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 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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
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 Plan 
contract says that enrollees must pay a $120 copayment for urgently needed services. You can find this 
information on pages 62 to 63 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit 
must be obtained from the Plans dental vendor network. Services obtained outside of this network are not 
covered. You can find this information on page 45 of the Plans 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 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. 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. 
 
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). 
 
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. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. The only exception is as 
follows:  
 For the same date of service only one physician of the same specialty in the group practice may report code 
99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care 
services with CPT code 99292. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules state that based on information in the scientific literature, intra-operative testing may be considered 
reasonable and necessary for the following: 
- Surgery of the aortic arch, its branch vessels, or thoracic aorta, including carotid artery surgery, when 
there is risk of cerebral or spinal cord ischemia 
- Resection of epileptogenic brain tissue or tumor 
- Resection of brain tissue close to the primary motor cortex and requiring brain mapping 
- Protection of cranial nerves: 
~ Resection of tumors involving the cranial nerves 
~ Cavernous sinus tumors 
~ Microvascular decompression of cranial nerves 
~ Skull base surgery in the vicinity of the cranial nerves and surgeries of the foramen magnum 
~ Oval or round window graft 
- Endolymphatic shunt for Meniere's disease 
- Vestibular section for vertigo 
- Correction of scoliosis or deformity of spinal cord involving traction of the cord 
- Protection of spinal cord where work is performed in close proximity to cord as in the placement or 
removal of old hardware or where there have been numerous interventions 
- Spinal instrumentation requiring pedicle screws or distraction 
- Decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or 
claudication where function of spinal cord or spinal nerves is at risk 
- Spinal cord tumors and spinal fractures (with the risk of cord compression) 
- Neuromas of peripheral nerves of brachial plexus, when there is risk to major sensory or motor nerves 
- Surgery or embolization for intracranial AV malformations 
- Surgery for arteriovenous malformation of spinal cord 
- Embolization of bronchial artery AVMs or tumors 
- Cerebral vascular aneurysms 
- Surgery for intractable movement disorders 
- Arteriography, during which there is a test occlusion of the carotid artery 
- Circulatory arrest with hypothermia (does not include surgeries performed under circulatory bypass) 
- Distal aortic procedures, where there is risk of ischemia to spinal cord 
- Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks 
- Basal ganglia movement disorders 
- Surgery as a result of traumatic injury to spinal cord/brain 
- Deep brain stimulation, and 
- Certain thyroid surgeries 
 
You can find these rules in Local Coverage Determination (LCD) Intraoperative Neurophysiological Testing 
(L35003). 
 
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 the purposes of this policy, blepharoplasty, blepharoptosis repair, and brow ptosis repair 
are functional when overhanging skin or upper lid position secondary to dermatochalasis, blepharochalasis, 
blepharoptosis, or pseudoptosis is sufficiently low to produce a visually-significant field restriction considered 
by this policy to be approximately 30 degrees or less from fixation. Published literature correlates this amount 
of field restriction with a Margin Reflex Distance of 2.0 millimeters (mm) or less. You can find this 
information in Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift 
(L34194). 
 
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 
periodic oral evaluation, and prophylaxis but is limited to once per year. You can find this information in 
Chapter 4 on pages 81 and 82 of the Plan's 2022 Evidence of Coverage (EOC).   
 
The Plan contract also says that intraoral - complete series of radiographic images are not a covered service. 
You can find this information in Chapter 4 on pages 81 and 82 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 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 the plan must pay for emergency and urgently needed services. This rule applies whether the 
services are obtained in or out of the plans network. This rule applies whether or not there is prior 
authorization for the services. The rules say that an emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules 
say that urgently needed services are those needed because of an unforeseen illness or condition and it is not 
reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside 
of the service area. You can find this rule at 42 CFR Section 422.113. 
 
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 there is a $495 copayment per day for days 1-27 for out-of-network inpatient hospital care. 
You can find this information on page 59 of the 2023 Evidence of Coverage (EOC). 
 
