision of this NPP. 
- The rTMS treatment is delivered by a device that is Food & Drug Administration (FDA)-approved or 
cleared for the treatment of MDD in a safe and effective manner. rTMS treatment should generally follow the protocol and parameters specified in the manufacturers user manual, with modifications 
only as supported by the published scientific evidence base. 
 
You can find these rules in Local Coverage Determination (LCD) Transcranial Magnetic Stimulation 
(L33398). 
 
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 $35 copayment for a specialist visit. You can find this information on 
pages 81 to 82 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 professional component (PC)/technical component (TC) indicator of 3 is a technical 
component only code. This indicator identifies standalone 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 test only. It also identifies codes that are covered only as diagnostic 
tests and therefore do not have a related professional code. Modifiers 26 and TC cannot be used with these 
codes. The total relative value units for technical component only codes include values for practice expense and 
malpractice expense only. 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 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.