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 modifiers XE, XS, XP, XU were effective January 1, 2015. These modifiers were developed 
to provide greater reporting specificity in situations where modifier 59 was previously reported and may be 
used in lieu of modifier 59 whenever possible. Modifier XP means a service that is distinct because it was 
performed by a different practitioner. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E (e). 
  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 Original Medicare pays for the routine costs of qualifying clinical trials. Medicare also pays 
for reasonable and necessary items and services used to diagnose and treat complications arising from 
participation in all clinical trials. The rules also say that Medicare plans must cover these services even if they 
are not available through in-network providers. Medicare plans may require reporting when enrollees 
participate in clinical trials but cannot require prior authorization or approval. You can find these rules in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National 
Coverage Determinations Manual, Chapter 1, Section 310.1.  
 
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 also says that a clinical research study or clinical trial is a way that doctors and scientists test new 
types of medical care. They test new medical care procedures or drugs by asking for volunteers to help with the 
study. This kind of study is one of the final stages of a research process that helps doctors and scientists see if a 
new approach works and if it is safe. 
 
An enrollee who is in a clinical research study may stay enrolled in the Plan and continue to get the care that is 
not related to the study through the Plan. Enrollees must tell the plan before they start participating in a clinical 
research study. 
 
If an enrollee participates in a Medicare-approved study, Original Medicare pays most of the costs for the 
covered services received as part of the study. After Medicare has paid its share of the cost for these services, 
the Plan will also pay for part of the costs. The Plan will pay the difference between the cost-sharing in 
Original Medicare and the cost-sharing as a member of the Plan. This means the enrollee will pay the same 
amount for the services received as part of the study as he or she would if these services were received from the 
Plan. You can find this information on pages in Chapter 3 on pages 39 to 40 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 repeat thermal facet joint radio frequency ablation (RFA) at the same anatomic site is 
considered medically reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform 
previously painful movements and activities of daily living (ADLs) as compared to baseline measurement 
using the same scale. You can find this information in 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. 
 
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 carriers must pay a set-up component for each radiologic procedure (other than retakes of the 
same procedure) during both single patient and multiple patient trips under Level II HCPCS code Q0092. 
Carriers do not make the set-up payment for EKG services furnished by the portable x-ray supplier.  
 
The transportation component (Codes R0070-R0076) represents the transportation of the equipment to the 
patient. Establish local RVUs for the transportation R codes based on Medicare Administrative Contractor 
(MAC) knowledge of the nature of the service furnished. The MACs shall allow only a single transportation 
payment for each trip the portable x-ray supplier makes to a particular location. If only one patient is served, 
R0070 should be reported with no modifier since the descriptor for this code reflects only one patient seen. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 13, Sections 90.3 and 90.4. 
 
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 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. The surgical removal of erupted tooth is covered by the Plan's dental benefits. You can find this 
information on pages 81 to 84 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 Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
requested item or service but is limited to once every 5 years. You can find this information in Chapter 4 on 
page 53 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 type of NMES that is used to enhance the ability to walk of SCI patients is commonly referred to as 
functional electrical stimulation (FES). Coverage of NMES to treat muscle atrophy is limited to the treatment 
of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, 
and other non-neurological reasons for disuse atrophy. Some examples would be casting or splinting of a limb, 
contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery. You can find this 
information in the National Coverage Determination (NCD) Neuromuscular Electrical Stimulation (NMES) 
160.12. 
 
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 the date of service (DOS) for laboratory tests must be the date the specimen was collected. 
One exception is testing on stored specimens which only changes the DOS if it would be medically 
inappropriate to have collected the sample other than during the hospital procedure for which the patient was 
admitted. There are other exceptions for chemotherapy sensitivity testing on live tissue and advanced 
diagnostic laboratory/molecular pathology tests. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
16, Section 40.8. 
 
