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 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 sub-regulatory 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 protective outer surface covering systems (L5962, L5964, and L5966) are specialized covers 
intended to be worn over an existing prosthesis. They are used by a beneficiary who has special needs for 
protection against unusually harsh environmental situations where it is necessary to protect the lower limb 
prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707. They are not for 
cosmetic or convenience reasons, or for everyday usage in a typical environment. Protective outer surface 
coverings are different from the covering that is already reimbursed as part of L5704, L5705, L5706, 
and L5707. You can find these rules in the Local Coverage Article Lower Limb Prostheses - Policy Article 
A52496. 
 
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 does not include 
Incomplete endodontic therapy. You can find this information on pages 58-59 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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
The rules say that pharmacogenomics testing (PGx) testing is considered reasonable and necessary in limited 
circumstances as described below as an adjunctive personalized medical decision-making tool once a treating 
clinician has narrowed treatment possibilities to specific medications under consideration for use, or is already 
using a specified medication, based on other clinical considerations including the patients diagnosis, the 
patients other medical conditions, other medications, professional judgment, clinical science and basic science 
pertinent to the drug, and the patients preferences and values.
 
You can find this rule in Local Coverage 
Determination (LCD) MolDX: Pharmacogenomics Testing L38337. 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a segmented, calibrated gradient pneumatic compression device (PCD) (E0652) is only 
covered when the individual has unique characteristics which prevent them from receiving adequate 
  
  satisfactory pneumatic compression treatment using a nonsegmented device along with a segmented appliance 
or compression device without manual control of the pressure in each chamber. A PCD coded as E0652, is 
covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when all of the 
following are met: 
- The beneficiary has lymphedema of an extremity as defined above 
- The coverage criteria for a basic pump (E0650 or E0651) are met 
- The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the 
limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed 
to improve with a four-week trial. 
 
A PCD coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen that does not 
meet all of the requirements above is not eligible for reimbursement. PCD related accessories are eligible for 
reimbursement only when the appropriate, related base PCDs meets the applicable coverage criteria for that 
type of PCD. If the base PCD is not covered, related accessories are not eligible for reimbursement. Claims for 
related items will be denied as not reasonable and necessary. You can find these rules in Local Coverage 
Determination (LCD) Pneumatic Compression Devices (L33829). 
 
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 Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 on pages 8 and 9 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 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 on page(s) 35-37 of the Plan's 
2023 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 say that Medicare has determined for which surgical services an assistant surgeon is medically 
necessary. This information can be found in the Medicare Fee Schedule Database. If the database contains an 
assistant at surgery indicator of 1 for the surgical procedure in question, Medicare has determined that an 
assistant is not medically necessary. Assistant surgeons will not be paid for these procedures. You can find this 
rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, Medicare Claims Processing 
Manual, Chapter 12, Section 40.8. 
 
The rules say that Medicare pays for an assistant at surgery only when the procedure is authorized for an 
assistant. The assistant must be a physician, physician assistant (PA), nurse practitioner (NP) or clinical nurse 
specialist (CNS). Medicare does not pay for assistant at surgery services performed by a person who bears any 
title or license other than those listed. You can find this rule in the Centers for Medicare & Medicaid Services, 
Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 250.9.1. 
 
 
 The rules say that Medicare makes payment for an assistant at surgery when the procedure is authorized for an 
assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) 
or a clinical nurse specialist (CNS). Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon), or 82 
(when qualified resident surgeon not available) is used to bill for assistant at surgery services. When billed 
without modifier AS (PA, NP, or CNS services for assistant at surgery) the use of these modifiers indicate that 
a physician served as an assistant at surgery. Modifier AS is billed to indicate that a PA, NP, or CNS served as 
the assistant at surgery. Modifier 80, 81 or 82 must also be billed when modifier AS is billed. Claims submitted 
with modifier AS and without modifiers 80, 81 or 82 are returned to the provider (RTPd). You can find this 
rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 4, Section 250.9. 
 
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 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 
intraoral x-rays but is limited to 1 procedure code per 3 Plan years.. You can find this information on pages 
152-162 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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers a $0 copayment for up to 10 one-way trips to plan-approved locations every year. You can find this 
information on pages 51-52 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 a LTACH a hospital that has an average inpatient length of stay of greater than 25 days. You 
can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).   
 
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need 
medical care. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2. 
 
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 all the following must be present for coverage eligibility: 
 
- This test is reasonable and necessary when: 
   - the patient has either: 
      - Recurrent cancer 
      - Relapsed cancer 
      - Refractory cancer 
      - Metastatic cancer 
      - Advanced cancer (stages III or IV) 
   - AND has not been previously tested by the same test for the same genetic content 
   - AND is seeking further treatment 
- The test has satisfactorily completed a technical assessment (TA) by Molecular Diagnostic Services 
(MolDX) for the stated indications of the test 
- The assay performed includes at least the minimum genes and genomic positions required for the 
identification of clinically relevant Food and Drug Administration (FDA)-approved therapies with a companion 
diagnostic biomarker as well as other biomarkers known to be necessary for clinical decision making for its 
intended use that can be reasonably detected by the test. Because these genes and variants will change as the 
literature and drug indications evolve, they are listed separately in associated documents such as the MolDX 
TA forms. 
 
You can find this information in the Local Coverage Determination (LCD): MolDX: Next-Generation 
Sequencing for Solid Tumors (L38121). 
 
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 an Outpatient Prospective Payment System (OPPS) payment status indicator is assigned to 
every HCPCS code. The status indicator identifies whether the service described by the HCPCS code is paid 
under the OPPS and if so, whether payment is made separately or packaged. The status indicator may also 
provide additional information about how the code is paid under the OPPS or under another payment system or 
fee schedule. For example, services with status indicator A are paid under a fee schedule or payment system 
other than the OPPS. Services with status indicator N are paid under the OPPS, but their payment is packaged 
into payment for a separately paid service. Services with status indicator T are paid separately under OPPS but 
a multiple procedure payment reduction applies when two or more services with a status indicator of T are 
billed on the same date of service. You can find this rule in the Centers for Medicare & Medicaid Services, 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 10.1.1. 
 
The rules say that STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. See 
the OPPS Webpage at http://www.cms.hhs.gov/HospitalOutpatientPPS/ for identification of STV-packaged 
codes. You can find this rule in the Centers for Medicare & Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 10.4(C2). 
 
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.