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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
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 health plans, physicians, hospitals, and other health care providers must comply with the 
Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding 
Guidelines. You can find this rule in the Medicare Claims Processing Manual, Chapter 23, Section 10. 
 
The rules say that the ICD-10-CM has two types of excludes notes. Each type of note has a different definition 
for use, but they are all similar in that they indicate that codes excluded from each other are independent of 
each other. 
a. Excludes1 
A type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. An 
Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired 
form of the same condition. 
 
An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each 
other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider. For example, code F45.8, Other somatoform disorders, has an Excludes1 note for "sleep related teeth 
grinding (G47.63)," because "teeth grinding" is an inclusion term under F45.8. Only one of these two codes 
should be assigned for teeth grinding. However psychogenic dysmenorrhea is also an inclusion term under 
F45.8, and a patient could have both this condition and sleep related teeth grinding. In this case, the two 
conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 
together. 
b. Excludes2 
A type 2 Excludes note represents Not included here. An excludes2 note indicates that the condition 
excluded is not part of the condition represented by the code, but a patient may have both conditions at the 
same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the 
excluded code together, when appropriate. You can find this in the International Classification of Diseases 
(ICD)-10-CM Official Guidelines for Coding and Reporting FY 2023 -- UPDATED April 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.