The Plan contract says that you are covered for emergency care world-wide. You can find this information on 
page 54 of the 2023 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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information in Chapter 3 on pages 3-3 to 3-4 
of the Plan's 2021 Evidence of Coverage.
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 noninvasive stimulator device is covered only for the following indications: 
Nonunion of long bone fractures; 
Failed fusion, where a minimum of 9 months has elapsed since the last surgery; 
Congenital pseudarthroses; 
 
Effective April 1, 2000, nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical osteogenic stimulator. Serial radiographs must include a minimum of 2 sets of radiographs, each 
including multipleviews of the fracture site, separated by a minimum of 90 days. 
 
You can find this information in the Local Coverage Determination (LCD): Osteogenesis Stimulators 
(L33796). 
 
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 certain conditions have both an underlying etiology and multiple body system manifestations 
due to the underlying etiology. For such conditions, the International Classification of Diseases, Tenth 
Revision, Clinical Modification (ICD-10-CM) has a coding convention that requires the underlying condition 
be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a 
use additional code note at the etiology code, and a code first note at the manifestation code. These 
instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. You 
can find this information in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
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 there is no payment under the OPPS for services that CMS designates to be inpatient only 
services. These services have an OPPS status indicator of C in the OPPS Addendum B and are listed together 
in Addendum E of each years OPPS/ASC final rule. For the most current Addendum B and for Addendum E 
published with the OPPS notices and regulations, see http://www.cms.gov/Medicare/Medicare-Fee-for-Service- 
Payment/HospitalOutpatientPPS/index.html. 
 
Excluding the handful of exceptions discussed below, CMS does not pay for an inpatient-only service 
furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient 
hospital bill type (TOB 13X). CMS also does not pay for all other services on the same day as the inpatient 
only procedure. 
 
There are two exceptions to the policy of not paying for outpatient services furnished on the same day with an 
inpatient only service that would be paid under the OPPS if the inpatient service had not been furnished: 
 
Exception 1: If the inpatient-only service is defined in CPT to be a separate procedure and the other 
services billed with the inpatient-only service contain a procedure that can be paid under the OPPS and that 
has an OPPS SI=T on the same date as the inpatient-only procedure or OPPS SI = J1 on the same claim as 
the inpatient only procedure, then the Inpatient-only service is denied but CMS makes payment for the 
separate procedure and any remaining payable OPPS services. The list of separate procedures is available 
with the Integrated Outpatient Code Editor (I/OCE) documentation. See  http://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/. 
 
You can find this rule in the Centers for Medicare & Medicaid Services, Medicare Claims Processing Manual 
Chapter 4, Section 180.7. 
 
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 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 a private room is medically necessary where isolation of a beneficiary is required to avoid 
jeopardizing their health or recovery, or that of other patients who are likely to be alarmed or disturbed by the 
beneficiary's symptoms or treatment or subjected to infection by the beneficiary's communicable disease. You 
can find this rule in the Center for Medicare Services (CMS) Publication 100-02, Medicare Benefit Policy 
Manual, Chapter 1, Section 10.1.2. 
 
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). 
 
Effective for dates of service on and after July 1, 2011, A/B Medicare Administrative Contractors (MACs) 
shall automatically deny claim line(s) items submitted with a GZ modifier. A/B MACs shall not perform 
complex medical review on claim line(s) items submitted with a GZ modifier. 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, Section 20.9.1.1. 
 
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 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 patients 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.  
 
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 a pneumatic compression device coded with E0675 is used in the treatment of peripheral 
arterial disease. There is insufficient evidence to demonstrate that reimbursement is justified. Claims for E0675 
will be denied as not reasonable and necessary. You can find this rule in the Local Coverage Determination 
(LCD) - Pneumatic Compression Devices (L33829) - Effective January 1, 2020. 
 
The rules say that a water circulating heat pad with pump (E0217) has not been established as reasonable and 
necessary compared to a standard electric heating paid. Therefore, if E0217 is provided, it will be denied as not 
reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD) - Heating Pads 
and Heat Lamps (L33784). 
 
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.