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 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. The periodontal scaling and root planing is not covered by the Plan's dental benefits. You can 
find this information on pages 81 to 82 of the Plans 2022 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 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.  
 
The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
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 Plan 
contract says that enrollees must pay a $350 copayment for outpatient hospital services. You can find this 
information on page 101 of the Plan's 2022 Evidence of Coverage (EOC). 
 
The Plan contract also says that drugs that usually are not self-administered are covered. You can find this 
information on page 94 of the Plan's 2022 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 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 state that virtual colonoscopy is only indicated in those patients in whom a diagnostic or surveillance 
instrument colonoscopy of the entire colon is incomplete due to an inability to fully pass the colonoscope 
proximally, and a repeat attempt is not indicated, or in patients with a valid contraindication to the safe 
performance of an instrument colonoscopy. Incomplete colonoscopy must be due to 1 of the following: 
 
1. An obstructing neoplasm 
 
2. Intrinsic scarring, stricture, aberrant anatomy, or obstruction from prior surgery, radiation, or diverticular 
disease 
 
3. Extrinsic compression 
 
There are few absolute contraindications to instrument colonoscopy. Relative contraindications do not create 
medical necessity for using computed tomography (CT) colonography as a screening procedure, and the above 
indications must still be met. 
 
The following relative contraindications to instrument colonoscopy may be indications for CT colonography if 
well documented in the medical record: 
 
Severe coagulopathy 
Long-term anticoagulation 
Increased sedation risk (such as from severe chronic obstructive pulmonary disease (COPD) or previous 
anesthesia adverse reaction) 
 
CT colonography is not covered when used for screening, or in the absence of signs or symptoms of disease, 
regardless of family history or other risk factors for the development of colonic disease. 
 
CT colonography is not covered when used as an alternative to instrument colonoscopy for screening or in the 
absence of signs or symptoms of disease. 
 
CT colonography is not covered following incomplete colonoscopy if the reason for the colonoscopy is other 
than one of those described above. 
 CT colonography is intended for use in pre-operative planning when imaging of the non-visualized colon 
proximal to the obstruction is necessary in making decisions involving the approach to the patient. 
 
You can find these rules in Local Coverage Determination (LCD) Virtual Colonoscopy (CT Colonography) 
(L33452). 
 
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 if an attendant control (E2331) is provided in addition to a beneficiary-operated drive 
control system, it will be denied as non-covered. 
 
You can find this information in the Local Coverage Article Wheelchair Options/Accessories (A52504). 
 
The rules state that code E1028 (swingaway or removable mounting hardware upgrade) may be billed in 
addition to codes E0953, E0955, E0956, and E0957. It must not be billed in addition to code E0960. It must not 
be used for mounting hardware related to a wheelchair seat cushion or back cushion code. 
 
You can find this information in the Local Coverage Article Wheelchair Seating (A52505). 
 
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  
intraoral - periapical each additional radiographic image (D0230) but is limited to 1 procedure code per 
calendar year. This benefit also includes the prophylaxis - adult (D1110) but is limited to 2 procedure codes per 
calendar year. You can find this information on page 87 of the Plan's 2022 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 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 a table 
of covered dental services. Dental services not listed in the table are not covered under any condition. A 
prefabricated abutment and abutment supported cast metal crown are not among the services covered by the 
Plan's dental benefits. The Plan says to approve a bridge you must be missing only one upper front tooth or 
only two lower front teeth. You also cannot be missing any of your back teeth. You can find this information in 
Chapter 4 on pages 95 to 102 of the Plans 2022 Evidence of Coverage (EOC) and in the 2022 Office 
Reference Manual maintained by the Plans dental benefit administrator.
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 
an incisional biopsy of oral tissue. You can find this information on page 41 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 accessories, including but not limited to, trans-tracheal catheters (A4608), cannulas (A4615), 
tubing (A4616), mouthpieces (A4617), face tent (A4619), masks (A4620, A7525), oxygen conserving devices 
(A9900), oxygen tent (E0455), humidifiers (E0555), nebulizer for humidification (E0580), regulators (E1353), 
and stand/rack (E1355) are included in the allowance for rented oxygen equipment. The supplier must provide 
any accessory ordered by the treating practitioner. Accessories used with beneficiary-owned oxygen equipment 
will be denied as non-covered. You can find this rule in the Local Coverage Article Oxygen and Oxygen 
Equipment - Policy Article A52514. 
 
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. 
 
The rules 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. The Plan 
contract says that enrollees must pay a $45 copayment for each Medicare-covered acupuncture visit from an  
in-network and out-of-network provider. You can find this information on pages 72-73 of the Plan's 2022  
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 also 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. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Claims Processing Manual Chapter 4, Section 40.1. 
 
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 for a custom fabricated seat or back cushion (E2609, E2617), a KX modifier must be added 
to the code only if criterion (a) is met and criterion (b), (c), or (d) is met: 
 
    a. For E2609 or E2617, there is a comprehensive written evaluation by a licensed/certified medical 
professional, such as a PT or OT (who has no financial relationship with the supplier) which explains why a 
prefabricated seating system is not sufficient to meet the beneficiarys seating and positioning needs; and 
 
    b. For E2609, there is a past history of, or current, pressure ulcer in the area of contact with the seating 
surface; or 
 
    c. For E2609, there is absent or impaired sensation in the area of contact with the seating surface or an 
inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis for skin 
protection cushions (refer to the ICD-10 code list section); or 
 
    d. For E2609 or E2617, the beneficiary has significant postural asymmetries due to one of the diagnoses 
listed as a covered diagnosis for positioning cushions (refer to the ICD-10 code list section). 
 
In addition to meeting the specific requirements listed above, for all seat and back cushions and positioning 
accessories, the KX modifier must be added to the code only if the item is being used with a wheelchair that 
meets coverage criteria specified in the Manual Wheelchair Bases or Power Mobility Devices LCD. 
When billing for a custom fabricated cushion (E2609, E2617), the claim must include the manufacturer and 
model name/ number of the product (if applicable), or if not, a detailed description of the product that was 
provided. 
 
A custom fabricated seat cushion (E2609) and a custom fabricated back cushion (E2617) are cushions that are 
individually made for a specific beneficiary starting with basic materials including: 
 
    a. liquid foam or a block of foam and 
 
    b. sheets of fabric or liquid coating material 
 
 
 The cushion must have structural features that significantly exceed the minimum requirements for a seat or 
back positioning cushion. The cushion must have a removable vapor permeable or waterproof cover, or it must 
have a waterproof surface. A custom fabricated cushion may include certain prefabricated components (e.g., 
gel or multi-cellular air inserts); these components must not be billed separately. If a custom fabricated seat and 
back are integrated into a one-piece cushion, code as E2609 plus E2617. 
 
You can find these rules in the Local Coverage Article Wheelchair Seating - Policy Article A52505. 
 
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 some international classification of diseases, tenth edition, clinical modification (ICD-10-
CM) codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no 
bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If 
the side is not identified in the medical record, assign the code for the unspecified side. You can find this rule 
in the 2022 ICD-10-CM Diagnosis Codebook, Section 1.B.13. 
 
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.