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 a disposition of claim return to provider (RTP) indicates that there are one or more edits 
present that cause the whole claim to be returned. A claim returned to the provider means that the provider can 
resubmit the claim once the problems are corrected. 
 
Codes with a status indicator E1 are non-covered under any Medicare outpatient benefit, based on statutory 
exclusion and have a disposition for RTP. You can find this rule Integrated Outpatient Code Editor (OCE), 
Centers for Medicare and Medicaid Services Specification V24.1, Sections 6.1.1 and 6.2. 
 
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 state that an Outpatient Prospective Payment System (OPPS) payment status indicator is assigned to 
every Healthcare Common Procedure Coding System (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. Services with status indicator N are paid under the OPPS, but their payment is 
packaged into payment for a separately paid service. You can find this information at the Centers for Medicare 
& Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
4, Section 10.1.1. 
 
The rules also say that STV-packaged services are services for which separate payment is made only if there is 
no service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is 
assigned status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for 
the STV-packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no 
separate payment is made for the STV-packaged service. STV-packaged services are assigned status indicator 
Q1. See the Outpatient Prospective Payment System (OPPS) Webpage at 
http://www.cms.hhs.gov/HospitalOutpatientPPS/ for identification of STV-packaged codes. You can find this 
information at the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, 
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.
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 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 also say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on 
the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes 
for both the left and right side. When laterality is not documented by the patient's provider, code assignment for 
the affected side may be based on medical record documentation from other clinicians. If there is conflicting 
medical record documentation regarding the affected side, the patient's provider should be queried for 
clarification. Codes for "unspecified" side should rarely be used, such as when the documentation in the record 
is insufficient to determine the affected side and it is not possible to obtain clarification. You can find this 
information in the ICD-10-CM Official Guidelines for Coding and Reporting, Section I, Conventions, general 
coding guidelines and chapter specific guidelines. 
 
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 blepharoplasty, blepharoptosis repair, and brow ptosis repair (brow lift) are surgeries that 
may be functional (i.e., to improve abnormal function) and therefore reasonable and necessary, or cosmetic 
(i.e., to enhance appearance). 
 
For the purposes of this policy, these surgeries (either individually or in the minimum combination required to 
achieve a satisfactory surgical outcome) are functional when overhanging skin or upper lid position secondary 
to dermatochalasis, blepharochalasis, blepharoptosis, or pseudoptosis is sufficiently low to produce a visually-
significant field restriction considered by this policy to be approximately 30 degrees or less from fixation. 
Published literature correlates this amount of field restriction with a Margin Reflex Distance (see below) of 2.0 
mm or less. 
 
You can find this information at Local Coverage Determination (LCD): Blepharoplasty, Eyelid surgery, and 
Brow repair (L36286). 
 
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 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 XU is used to indicate that a service 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, 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 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). 
 
The rules say that genetic testing of JAK2 exon 12, performed to identify PV, is medically necessary when the 
following criteria are met: 
 Genetic testing impacts medical management; and 
 Patient would meet World Health Organizations (WHO) diagnostic criteria for polycythemia vera 
(PV), if JAK2 exon 12 testing were positive; and 
 JAK2 V617F mutation analysis was previously completed and was negative. 
You can find this rule in Local Coverage Determination (LCD) MolDX: Genetic Testing for BCR-ABL 
Negative Myeloproliferative Disease L36180. 
 
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 Outpatient Prospective Payment System (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, 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 10.1.1. 
 
The rules say that STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. See 
the OPPS Webpage at http://www.cms.hhs.gov/HospitalOutpatientPPS/ for identification of STV-packaged codes. You can find this rule in the Centers for Medicare & Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 10.4(C2). 
 
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 screening tests are excluded from coverage. You can find this rule at 42 CFR Section
411.15(a)(1) and 42 CFR Section 410.64.

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 bacterial urine culture is used when a patient has clinical signs and symptoms indicative of 
a possible urinary tract infection (UTI). You can find this rule in the Centers for Medicare & Medicaid Services 
(CMS), Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) 
Manual, Section 190.12. 
 
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 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 also say that the right (RT) and left (LT) modifiers are optional on claim lines billed for wheelchair options and accessories. Effective for claims with dates of service (DOS) on or after 3/1/2019, if RT and LT modifiers are appended to claim lines billed for bilateral wheelchair options and accessories (left and right) and the unit of service of the code is "each," then bill each item on two separate claim lines with the RT modifier on one line and the LT modifier on the other, and 1 unit of service (UOS) on each claim line. If the RT and LT are appended, do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims with RTLT on the same claim line and 2 UOS will be rejected as incorrect coding. If RT and LT modifiers are not appended, then the bilateral items (left and right) with a unit of service "each" may be billed on a single claim line with 2 UOS. If bilateral items are provided and the unit of service is "pair," the LT and RT modifiers are not applicable. You can find this rule in the Local Coverage Article (LCA) for Wheelchair Options/Accessories - Policy Article (A52504).

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, if performed to facilitate the chemotherapy infusion or injection, the following services and 
items are included and are not separately billable: 
 
1. Use of local anesthesia; 
2. IV access; 
3. Access to indwelling IV, subcutaneous catheter or port; 
4. Flush at conclusion of infusion; 
5. Standard tubing, syringes and supplies; and 
6. Preparation of chemotherapy agent(s). 
 
Payment for the above is included in the payment for the chemotherapy administration service. You can find 
this rule in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual Publication 100-04, 
Medicare Claims Processing Manual, Chapter 12, Section 30.5. 
 
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 test panel is a single test with multiple components and is characterized by a single unit of
service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact that
the test reports multiple individual pathogens and/or targets. You can find this rule in the Centers for Medicare
and Medicaid Services, Local Coverage Article (LCA) Billing and Coding: MolDX: Molecular Syndromic
Panels for Infectious Disease Pathogen Identification Testing (A58710).

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 outpatient diagnostic services, such as lab tests, may require prior authorization and is the
responsibility of the provider. You can see this on page 78 of the Plans 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 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 the dental services (D0140 and D0220) but is limited to 1 procedure code per calendar year. You can 
find this information in Chapter 4 on pages 51-52, 76-77, and 82-92 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 state that payment can be made under the fee schedule for anesthesia services associated with 
multiple surgical procedures or multiple bilateral procedures. Payment is determined based on the base unit of 
the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of 
the multiple procedures. You can find this information in the Centers for Medicare & Medicaid Services, 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 12, Section 5. E. 
 
The rules also say that physicians in the same group practice who are in the same specialty must bill and be 
paid as though they were a single physician. If more than one evaluation and management (face-to-face) 
service is provided on the same day to the same patient by the same physician or more than one physician in 
the same specialty in the same group, only one evaluation and management service may be reported unless the 
evaluation and management services are for unrelated problems. You can find this information in the Centers 
for Medicare & Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing 
Manual Chapter 12, Section 30.6.5. 
 
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.