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 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. The modifier XU is defined as an unusual non-overlapping service; the use of a service that is distinct 
because it does not overlap usual components of the main service. 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(E). 
 The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing 
procedure, the lab shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 
If no CPT code accurately describes the procedure performed, the lab may report CPT code 81479 with one 
unit of service. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be 
reported for the procedure. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare 
National Correct Coding Initiative Manual, Chapter X(F). 
 
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 following indications are covered for implanted permanent single chamber or dual 
chamber cardiac pacemakers: 
1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and 
2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree 
atrioventricular block. 
The following indications are non-covered for implanted permanent single chamber or dual chamber cardiac 
pacemakers: 
1. Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and 
hypothermia, 
2. Asymptomatic first degree atrioventricular block, 
3. Asymptomatic sinus bradycardia, 
4. Asymptomatic sino-atrial block or asymptomatic sinus arrest, 
5. Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without 
symptomatic bradycardia, 
6. Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are 
prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of 
the His Bundle (a component of the electrical conduction system of the heart), 
7. Syncope of undetermined cause, 
8. Bradycardia during sleep, 
9. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch 
block) without syncope or other symptoms of intermittent atrioventricular block, 
10. Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-
blocker drug therapy, 
11. Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the 
control of tachycardia, and 12. A clinical condition in which pacing takes place only intermittently and briefly, and which is not 
associated with a reasonable likelihood that pacing needs will become prolonged. 
You can find this rule at the Medicare National Coverage Determination (NCD) 20.8.3: Cardiac Pacemakers: 
Single Chamber and Dual Chamber Permanent Cardiac Pacemakers. 
 
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 when treatment for complications requires a return trip to the operating room, physicians 
must bill the CPT code that describes the procedure(s) performed during the return trip. When this subsequent 
procedure is related to the first procedure and requires the use of the operating room, this circumstance may be 
reported by adding the modifier "-78" to the related procedure. 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 40.2.A(5). 
 
The rules say that physicians report the appropriate modifier to denote whether the service meets the 
requirements for payment at the personally performed rate, medically directed rate, or medically supervised 
rate. The contractor must determine payment for anesthesia in accordance with these instructions. They must be 
able to determine the uniform base unit that is assigned to the anesthesia code and apply the appropriate 
reduction where the anesthesia procedure meets the requirements for payment at the medically directed rate. 
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 50(I). 
 
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 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. You can find this rule in the 2023 international classification of 
diseases, tenth edition, clinical modification (ICD-10-CM) Diagnosis Codebook, Section I.A(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 say that a manual wheelchair for use inside the home (E1037, E1038, E1039, E1161, K0001, K0002, 
K0003, K0004, K0005, K0006, K0007, K0008, K0009) is covered if: 
 Criteria A, B, C, D, and E are met; and 
 Criterion F or G is met. 
A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, 
grooming, and bathing in customary locations in the home. A mobility limitation is one that: 
  1.  Prevents the beneficiary from accomplishing an MRADL entirely, or 
  2.  Places the beneficiary at reasonably determined heightened risk of morbidity or mortality 
secondary to the attempts to perform an MRADL; or 
  3.  Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
B. The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately 
fitted cane or walker. 
C. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for 
use of the manual wheelchair that is provided. 
D. Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in 
MRADLs and the beneficiary will use it on a regular basis in the home. 
E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the 
home. 
F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities 
needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. 
Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or 
absence of one or both upper extremities are relevant to the assessment of upper extremity function. G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the 
wheelchair. 
You can find this rule at Local Coverage Determination (LCD) L33788: Manual Wheelchair Bases (eff. 
1/1/20). 
 
The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). 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(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.
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 botulinum toxins are potent neuromuscular blocking agents that are useful in treating various 
focal muscle spastic disorders and excessive muscle contractions, such as dystonia, spasms, and twitches. They 
produce a presynaptic neuromuscular blockade by preventing the release of acetylcholine from the nerve 
endings. Since the resulting chemical denervation of muscle produces local paresis or paralysis, selected 
muscles can be treated. Botulinum toxins are used in the treatment of overactive skeletal muscles (for example, 
Hemifacial spasm, dystonia and spasticity), smooth muscles (for example, Detrusor overactivity and achalasia), 
glands (for example, Sialorrhoea and hyperhidrosis) and additional conditions that are being investigated. 
There are currently four botulinum toxin products commercially available in the United States: 
onabotulinumtoxinA, rimabotulinumtoxinB, abobotulinumtoxinA, and incobotulinumtoxinA. Each preparation 
has distinct pharmacological and clinical profiles specified on the product insert. Dosing patterns are specific to 
the preparation of neurotoxin and varies between different serotypes. Failure to recognize the unique 
characteristics of each formulation of botulinum toxin can lead to undesired patient outcomes. It is expected 
that physicians will be familiar with and experienced in the use of these agents and utilize evidence-based 
medicine to select the appropriate drug and dose regimen for each patient condition. A patient who is not 
responsive or who ceases to respond to one serotype may respond to the other. 
You can find this information in the Local Coverage Determination (LCD) for Botulinum Toxin Type A & 
Type B (L34635). 
 
