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 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 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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 
 
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 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 payment is made under the physician fee schedule for technical component (TC) services 
furnished in institutional settings where the TC service is not bundled into the facility payment, e.g., an 
ambulatory surgery center (ASC). 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual Publication 100-04, Medicare Claims Processing Manual Chapter 12, Section 60.B.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 some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the 
left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for 
both the left and right side.  If the side is not identified in the medical record, assign the code for the 
unspecified side. 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 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 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: 
 
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 that the following ICD-10 codes support medical necessity and provide coverage for CPT 
codes: 00100, 00124, 00148, 00160, 00164, 00300, 00322, 00400, 00410, 00454, 00520, 00522, 00524, 00530, 
00532, 00635, 00640, 00702, 00731, 00732, 00842, 00920, 00921, 01130, 01380, 01420, 01490, 01680, 01730, 
01780, 01782, 01820, 01829, 01860, 01916, 01920, 01922, 01930, 01937, 01938, 01939, 01940, 01941, 01942, 
01991, 01992, and 01999. 
 
E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene 
 
You can find this rule in the Medicare Local Coverage Article (LCA)-A57361, BILLING AND CODING: 
MONITORED ANESTHESIA CARE. 
 
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 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 43 of the 2021 and 2022 
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 Medicare has developed Medically Unlikely Edits (MUEs) to reduce errors in claims 
payment. An MUE is the maximum units of a service that a provider would report under most circumstances 
for a single patient on a single date of service. Codes with a MUE are assigned a MUE Adjudication Indicator 
(MAI). The MAI describes the type of MUE.  Codes with a MAI of 1 mean that the MUE is applied at the 
claim line level.  Appropriate use of modifiers to report the same code on separate lines of a claim will enable 
the reporting of medically necessary units of service in excess of the MUE. You can find this rule at Centers for 
Medicare and Medicaid Services, Noridian Healthcare Solutions article entitled Medically Unlikely Edits. 
 
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that they have a link that will take you to a list of Part B Drugs that may be subject to step 
therapy. You can find this information in Chapter 4 on page 74 of the Plan's 2022 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 a positron emission tomography (PET) scan is considered reasonable and necessary in 
patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet 
diagnostic criteria for both Alzheimers Disease (AD) and Frontotemporal Dementia (FTD). These patients 
have been evaluated for specific alternative neurodegenerative diseases or other causative factors, but the cause 
of the clinical symptoms remains uncertain. You can find this rule in National Coverage Determination (NCD) 
FDG PET for Dementia and Neurodegenerative Diseases (220.6.13). 
 
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 thrombophilia (or hypercoagulability) is the propensity to develop thrombosis due to either 
an acquired or inherited defect in the coagulation system. The major clinical manifestation of thrombophilia is 
VTE. Acquired thrombophilia risk factors include but are not limited to advancing age (> 50), trauma, 
malignancy, chemotherapy, major surgery, immobilization, pregnancy, estrogen, inflammation, 
antiphospholipid antibody syndrome, myeloproliferative disorders, heparin-induced thrombocytopenia, liver 
disease, nephrotic syndrome and prolonged air travel. Inherited thrombophilia risk factors include deficiencies 
in antithrombin, Protein C, Protein S, mutation in FVL and F2, and dysfibrinogenemias. Mixed or unknown 
risk factors include hyperhomocysteinemia, elevated levels of Factor VIII, acquired Protein C resistance in the 
absence of Factor V Leiden, and elevated levels of Factors IX and XI. 
 
Genetic testing is available for a number of types of inherited thrombophilia, including mutations in the FVL, 
F2 and the MTHFR genes. However, the clinical utility of testing is uncertain. The clinical utility of genetic 
testing depends on the ability of testing results to change management that results in improved clinical 
outcomes. The clinical utility of genetic testing for thrombophilia is based on the overall risk of 
thromboembolism and the risk/benefit ratio of treatment, primarily with anticoagulants. 
 