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 a 
$1,500 annual dental allowance amount for covered dental services. You can find this information on page 73 
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 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 beginning January 1, 2023, the CPT is merging the two E/M visit families currently titled 
Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services and Home Services. The new 
family will be titled Home or Residence Services. The codes in this family (CPT codes 99341  99350) will 
be used to report E/M services furnished to a patient residing in their home, in an assisted living facility, in a 
group home (that is not licensed as an intermediate care facility for individuals with intellectual disabilities), in 
a custodial care facility, or in a residential substance abuse treatment facility. There are no changes to the 
included care settings from each respective family, rather the current care settings for each of the current 
families are being included within the new, merged family. For services in an intermediate care facility for 
individuals with intellectual disabilities and services provided in a psychiatric residential treatment center, see 
Nursing Facility Services in Section 30.6.13. Physicians and qualified nonphysician practitioners (NPPs) 
furnishing E/M services to residents in a living arrangement described by one of the POS listed above must use 
the level of service code in the CPT code range 99341 - 99350 to report the service they provide. You can find 
this rule in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.14. 
 
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 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 effective for claims with dates of service July 1, 2007 and after, the non-Outpatient 
Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. 
This integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital 
claims, through a single integrated OCE eliminating the need to update two separate OCE software packages 
on a quarterly basis. The integrated OCE does not change the current logic that is applied to outpatient bill 
types that already pass through the OPPS OCE software. It merely expands the software usage to include non-
OPPS hospitals. This new software product will be referred to as the Integrated OCE (I/OCE). The I/OCE 
instructions and specifications are provided via Recurring Update Notifications. They are also posted on the 
Web at the following address 
https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs.  
 
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 40.1. 
 
The rules say that Edit 62 is invoked when a procedure code has a Not recognized by Medicare for OPPS 
indicator. Services with a status indicator of B always return edit 62. Note: Edit 62 is bypassed if the bill type is 
022x or 023x with or without condition code 07. The disposition for this edit is "return to provider" (RTP), 
which means that there is one or more edits present which cause the entire claim to be denied and returned to 
the provider. A claim returned to the provider means that the provider can resubmit the claim once the 
problems are corrected. You can find this information in the Integrated OCE Centers for Medicare and 
Medicaid Services (CMS) Specifications V24.0 Effective July 1, 2023. 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 to be eligible for bariatric surgery the patient must have a body-mass index (BMI) at least 35, 
and at least one co-morbidity related to obesity. Further, the documentation must clearly demonstrate the 
  
  failure of reasonable non-invasive/non-surgical treatments for obesity with which the beneficiary has been 
compliant.  
 
Noridian considers the following, based on national guidelines for bariatric care, to be the minimum 
specifications to be documented in the patient record in order to demonstrate the beneficiary has been 
previously unsuccessful with medical treatment for obesity as required by the NCD (100.1): 
 
1. The beneficiary has been previously unsuccessful with medical treatments for obesity. The latter 
includes but is not limited to: active participation within the last 12 months prior to bariatric surgery in 
a weight-management program that is supervised by a physician or other health care professionals for a 
minimum of four consecutive months. The weight-management program must include monthly 
documentation of patients weight and body mass index (BMI), current dietary regimen and physical 
activity (e.g., exercise program). 
2. Physician-supervised programs consisting exclusively of pharmacological management are not 
sufficient to meet this requirement. 
3. A thorough multidisciplinary evaluation is required within the previous six months which 
includes all of the following: 
a. an evaluation by a bariatric surgeon recommending surgical treatment, including a description of 
the proposed procedure(s) 
b. a separate medical evaluation from a physician other than a surgeon and preferably the 
beneficiarys primary care physician that includes both a recommendation for bariatric surgery 
as well as a medical clearance for the proposed bariatric surgery 
c. mental health and psychosocial clearance for bariatric surgery by a mental health provider 
including a statement regarding motivation and ability to follow post-surgical requirements 
d. a nutritional evaluation by a physician or registered dietician. 
 
You can find this information in Local Coverage Article: Billing and Coding: Bariatric Surgery Coverage 
(A53028). 
 
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 global surgery package of procedures with a global period of 10 or 90 days includes all 
additional medical or surgical services required of the surgeon during the postoperative period of the surgery 
because of complications which do not require additional trips to the operating room, follow-up visits during 
the postoperative period of the surgery that are related to recovery from the surgery, among other related 
services. Not included in the global surgery payment are clearly distinct surgical procedures during the 
postoperative period which are not re-operations or treatment for complications. These services should be 
billed with modifier -79. 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 40.1. 
 
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.