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 outpatient services which are related to a hospital admission and are provided by the hospital 
(or entity wholly owned or wholly operated by the hospital) occurring on the date of an inpatient admission, or 
during the 3 calendar days (or 1 calendar day) immediately preceding the date of an inpatient admission must 
be billed with the inpatient admission. You can find this information in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 
90.7. 
 
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 state that Facet Joint Interventions generally consist of four types of procedures: Intraarticular (IA) 
Facet Joint Injections, Medial Branch Blocks (MBB), Radiofrequency Ablations (RFA) and Facet cyst 
rupture/aspiration: 
 
Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of 
chronic pain in patients who meet ALL the following criteria: 
 
Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured 
on pain or disability scale* 
Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint 
synovial cyst) 
There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the 
patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
One to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or 
four-level procedure bilaterally may be considered under unique circumstances and with sufficient 
documentation of medical necessity on appeal. A session is a time period, which includes all procedures (i.e., 
medial branch block (MBB), intraarticular injections (IA), facet cyst ruptures, and RFA ablations that are 
performed during the same day. 
 
You can find this information in the Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management L35936. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 BRCA1 and BRCA2 genetic testing for susceptibility to breast or ovarian cancer is covered 
in adults as medically necessary when there is a personal history of breast or ovarian cancer or ANY of the 
following indications: 
 Personal history of epithelial ovarian, fallopian tube, or primary peritoneal cancer; 
 Personal history of male breast cancer; 
 Personal history of pancreatic cancer or prostate cancer with Gleason score =7 at any age, =1 close 
blood relatives* with breast (=50 y), invasive ovarian, pancreatic cancer, or prostate cancer with 
Gleason score =7 at any age; 
 Personal history of pancreatic cancer at any age with Ashkenazi Jewish ancestry (Begin testing with 
Ashkenazi Jewish founder specific mutations). If negative, complete analysis should be performed. 
Complete analysis may be considered if an 
You can find this rule at Local Coverage Determination (LCD) L36499: BRCA1 and BRCA2 Genetic Testing 
(eff. 12/10/20). 
 
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 effective January 01, 2015 (V16.0), the submission of a device-intensive procedure also 
requires that a device be submitted on the same claim/day. If any device-intensive procedure is submitted 
without a code for a device on the same claim with the same date of service, the claim is returned to the 
provider (edit 92). Discontinued procedures (indicated by the presence of modifier 52, 73 or 74 on the line) are 
not edited for a missing device code. Effective 1/1/2019 (v20.3), certain device-intensive procedures codes are 
applicable for bypassing edit 92 if an insertion of a device is not completed (e.g., revision only). For the edit to 
be bypassed a device procedure on the BYPASS_E92_MODIFIER list is reported with modifier CG. For a 
list of applicable device procedures, reference the corresponding bypass column in the DATA_HCPCS table in 
the quarterly data files. You can find this rule in the Integrated OCE (IOCE) CMS Specifications V24.1 
Effective April 01, 2023, Section 5.6. 
 
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 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 a bilateral surgery indicator of 1 indicates that there is 150% payment adjustment for 
bilateral procedures. If code is billed with the bilateral modifier base payment for these codes when reported as 
bilateral procedures on the lower of: (a) the total actual charge for both sides, or (b) 150 percent of the fee 
schedule amount for a single code. 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 
50.6. 
 
Modifiers LT and RT apply to codes that identify procedures that can be performed on paired organs, e.g., ears, 
eyes, nostrils, kidneys, lungs, and ovaries. These modifiers should be used whenever a procedure is performed 
on only one side. Hospitals should report the appropriate RT or LT modifier to identify which of the paired 
organs was operated upon. Do not report modifiers RT and LT when modifier 50 applies. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 4, Section 20.6.3. 
 
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.
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 3-3 to 3-7 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 coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that an axial rotation unit (L5984) is covered for beneficiaries whose functional level is 2 or 
above. You can find this rule in the Local Coverage Determination (LCD) - Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
The rules say that L5988 describes an endoskeletal pylon device that allows vertical shock reduction between 
the foot and pelvis during ambulation. The vertical shock reducing pylon feature of L5988 is a separate 
function from other products which use a piston/telescoping mechanism such as products described by L5781 
or L5782. The predicate product is the Total Shock that was manufactured by Century XXII International, Inc. 
You can find this rule in the Local Coverage Article (LCA) - 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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c).  
 