During the previous 5 years, a number of guidelines and/or position statements on testing for thrombophilia 
have been published. In 2011, The Evaluation of Genomic Applications in Practice and Prevention Working 
Groups (EGAPP) addressed genetic testing for FVL and F2 mutations. The expert consensus recommended: 
 
    There is no evidence that knowledge of FVL/F2 mutation status in patients with VTE affects anticoagulation 
treatment to avoid recurrence; 
    There is convincing evidence that anticoagulation beyond three months reduces recurrence of VTE, 
regardless of mutation status; 
    There is no evidence that knowledge of FVL/F2 mutation status among symptomatic family members of 
patients with VTE leads to anticoagulation aimed at avoiding initial episodes of VTE (See note). 
 
Note: The Medicare benefit applies only to individuals with signs and symptoms of disease. There is no 
Medicare benefit for assessment of thrombosis risk in asymptomatic patients (aka screening for inherited 
thrombophilia) or in asymptomatic individuals whose relatives have documented inherited thrombophilia. 
 
You can find this information in the Local Coverage Determination (LCD) MolDX: Genetic Testing for 
Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) L36400.  
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 a provider/supplier shall not report multiple HCPCS/CPT codes if a single HCPCS/CPT code 
exists that describes the services. This type of unbundling is incorrect coding. HCPCS/CPT codes include all 
services usually performed as part of the procedure as a standard of medical/surgical practice. A 
provider/supplier shall not separately report these services simply because HCPCS/CPT codes exist for them. 
You can find this information in the National Correct Coding Initiative (NCCI) Coding Policy Manual for 
Medicare Services; Chapter X Pathology and Laboratory Services CPT Codes 80000 - 89999. 
 
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 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 $35 copayment for diagnostic procedures and tests provided in a 
specialists office. You can find this information on page 71 of the Plan's 2022 Evidence of Coverage (EOC). 
 
The Plan contract says that enrollees must pay 20% coinsurance for drugs that are covered under Part B of 
Original Medicare. You can find this information on page 70 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 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 molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage when ALL 
of the following criteria are met: 
 
Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are 
unavailable or results are clearly equivocal; AND 
Availability of a clinically valid test, based on published peer reviewed medical literature; AND 
Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed test) or 
LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) of analytical 
validity and clinical utility; AND 
Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND 
For testing panels, including but not limited to, multiple genes or multiple conditions, and in cases where a 
tiered approach/method is clinically available, testing would be covered ONLY for the number of genes or test 
that are reasonable and necessary to obtain necessary information for therapeutic decision making; AND 
Individual has not previously received genetic testing for the disease/condition. (In general, diagnostic genetic 
testing for a disease should be performed once in a lifetime.) Exceptions include clinical scenarios whereby 
repeat testing of somatically-acquired mutations (for example, pre- and post- therapy) may be required to 
inform appropriate therapeutic decision-making. 
 Limitations: 
 Any procedures required prior to cell lysis should be reported separately and utilization must be clearly 
supported based on the application and clinical utility. Such claims may be subject to prepayment medical 
review. The medically necessary interpretation and report of a molecular pathology test, written by a 
pathologist, which is above and beyond the report of standard laboratory results may not be reported by Non- 
physician practitioners (e.g., PhD, scientists etc.); only physicians are eligible to report this service. 
Testing for quality assurance component of the service is not separately billable. You can find this information 
in Medicare's Local Coverage Determination (LCD): Molecular Pathology Procedures (L35000). 
 
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 payment may be made for a one-time ultrasound screening for AAA for beneficiaries who 
meet the following criteria: (i) receives a referral for such an ultrasound screening from the beneficiarys 
attending physician, physician assistant, nurse practitioner or clinical nurse specialist; (ii) receives such 
ultrasound screening from a provider or supplier who is authorized to provide covered ultrasound diagnostic 
services; (iii) has not been previously furnished such an ultrasound screening under the Medicare Program; and 
(vi) is included in at least one of the following risk categories-- (I) has a family history of abdominal aortic 
aneurysm; (II) is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or (III) is a 
beneficiary who manifests other risk factors in a beneficiary category recommended for screening by the 
United States Preventive Services Task Force regarding AAA, as specified by the Secretary of Health and 
Human Services, through the national coverage determination process. You can find this information in the 
Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services, Section 110.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.