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 pages 34-39 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 an air-fluidized bed is covered only if all of the following criteria are met: 
1. The beneficiary has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure 
ulcer (Refer to the ICD-10 codes in the LCD-related Policy Article for applicable diagnoses). 
2. The beneficiary is bedridden or chair bound as a result of severely limited mobility. 
3. In the absence of an air-fluidized bed, the beneficiary would require institutionalization. 
4. The air-fluidized bed is ordered in writing by the beneficiarys treating practitioner based upon a 
comprehensive assessment and evaluation of the beneficiary after completion of a course of 
conservative treatment designed to optimize conditions that promote wound healing. The evaluation 
generally must be performed within one month prior to initiation of therapy with the air-fluidized bed. 
5. The course of conservative treatment must have been at least one month in duration without progression 
toward wound healing. This month of prerequisite conservative treatment may include some period in 
an institution as long as there is documentation available to verify that the necessary conservative 
treatment was rendered. Conservative treatment must include: 
a. Frequent repositioning of the beneficiary with particular attention to relief of pressure over bony 
prominences (usually every 2 hours); and 
b. Use of a Group 2 support surface to reduce pressure and shear forces on healing ulcers and to 
prevent new ulcer formation; and 
c. Necessary treatment to resolve any wound infection; and 
d. Optimization of nutrition status to promote wound healing; and 
e. Debridement by any means, including wet-to-dry gauze dressings, to remove devitalized tissue 
from the wound bed; and 
f. Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings 
protected by an occlusive covering, while the wound heals. 
In addition, conservative treatment should generally include: 
g. Education of the beneficiary and caregiver on the prevention and management of pressure 
ulcers; and 
h. Assessment by a physician, nurse, or other licensed healthcare practitioner at least weekly, and 
i. Appropriate management of moisture/incontinence. 
You can find this rule at Local Coverage Determination (LCD) L33692: Pressure Reducing Support Surfaces - 
Group 3 (eff. 5/1/21). 
 
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 Centers for Medicare & Medicaid Services (CMS) payment policy does not allow separate 
payment for multiple methods to test for the same analyte. You can find this rule in the Local Coverage Article 
Billing and Coding: Molecular Pathology and Genetic Testing, A58917. 
 
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 for durable medical equipment, the general rule is that the date of service is equal to the date 
of delivery. However, pre-discharge delivery of items intended for use upon discharge are considered provided 
on the date of discharge. If the supplier leaves the item with the beneficiary two days prior to the date of 
discharge, and if the supplier, as a practical matter, need do nothing further to effect the delivery of the item to 
the beneficiary's home (because the beneficiary or a caregiver takes it home), then the date of discharge is 
deemed to be the date of delivery of the item. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 
110.3.2. 
 
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 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 An OPPS payment status indicator is assigned to every HCPCS code. The status indicator 
identifies whether the service described by the HCPCS code is paid under the OPPS and if so, whether payment 
is made separately or packaged. The status indicator may also provide additional information about how the 
code is paid under the OPPS or under another payment system or fee schedule. For example, services with 
status indicator A are paid under a fee schedule or payment system other than the OPPS. Services with status 
indicator N are paid under the OPPS, but their payment is packaged into payment for a separately paid service. 
Services with status indicator T are paid separately under OPPS but a multiple procedure payment reduction 
applies when two or more services with a status indicator of T are billed on the same date of service. 
You can find this rule in the Centers for Medicare & Medicaid Services, Medicare Claims Processing Manual, 
Chapter 4, Section 10.1.1. 
 
The rules say that Composite APCs provide a single payment for a comprehensive diagnostic and/or treatment 
service that is defined, for purposes of the APC, as a service typically reported with multiple HCPCS codes. 
When HCPCS codes that meet the criteria for payment of the composite APC are billed on the same date of 
service, CMS makes a single payment for all of the codes as a whole, rather than paying individually for each 
code. You can find this rule in the Centers for Medicare & Medicaid Services, Medicare Claims Processing 
Manual, Chapter 4, Section 10.2.1. 
 
The rules also say that a service that is assigned to a composite APC is a major component of a single episode 
of care. The hospital receives one payment through a composite APC for multiple major separately identifiable services. Services mapped to composite APCs are assigned status indicator Q3. See the discussion of composite 
APCs in section 10.2.1. You can find this rule in the Centers for Medicare & Medicaid Services, Medicare 
Claims Processing Manual, Chapter 4, Section 10.4. 
 
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.