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 The rules say that modifier XU is used to indicate an Unusual Non-Overlapping Service, the 
use of a service that is distinct because it does not overlap usual components of the main service. When used 
appropriately, this modifier may allow for separate payment of codes that would normally be bundled into 
payment for other codes under the National Correct Coding Initiative (NCCI) Edits. You can find this rule in 
the Centers for Medicare and Medicaid Services, MLN Fact Sheet entitled "Proper Use of Modifiers 59, XE, 
XP, XS, and XU." 
 
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 presumptive drug testing may be reported with CPT codes 80305-80307. These codes differ 
based on the level of complexity of the testing methodology. Only one code from this code range may be 
reported per date of service. Definitive drug testing may be reported with HCPCS codes G0480-G0483 and 
G0659. These codes differ based on the number of drug classes including metabolites tested. Only one code 
from this group of codes may be reported per date of service. You can find this information in the Centers for 
Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare 
Services, Chapter X(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 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). 
 
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 rules say the 
implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic 
intractable pain; with respect to item a, other treatment modalities (pharmacological, surgical, physical, or 
psychological therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or 
contraindicated for the given patient; patients have undergone careful screening, evaluation and diagnosis by a 
multidisciplinary team prior to implantation. (Such screening must include psychological, as well as physical 
evaluation); all the facilities, equipment, and professional and support personnel required for the proper 
diagnosis, treatment training, and follow up of the patient (including that required to satisfy item c) must be 
available; and demonstration of pain relief with a temporarily implanted electrode precedes permanent 
implantation. You can find this information in Medicares National Coverage Determination  Electrical Nerve 
Stimulators 160.7.
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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 36 one-way trips, combined in and out-of-network, each year. You can find this information on 
page 119 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 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 National Correct Coding Initiative (NCCI) was developed to prevent inappropriate 
payment of services that should not be reported together. NCCI edits are organized in a Column I/Column 2 
table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of an edit 
pair, only the Column 1 code is payable. For edits with a modifier indicator of 0, the Column 2 code cannot be 
paid regardless of whether a modifier is used. You can find this in the NCCI Manual, Chapter I. 
 
The rules say that diagnosis codes with 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 note is used when two conditions 
cannot occur together. You can find this rule at Centers for Medicare and Medicaid Services, ICD-19-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 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 
coverage for specific dental items/services stated in the Plans contract. A core buildup, including any pins 
when required (D2950) is not covered. You can find this information on pages 60-61 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 state that disposable drug delivery systems, including elastomeric infusion pumps (A4305, A4306, 
A9274) 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 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 modifier XU  is used to indicate an Unusual Non-Overlapping Service, the use of a service 
that is distinct because it does not overlap usual components of the main service. When used appropriately, 
this modifier may allow for separate payment of codes that would normally be bundled into payment for other 
codes under the National Correct Coding Initiative (NCCI) Edits. You can find this rule in the Centers for 
Medicare and Medicaid Services, MLN Fact Sheet entitled "Proper Use of Modifiers 59, XE, XP, XS, and 
XU." 
 
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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
The rules say that definitive drug testing is indicated when: 
1. The results of the screen are presumptively positive. 
2. Results of the screen are negative, and this negative finding is inconsistent with the patient's medical history. 
3. This test may also be used, when the coverage criteria of the policy are met and there is no presumptive test 
available, locally and/or commercially, as may be the case for certain synthetic or semi-synthetic opioids. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD): Drug Testing (L34645). 
 
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 SNF providers must bill the appropriate Type of Bill code on their claims.  The fourth digit 
of the Type of Bill code is called a 'frequency' code.  When the fourth digit of the Type of Bill code is a 0, the 
provider is indicating that this is a nonpayment/zero payment claim.  This is used when the provider does not 
anticipate payment for the bill, but it is informing the payer about a period of non-payable confinement.  You 
can find this rule at Centers for Medicare and Medicaid Services, Internet-only Publication 100-04, Medicare 
Claims Processing Manual, Transmittal 1775, Change Request 6478. 
 
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)/ Healthcare Common Procedure Coding System (HCPCS) 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 I means that this code is not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment for, these services. 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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 12 one-way trips to a plan-approved location. You can find this information on pages 108-109 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 
periodic oral evaluation and prophylaxis but is limited to one routine cleaning in a calendar year. Cleanings are 
limited to one per calendar year: you may choose from either a routine cleaning (Category A) or a periodontal 
cleaning (Category B). You can find this information on page 62 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 Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 they cover hearing aids (includes digital hearing aids). The Plan contract also says that 
the Plan pays up to a $5,000 allowance for hearing aids every 3 years. The Plan contract also says that the 
hearing aid benefit includes an allowance toward the purchase, fitting and professional maintenance or repair as 
required by the manufacturer of the device, of the most basic hearing aid(s) that will compensate for the loss of 
function. You can find this information on pages 87 and 139 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 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 not make separate payment for EKG interpretations performed or ordered as 
part of, or in conjunction with, visit or consultation services. The EKG interpretation codes that are bundled in 
this way are 93000, 93010, 93040, and 93042. Virtually, all EKGs are performed as part of or ordered in 
conjunction with a visit, including a hospital visit. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
12, Section 20.3(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 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 contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information in Chapter 4 on pages 102 to 104 of the Plan's 2023 Evidence of Coverage.