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 state that on claims for the first through third months, suppliers must add a KX modifier to codes for 
PAP equipment (E0470 or E0601) and accessories only if all of the criteria in the Coverage Indications, 
Limitations, and/or Medical Necessity section of the related LCD ("Initial Coverage") have been met. 
 
On the fourth months claim (and any month thereafter), the supplier must add a KX modifier to codes for PAP 
equipment (E0470 or E0601) and accessories only if both the "Initial Coverage" criteria and the "Continued 
Coverage" criteria in the Coverage Indications, Limitations, and/or Medical Necessity section of the related 
LCD have been met. 
 
Claim lines billed without a GA, GZ or KX modifier will be rejected as missing information. 
 
You can find this rule in the Local Coverage Article (LCA) for Positive Airway Pressure (PAP) Devices for the 
Treatment of Obstructive Sleep Apnea - Policy Article (A52467). 
 
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 Covered Indications 
 
Functional blepharoplasty procedures and surgical procedures of the brow  will be considered medically 
reasonable and necessary in the following situations: 
 
    When the goal of the surgery is to restore function and normalcy to a structure that has been altered by 
trauma, infection, inflammation, degeneration, neoplasia, or developmental errors or; 
    When there is interference with visual field, near or far visual impairment, or difficulty reading due to any of 
the following: 
 
        Dermatochalasis 
        Blepharochalasis 
        Blepharoptosis 
        Brow ptosis causing malposition of the upper eyelid1 and demonstrating a MRD1 (Margin reflex distance) 
of 2 mm or less 
        Looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis 
        Pseudoptosis 
        When there is visual impairment secondary to redundant skin weighing down on upper lashes resulting in 
eye strain, headache and loss of vision. 
        When there is chronic, symptomatic dermatitis3 of pretarsal skin1 caused by redundant upper lid skin 
which has not been successfully treated by conservative measures such as education regarding hygiene, 
antibiotics, etc.; or 
 
    Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual field 
impairment; or 
    When there is the presence of prosthesis difficulties in an anophthalmic socket; or 
    When there is laxity of the lower eyelid tissues causing lower eyelid ectropion resulting in eye irritation and 
inflammation and excessive tearing; or 
    When there is inward rotation of the eyelid margin causing entropion where the eyelashes are contacting the 
cornea resulting in discomfort, redness, tearing, and foreign body sensation; or 
    Lower eyelid edema, tumor or mass causing signs and symptoms of eyelid ectropion. 
 
Limitations  
    Blepharoplasty and surgical procedures of the brow performed for the sole purpose of improving 
appearances are considered not medically reasonable and necessary. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Blepharoplasty, 
Blepharoptosis Repair and Surgical Procedures of the Brow (L34028). 
 
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 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. 
 
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 for SNF care, you pay $0 copayment per day, per admission for days 1 to 20. For days 21 to 
100, you pay a $100 copayment per day, per admission.  You can find this information on page 113 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 state that providers/suppliers must report one of the following modifiers for any therapy code on the 
list of applicable therapy codes with limited exceptions. Claim lines with therapy services must include one of 
the following modifiers to distinguish the discipline of the plan of care under which the service is delivered: 
 
 GN Services delivered under an outpatient speech-language pathology plan of care; 
 GO Services delivered under an outpatient occupational therapy plan of care; or, 
 GP Services delivered under an outpatient physical therapy plan of care. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.1. 
 
The rules say that an incomplete or invalid claim may be returned to the provider if a required data element is 
not accurately entered in the appropriate field. Incomplete information is defined as missing, required or 
conditional information on a claim (e.g., no Unique Physician Identification Number (UPIN) / Provider 
Identification Number (PIN) or National Provider Identifier (NPI) when effective). Invalid information is 
complete required or conditional information on a claim that is illogical, or incorrect (e.g., incorrect UPIN/PIN 
or NPI when effective), or no longer in effect (e.g., an expired number). Required information is defined as any 
data element that is needed in order to process a claim (e.g., Provider Name, Date of Service).  You can find this this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Sections 70.2.3.2 and 80.3.1. 
 
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 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 $10 per day for other Medicare-covered laboratory tests that are not  fecal 
immunochemical tests (FIT tests). You can find this information on page 98 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 the primary indication of a diagnostic facet joint procedure is to diagnose whether the patient 
has facet syndrome. Intraarticular (IA) facet block(s) are considered reasonable and necessary as a diagnostic 
test only if medial branch blocks (MMB) cannot be performed due to specific documented anatomic 
restrictions or there is an indication to proceed with therapeutic intraarticular injections. These restrictions must 
be clearly documented in the medical record and made available upon request. 
 