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 also says that routine vision services have a $200 single-purchase annual allowance for eyewear 
through the Plan's Vision provider. You can find this information on page 83 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 state that payment may not be made if therapy services are provided to either a hospital outpatient or 
a hospital inpatient by a physical therapist, occupational therapist, or speech-language pathologist in private 
practice. You can find this rule at Centers for Medicare and Medicaid Services, Internet-Only Publication 100-
04, Medicare Claims Processing Manual Chapter 5, Section 10. 
 
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 modifier -52 is used to indicate partial reduction or discontinuation of radiology procedures 
and other services that do not require anesthesia. You can find this rule in the Centers for Medicare and 
Medicaid Services (CMS) Manual System, Pub. 100-04 Medicare Claims Processing, Transmittal 442, Change 
Request 3507, Effective January 21, 2005. 
 
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 as of October 1, 2018, the GT modifier is only allowed on institutional claims billed under 
CAH Method II. If the GT modifier is billed under any circumstances, except as just outlined for Method II 
CAHs, the claim line will be rejected. You can find this rule in the Medicare Learning Network (MLN) Matters 
Number: MM10583 Revised. 
 
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 P means that these codes are bundled/excluded. 
There are no relative value units (RVUs) and no payment amounts for these services. No separate payment 
should be 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. 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 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. 
 
The rules say that A cystourethroscopy (e.g., CPT code 52000) or cystourethroscopy with ureteroscopy (e.g., 
CPT code 52351) performed near the termination of an intra-abdominal, intra-pelvic, or retroperitoneal surgical 
procedure to assure that there was no intraoperative injury to the ureters or urinary bladder and that they are 
functioning properly is not separately reportable with the surgical procedure. You can find this rule in the 
Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter VII. 
 
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 CPT codes 87483 (Multiplex infectious agent detection by nucleic acid methodology for 
central nervous system pathogens), 87505-87507 (Multiplex infectious agent detection by nucleic acid 
methodology for gastrointestinal pathogens), and 87631-87633 (Multiplex infectious agent detection by nucleic 
acid methodology for respiratory virus) describe multiplex testing procedures for multiple microorganisms 
using reverse transcription and/or amplified probe techniques. The codes describe an anatomic region and the 
number of targets tested. 
 
If one of these multiplex tests is performed and additional testing by these methodologies for additional 
microorganisms that might cause disease in the anatomic region described by the code descriptor is performed, 
only one multiplex testing code summing the testing for all targets shall be reported. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National Correct 
Coding Initiative (NCCI) Manual, Chapter 10, Section K(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 state that if a laboratory procedure produces multiple reportable test results, only a single code shall 
be reported for the procedure. If there is no code that describes the procedure, the laboratory shall report a 
miscellaneous or unlisted procedure code with a single unit of service. You can find this rule in the Centers for 
Medicare and Medicaid Services, National Correct Coding Initiative Policy Manual, Chapter X (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 a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and 
necessary. You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage 
Determination L33735 entitled Cold Therapy. 
 
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 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 ultraviolet cabinets are covered for selected patients with generalized intractable psoriasis. 
Using appropriate consultation, the MAC should determine whether medical and other factors justify treatment 
at home rather than at alternative sites, e.g., outpatient department of a hospital. You can find this rule in 
National Coverage Determination (NCD) Durable Medical Equipment Reference List 280.1. 
 
The rules say that psoriasis is a chronic skin disease, for which several conventional methods of treatment have 
been recognized as covered. These include topical application of steroids or other drugs; ultraviolet light 
(actinotherapy); and coal tar alone or in combination with ultraviolet B light (Goeckerman treatment). A newer 
treatment for psoriasis uses a psoralen derivative drug in combination with ultraviolet A light, known as 
PUVA. PUVA therapy is covered for treatment of intractable, disabling psoriasis, but only after the psoriasis 
has not responded to more conventional treatment. The Medicare Administrative Contractor should document 
this before paying for PUVA therapy. You can find this rule in National Coverage Determination (NCD) 
Treatment of Psoriasis 250.1. 
 
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.