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 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 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 effective for services performed on and after October 24, 2006, the Centers for Medicare & Medicaid Services has determined that there is sufficient evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act (the Act). The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. There are no indications for which this service is covered. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, National Coverage Determinations (NCD) Manual: Infrared Therapy Devices (270.6).
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.
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 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 effective for services performed on and after October 24, 2006, the Centers for Medicare & Medicaid Services has determined that there is sufficient evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act (the Act). The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. There are no indications for which this service is covered. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, National Coverage Determinations (NCD) Manual: Infrared Therapy Devices (270.6).
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).
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 CT scans are covered if there is literature to support its use for the patient's condition and the scan is reasonable and necessary for the patient. 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 220.1(A).
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 in accordance with code descriptor changes for HCPCS code G0416 effective January 1, 2015, CMS requires that surgical pathology, including gross and microscopic examination, of any and all submitted prostate needle biopsy specimens from a single patient be reported with one unit of service of HCPCS code G0416 rather than CPT code 88305. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter X (L).
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. 
The Physician Fee Schedule Status Indicator P means these 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. 
 
If the item or service is covered as incident to a physician service and is provided on the same day as a 
physician service, payment for it is bundled into the payment for the physician service to which it is incident 
(an example is an elastic bandage furnished by a physician incident to a physician service). 
 
If the item or service is covered as other than incident to a physician service, it is excluded from the fee 
schedule (for example, colostomy supplies) and is paid under the other payment provision of the Act. 
 
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. 
 
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. 
Thyroid function tests are used to define hyper function, euthyroidism, or hypofunction of thyroid disease. 
Thyroid testing may be reasonable and necessary to: 

- Distinguish between primary and secondary hypothyroidism; 
- Confirm or rule out primary hypothyroidism; 
- Monitor thyroid hormone levels (for example, patients with goiter, thyroid nodules, or thyroid cancer); 
- Monitor drug therapy in patients with primary hypothyroidism; 
- Confirm or rule out primary hyperthyroidism; and 
- Monitor therapy in patients with hyperthyroidism. 

Thyroid function testing may be medically necessary in patients with disease or neoplasm of the thyroid and 
other endocrine glands. Thyroid function testing may also be medically necessary in patients with metabolic 
disorders; malnutrition; hyperlipidemia; certain types of anemia; psychosis and non-psychotic personality 
disorders; unexplained depression; ophthalmologic disorders; various cardiac arrhythmias; disorders of 
menstruation; skin conditions; myalgias; and a wide array of signs and symptoms, including alterations in 
consciousness; malaise; hypothermia; symptoms of the nervous and musculoskeletal system; skin and 
integumentary system; nutrition and metabolism; cardiovascular; and gastrointestinal system. 
It may be medically necessary to do follow-up thyroid testing in patients with a personal history of malignant 
neoplasm of the endocrine system and in patients on long-term thyroid drug therapy. 

The rules state that thyroid testing billed with code 84443 is coverable when billed with certain diagnosis codes 
indicating that the testing is not performed for screening purposes. Diagnosis codes R25.2, R60.0, E11.9, and 
Z79.899 are listed as diagnosis codes that supports medical necessity for procedure code 84443.  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, Medicare National Coverage Determinations Manual, Section 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 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 
specified dental codes with benefit limitations. The Plan covers code D6010 twice every calendar year and 
once per tooth every 5 calendar years. The Plan covers code D6057 twice every calendar year and once per 
tooth every 5 calendar years. The Plan covers code D6075 twice every calendar year and once per tooth every 5 
calendar years.  Codes D6011, D7951, and D9630 are not included in the Plans dental benefits. You can find 
this information in Chapter 4 on pages 90 to 102 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 beginning on April 1, 2013, Medicare CMS introduced the Medically Unlikely Edit (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." MUEs for codes with an MAI of 3 are "per day edits based on clinical benchmarks." Codes with an MAI of "3" are based on criteria combined with data such that it would be possible, but medically unlikely, that higher values would represent correctly reported medically necessary services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, were correctly coded, and were medically necessary.
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).
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 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 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).
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 pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
The rules say a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered. 
  
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 (LCA): Wheelchair Options/Accessories 
(A52504). 
 
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 
requested item or service but is limited to 1 per calendar year. You can find this information in Chapter 4 on 
page 113 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 the 
periodic oral evaluation, intraoral radiographic images, bitewings, and cleanings but the periodic exams are 
limited to 2 procedure codes per calendar year, the intraoral radiographic images are limited to 1 procedure 
code per calendar year, bitewings are limited to 1 set per calendar year, and cleaning are limited to 2 procedure 
codes per calendar year. The limited oral evaluation and core buildup are not covered by the Plan's dental 
benefits. You can find this information on pages 78 to 79 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 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 $30 copayment for in-network Medicare-covered non-radiological 
diagnostic services. You can find this information on pages 4-41 to 4-45 of the Plan's 2022 Evidence of 
Coverage (EOC).