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 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 procedure codes with a status indicator of P are bundled/excluded codes. There are no RVUs 
and no payment amounts for these services. No separate payment is made for them under the fee schedule. You 
can find this rule in the Center for Medicare Services (CMS), Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. Medicare 
uses another code for reporting of, and payment for, these services. You can find this rule in Centers for 
Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 23, Section 30.2.2. 
 
The rules say that where a single anesthesia procedure involves both a physician medical direction service 
and the service of the medically directed qualified nonphysician anesthetist, the payment amount for the 
service of each is 50 percent of the allowance otherwise recognized had the service been furnished by the 
anesthesiologist alone. For the single medically directed service, the physician will use the QY modifier and the qualified nonphysician anesthetist will use the QX modifier.  
 
In unusual circumstances when it is medically necessary for both the CRNA and the anesthesiologist to be 
completely and fully involved during a procedure, full payment for the services of each provider is allowed. 
The physician would report using the AA modifier and the CRNA would report using the QZ modifier. 
Documentation must be submitted by each provider to support payment of the full fee. You can find these rules 
in the Medicare Claims Processing Manual, Chapter 12, Section 140.4.2. 
 
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 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 Centers for Medicare and 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. Codes with an MAI of 2 have been rigorously reviewed and vetted within 
CMS and obtain this MAI designation because units of service on the same date of service (DOS) in excess of 
the MUE value would be considered impossible because it was contrary to statute, regulation, or subregulatory 
guidance. 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(V). 
 
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 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. 
 
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 
preventative and comprehensive services which are listed in the Plan's contract with identifying procedure 
codes. Services and codes not listed are not covered. Covered resin-based fillings include codes D2330, D2331, 
D2332, D2391, D2392 and D2392. You can find this information on pages 110-114 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 state that the coverage indications for myocardial perfusion imaging (MPI) are: 
1. Acute myocardial infarction (AMI) - MPI is not typically performed during the acute period of 
myocardial infarction (MI), if the diagnosis is established by other means. In selected patients, imaging 
is appropriate in the assessment of: 
- Disease severity 
- Risk assessment and/or prognosis 
- Efficacy of acute reperfusion therapy 
- Evidence of myocardial salvage 
- Suspected infarction when the combination of history and other tests is not diagnostic. 
2. Unstable angina - MPI may be useful as an adjunct to other tests in the diagnosis or treatment of 
unstable angina only when the combination of history and other tests is not diagnostic. In selected 
patients, imaging is appropriate for: 
- Identification of ischemia in the distribution of a known lesion or in remote areas 
- Identification of the severity/extent of disease in patients with medically unstable angina or 
ongoing ischemia 
- Measurement of left ventricular function (LVF). 
3. Chronic ischemic heart disease - The use of MPI is well established in the diagnosis and management of 
coronary artery disease (CAD) and is covered in these situations: 
- Diagnosis of CAD, especially in patients with atypical chest pain 
- Evaluation of abnormal or suspected false positive stress electrocardiogram (ECG) 
- Evaluation of other symptoms suspicious for the diagnosis of CAD such as syncope and 
ventricular arrhythmia 
- Assessment of myocardial viability after revascularization or medical management 
- Planning percutaneous transluminal coronary angioplasty (PTCA) to identify lesions causing 
ischemia, if unknown 
- Evaluation of suspected or known CAD prior to high risk surgical procedure 
- Identification of the presence, location, extent, and severity of myocardial ischemia 
- Assessment of drug therapy 
- Assessment of symptoms suggesting restenosis following PTCA 
- Assessment of symptoms suggesting ischemia following Coronary Artery Bypass Graft (CABG) 
- Follow up of symptomatic ischemic heart disease 4. Congenital heart disease (CHD) - Echo is the method of choice for evaluating patients with known or 
suspected CHD. Selected patients may benefit from MPI when assessing for: 
- Diagnosis of anomalies of the coronary circulation 
- Kawasakis disease 
5. Post-transplant cardiac disease 
- Assessment of coronary arteriopathy 
- Evaluation for ventricular dysfunction with post-transplant rejection 
 
You can find these rules in Local Coverage Determination (LCD) Cardiac Radionuclide Imaging (L33457). 
 
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 
crown (D2740) and core buildup (D2950) but is limited to one procedure every five years. You can find this 
information in the dental rider to 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 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. Mandibular partial denture (D5226) is not listed as a 
covered dental benefit. You can find this information in the dental rider to 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 repeat epidural steroid injections (ESIs) when the first injection directly and significantly 
provided improvement of the condition being treated may be considered medically reasonable and necessary 
when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement 
in function measured from baseline using same scale for at least three months. If a patient fails to respond well 
to the initial ESI, a repeat ESI after 14 days can be performed, using a different approach, level and/or 
medication if appropriate, with the rationale and medical necessity for the second ESI documented in the 
medical record. You can find this information in Local Coverage Determination (LCD): Epidural Steroid 
Injections for Pain Management (L39242). 
 
