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.  
 
The rules also say that an add-on code is eligible for payment only if it is reported with an appropriate primary 
procedure performed by the same practitioner. An add-on code is not eligible for payment if it is the only 
procedure reported by a practitioner. The only exception is as follows:  
 
For the same date of service only one physician of the same specialty in the group practice may report code 
99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care 
services with CPT code 99292. 
 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 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 417.414. 
 
The rules state that a non-spinal electrical osteogenesis stimulator (E0747) is covered only if any of the 
following criteria are met: 
 
1. Nonunion of a long bone fracture (see Appendices section) defined as radiographic evidence that fracture 
healing has ceased for three or more months prior to starting treatment with the osteogenesis stimulator, or 
 
2. Failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last 
surgery, or  
 
3. Congenital pseudarthrosis. 
 
Nonunion of a long bone fracture must be documented by a minimum of two sets of radiographs obtained prior 
to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each including 
multiple views of the fracture site, and with a written interpretation by a treating practitioner stating that there 
has been no clinically significant evidence of fracture healing between the two sets of radiographs. 
 
A non-spinal electrical osteogenesis stimulator will be denied as not medically necessary if none of the criteria 
above are met. 
 
You can find these rules in Local Coverage Determination (LCD) Osteogenesis Stimulators (L33796). 
 
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 L5781 describes a complete device that is an addition to a lower limb prosthesis. The 
primary function of the vacuum pump is to suspend the prosthetic limb. Additionally, products coded L5781 
provide residual limb volume management and moisture evacuation. The pump mechanism evacuates air and 
accumulated moisture between the limb and socket walls. The pump mechanism can be actuated by either 
external power and/or mechanical system(s). You can find this rule in the Local Coverage Article (LCA) - 
Lower Limb Prosthesis - Policy Article (A52496) - Effective March 21, 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 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 a harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are 
required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, 
and mounting hardware. Code E2313 is separately billable in addition to an expandable controller both at initial 
issue and with complete replacement of the expandable controller. Code K0108 must not be used for any 
component or feature of an expandable controller at the time of initial issue. The reimbursement for any type of 
complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. However, if 
individual components of the harness are replaced, code K0108 should be used. You can find these rules in the 
Local Coverage Article 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 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 procedure codes L5968, L5982, L5984, L5985, L5986, L5988, L5990 are additional features 
and/or functions that do not describe a complete prosthetic foot and may be used in combination with L5970, 
L5971, L5972, L5974, L5975, L5976, L5978, L5979, L5980, L5981, and L5987. The use of additional feature 
L-codes may also depend on the assigned K-Level modifier (K0-K4). You can find this information in Local 
Coverage Article: Lower Limb Prostheses (A52496). 
 
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, 3.3.2.1. 
 
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/B MACs (B) apply the national definition of a global surgical package to all procedures 
with the appropriate entry in Field 16 of the MFSDB. 
 
The rules say that significant, separately identifiable evaluation and management services performed by the 
same physician on the day of a procedure must be reported with modifier "-25" for separate payment. 
 
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 40.2. 
 
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 multiple medical visits on the same day in the same revenue center may be submitted on 
separate claims. Hospitals should report condition code G0 on the second claim. Appropriate reporting of 
Condition Code G0 allows for accurate payment under OPPS in this situation. The OCE contains an edit that 
will reject multiple medical visits on the same day with the same revenue code without the presence of 
Condition Code G0. You can find this rule in the Centers for Medicare & Medicaid Services, Medicare Claims 
Processing Manual, Chapter 4, Section 180.4.   
 
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 Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. You can find this rule at 42 CFR Section 422.111(a) and (b). 
 