Diagnostic procedures should be performed with the intent that if successful, radiofrequency ablation (RFA) 
procedure would be considered the primary treatment goal at the diagnosed level(s). 
 
A second diagnostic facet procedure is considered medically necessary to confirm validity of the initial 
diagnostic facet procedure when administered at the same level. The second diagnostic procedure may only be 
performed a minimum of 2 weeks after the initial diagnostic procedure. Clinical circumstances that necessitate 
an exception to the two-week duration may be considered on an individual basis and must be clearly 
documented in the medical record. 
 
For the first diagnostic facet joint procedure: 
 
        For the first diagnostic facet joint procedure to be considered medically reasonable and necessary, the 
patient must meet the criteria outlined under indications for facet joint interventions. 
        A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary 
in patients who meet ALL the following criteria: 
 
            The patient meets the criteria for the first diagnostic procedure; AND 
            After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 
80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) 
 
Frequency limitation: For each covered spinal region no more than four (4) diagnostic joint sessions will be 
reimbursed per rolling 12 months, in recognition that the pain generator cannot always be identified with the 
initial and confirmatory diagnostic procedure. 
 
 You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Interventions 
for Pain Management (L38803). 
 
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. 
 
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 you must visit an in-network provider to access the vision care benefit. You can find this 
information on page 97 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 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 46 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 state that disposable drug delivery systems, including elastomeric infusion pumps (A4305) are non-
covered devices because they do not meet the Medicare definition of durable medical equipment. Drugs and 
supplies used with disposable drug delivery systems are also non-covered items. You can find this information 
in the Local Coverage Article (LCA): External Infusion Pumps - Policy Article A52507. 
 
 
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 condition code G0 specifies that multiple medical visits occurred on the same day with 
the same revenue center, and that these visits were distinct and constituted independent visits. Claims are 
returned to provider when there are two or more evaluation and management (E&M) codes on the same day, on 
the same claim, with the same revenue code. You can find this rule in the Integrated Outpatient Code Editor 
(IOCE) Centers for Medicare and Medicaid Services (CMS) Specifications V23.1, Section 5.1.2. 
 
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 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 home health Notices of Admission (NOA) are required for periods of care beginning on and 
after January 1, 2022. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.1.1. 
 
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 state that code 37195  thrombolysis, cerebral, by intravenous infusion  has a professional/technical 
component (PC/TC) indicator of 5, meaning incident to other code(s). This indicator identifies codes that 
describe services covered incident to a physicians service when they are provided by auxiliary personnel 
employed by the physician and working under the physicians direct personal supervision. Payment may not be 
made by carriers for these services when they are provided to hospital inpatients or patients in a hospital 
outpatient department. Modifiers -26 and -TC cannot be used with these codes. You can find this rule in the 
2022 National Physician Fee Schedule Relative Value File. 
 
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 external infusion pumps are covered under the Durable Medical Equipment benefit. Drugs 
are only covered as a supply to a covered DME infusion pump. Drugs billed alone (without a covered pump 
being used) will be denied as statutorily noncovered (no benefit). Use A4223 for infusion supplies not used 
with a covered external infusion pump. You can find this information in the Local Coverage Article (LCA): 
External Infusion Pumps - Policy Article (A52507). 
 
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 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 CFR Section 422.112(a)(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 Plan 
contract says that you may receive your care from an out-of-network provider (a provider who is not part of our 
plans network) for most covered services using your POS option. Out-of-network providers must be Medicare-
certified. Except in limited circumstances, services received from Medicare opt-out or Medicare excluded 
providers are not a covered benefit. Prior authorization rules may still apply for services received using your 
POS option. Your costs may be higher if you use out-of-network providers or see an in-network specialist 
without a referral. You can find this information on page 42 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will 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.  
 
The rules say that all canes and crutches are billed using the specific codes listed in the Local Coverage 
Determination regardless of their stated weight capacity. Do not use code E1399 (DME, miscellaneous) to code 
any type of cane or crutch regardless of special features or weight capacity. Code E0118 describes a crutch 
substitute which can be either a device strapped to the lower leg with a platform or a device with wheels and a 
platform the beneficiary propels with their sound limb. You can find this rule in the Local Coverage Article 
Canes and Crutches - Policy Article A52459. 
 
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.