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 total knee arthroplasty is considered reasonable and necessary for individuals with one or 
more of the following: 
 
1. Advanced joint disease and all of the following: 
 
a. The joint disease is evidenced by conventional radiography, or magnetic resonance imaging (MRI); and 
b. Pain or functional disability attributable to the advanced joint disease; and 
c. Unsuccessful non-surgical medical management, when appropriate, and attempted for a minimum of 3 
months. (When non-surgical medical management is not appropriate, the medical record must clearly document 
the basis for that conclusion); 
 
2. Failure of a previous osteotomy; or 
3. Distal femur fracture; or 
4. Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; or 
5. Failure of previous unicompartmental knee replacement; or 
6. Avascular necrosis of the knee; or 
7. Proximal tibia fracture 
 
You can find this rule in the Local Coverage Determination (LCD) - Total Joint Arthroplasty (L36039) - 
Effective October 10, 2019. 
 
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 pharmacogenomics (PGx) tests are indicated when medications are being considered for use 
(or already being administered) that are medically necessary, appropriate, and approved for use in the patients 
condition and are known to have a gene(s)-drug interaction that has been demonstrated to be clinically 
actionable as defined by the FDA (PGx information required for safe drug administration) or Clinical 
Pharmacogenetic Implementation Consortium (CPIC) guidelines (category A and B). The selection of the 
medications in question must be derived from clinical factors/necessity rather than from a PGx test. Once the 
putative therapeutic agents are selected, and those agents are known to have gene-drug interactions as 
identified above, then a PGx test may be considered reasonable and necessary when the result of that test is 
necessary for the physicians decision-making process regarding safely administering or dosing the drug. 
 
PGx testing is not considered reasonable and necessary merely on the basis of a patient having a particular 
diagnosis. Unless the record reflects that the treating clinician has already considered non-genetic factors to 
make a preliminary drug selection, PGx testing is not considered reasonable and necessary. You can find this 
information in the Local Coverage Determination (LCD): MolDX: Pharmacogenomics Testing (L38394). 
 
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 DME to only those preferred brands and 
manufacturers, as long as the following conditions are met (42 CFR 422.100(l)): 
 
 The MA plan provides all categories of DME covered under original Medicare Part B; 
 The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
 The MA plans contracted suppliers provide access to all preferred DME brands; 
 During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 
90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year; 
 Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
 The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
 The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the EOC and ANOC and on its website; and 
 The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by CMS to require full coverage. 
 
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. 
 
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 they cover diabetic supplies made by OneTouch/LifeScan. The Plan exclusively covers 
OneTouch/LifeScan glucose monitors and test strips. The Plan also cover OneTouch/LifeScan lancets, 
solutions, and lancing devices. The Plan does not cover other brands of monitors and test strips unless you 
or your provider requests a medical exception and it is approved. Non-LifeScan monitors and test strips without 
a medical exception, or a medical exception that is not approved, will not be covered. You can find this 
information on page 9 of the Plan's 2023 Schedule of Cost Sharing.
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 percutaneous vertebral augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP) is covered in patients with osteoporotic vertebral compression fracture (VCF) when both of 
the following: 
1. Inclusion criteria (all are required): 
a. Acute (less than 6 weeks) or subacute (6 to 12 weeks) osteoporotic VCF (T1  L5), based on 
symptom onset, and documented by advanced imaging 
b. Symptomatic (one): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score 8 or greater) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS 5 or greater) despite 
optimal non-surgical management (NSM)(one): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still 5 or greater) (with 2 or more of 
the following): 
A. Progression of vertebral body height loss 
B. Grater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) greater than 17 
c. Continuum of care (Both are required) 
i. All patients presenting with VCF should be referred for evaluation of bone mineral 
density (BMD) and osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program. 
2. Exclusion criteria (Can have none of the following): 
a. Absolute contraindication 
1. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
2. Osteomyelitis, discitis or active systemic or surgical site infection 
3. Pregnancy 
b. Relative contraindication 
1. Greater than three vertebral fractures per procedure 
2. Allergy to bone cement or opacification agents 3. Uncorrected coagulopathy 
4. Spinal instability 
5. Myelopathy from the fracture 
6. Neurologic deficit 
7. Neural impingement 
8. Fracture retropulsion/canal compromise 
 
Vertebral augmentation and Kyphoplasty for vertebral compression fractures with intractable spinal pain 
secondary not relieved with medical therapy will be covered for osteolytic vertebral metastatic disease or 
myeloma involving a vertebral body. You can find these rules in Local Coverage Determination (LCD) 
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38201). 
 
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.