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 these are the only covered brands of blood glucose monitors and test strips: ACCU-
CHEK manufactured by Roche, or Trividia products sometimes packaged under your pharmacys name. You 
can find this information on pages 51-52 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 ESA treatment for the anemia secondary to myelosuppressive anticancer chemotherapy in 
solid tumors, multiple myeloma, lymphoma, and lymphocytic leukemia is only reasonable and necessary under 
the following specified conditions: 
 The hemoglobin level immediately prior to initiation or maintenance of ESA treatment is < 10 g/dL (or 
the hematocrit is < 30%). 
 The starting dose for ESA treatment is the recommended FDA label starting dose, no more than 150 
U/kg/3 times weekly for epoetin and 2.25 mcg/kg/1 time weekly for darbepoetin alpha. Equivalent 
doses may be given over other approved time periods. 
 Maintenance of ESA therapy is the starting dose if the hemoglobin level remains below 10g/dL (or 
hematocrit is < 30%) 4 weeks after initiation of therapy and the rise in hemoglobin is  1g/dL 
(hematocrit  3%); 
 For patients whose hemoglobin rises < 1g/dl (hematocrit rise < 3%) compared to pretreatment baseline 
over 4 weeks of treatment and whose hemoglobin level remains < 10g/dL after the 4 weeks of treatment 
(or the hematocrit is < 30%), the recommended FDA label starting dose may be increased once by 25%. 
Continued use of the drug is not reasonable and necessary if the hemoglobin rises < 1g/dl (hematocrit 
rise < 3%) compared to pretreatment baseline by 8 weeks of treatment. 
 Continued administration of the drug is not reasonable and necessary if there is a rapid rise in 
hemoglobin > 1g/dl (hematocrit > 3%) over 2 weeks of treatment unless the hemoglobin remains below 
or subsequently falls to < 10g/dL (or the hematocrit is < 30%). Continuation and reinstitution of ESA 
therapy must include a dose reduction of 25% from the previously administered dose. 
 ESA treatment duration for each course of chemotherapy includes the 8 weeks following the final dose 
of myelosuppressive chemotherapy in a chemotherapy regimen. 
You can find this rule in the Center for Medicare Services (CMS) Publication 100-03, Medicare National 
Coverage Determination (NCD) Manual, Section 110.21. 
 
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 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 does not include 
coverage for dental service codes D7286 or D7250. You can find this information in Chapter 4 on pages 89-92 
and 95-100 of the Plans 2022 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 when submitting a prosthetic claim, the billed code for knee, foot, ankle and hip (HCPCS 
codes L5610, L5611, L5613, L5614, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, 
L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, 
L5840, L5848, L5856, L5857, L5858, L5859, L5930, L5961, L5970, L5971, L5972, L5973, L5974, L5975, 
L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987) components must be submitted 
with modifiers K0 - K4, indicating the expected beneficiary functional level. This expectation of functional 
ability information must be clearly documented and retained in the prosthetist's records. The simple entry of a 
K modifier in those records is not sufficient. There must be information about the beneficiary's history and 
current condition which supports the designation of the functional level by the prosthetist. 
 
Codes L5968, L5982, L5984, L5986 describe separate products which provide either a single motion or a 
combination of motions commonly attributed to the anatomic ankle. The use of these codes can be used to fully 
describe additional features or functions not found in the prosthetic foot system (L5969, L5970, L5971, L5972, 
L5973, L5974, L5975, L5976, L5978, L5979 L5980, L5981 and L5987). 
 
L5973 describes an endoskeletal device with integrated energy storage and release foot and microprocessor 
ankle system. The integrated microprocessor is programmable along with sensors to optimize plantar and 
dorsiflexion angles for stance and swing phase. L5973 includes foot cover, power source(s) and charger. 
 
A microprocessor ankle-foot system with power assist (BiOM Ankle-Foot System by iWalk, Inc) is coded as 
the combination of L5969 (addition, endoskeletal ankle-foot or ankle system, power assist, includes any type of 
motor(s)) and l5973 (endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or 
plantar flexion control, includes power source). You can find these rules in the Local Coverage Article Lower 
Limb Prostheses - Policy Article A52496. 
 
A microprocessor-controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot 
with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot 
system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. 
You can find this rule in the Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
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 Percutaneous Vertebral Augmentation (PVA) is only covered in patients with acute (less 
than 6 weeks) or subacute (6 to 12 weeks) osteoporotic vertebral compression fracture (VCF) based on 
symptom onset and documented by recent advanced imaging (bone marrow edema on magnetic resonance 
imaging (MRI) or bone-scan/single photon emission computed tomography (SPECT)/computed tomography 
(CT) uptake). You can find this information in the Local Coverage Determination (LCD): Percutaneous 
Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38201). 
 
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 only 
those items and services specifically listed in your Plan contract. D0350, D0160, D00470, D0367, D9215, 
D6119, D6118, D7912, D9243, D6010, D6056 and D6190 are not covered under the Plans dental benefits.  
This benefit includes the requested D0210 and D0330 but is limited to one procedure code every five calendar 
years. The contract also says that enrollees may be billed by the out-of-network provider for any charged 
amount greater than the payment made by the Plan. You can find this information on pages 77-80, 84-87, 90-93 
and 97-100 of the Plans 2022 Evidence of Coverage (EOC).