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 Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied.   
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. 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(V). 
 
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 certain conditions have both an underlying etiology and multiple body system manifestations 
due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the 
underlying condition be sequenced first, if applicable, followed by the manifestation. In most cases the 
manifestation codes will have in the code title, in diseases classified elsewhere. Codes with this title are a 
component of the etiology/ manifestation convention. The code title indicates that it is a manifestation code. 
In diseases classified elsewhere does are never permitted to be used as first listed or principal diagnosis 
codes. There are manifestation codes that do not have in diseases classified elsewhere in the title. For such 
codes, there is a use additional code note at the etiology code and a code first note at the manifestation 
code, and the rules for sequencing apply. You can find this rule in the ICD-10-CM Official Guidelines for 
Coding and Reporting FY 2021. 
 
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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules say that Medicare does not cover non-diagnostic tests (i.e., testing done for public health surveillance 
purposes). You can find this rule at CMS document https://www.cms.gov/files/document/covid-medicare-
payment-covid-19-viral-testing-flow-chart.pdf. 
 
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. The contract includes a list of 
covered supplemental benefits. Dental code D5650 is not on this list and is not a covered supplemental benefit. 
You can find this information on pages 4-58 to 4-66 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 state that wireless capsule endoscopy of the small bowel is considered medically reasonable and 
necessary when the following conditions have been met:  
 
 documented continuous blood loss and anemia secondary to obscure bleeding of the small bowel; 
 the site of bleeding could not be previously identified by colonoscopy, or endoscopy, or;  
 radiographic exams of the small bowel have failed to reveal a source, or; 
 intraoperative enteroscopy is being considered, or; 
 initial diagnosis of suspected Crohns Disease when there is no evidence provided by conventional 
diagnostic tests such as small bowel follow-through (SBFT), and upper and lower endoscopy. 
 
You can find this information in Local Coverage Determination (LCD): L33774). 
 
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 Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL the following criteria: 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale* 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant 
deformity. 
*
Pain assessment must be performed and documented at baseline, after each diagnostic procedure using 
the same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for 
functional assessment (if patient qualifies for treatment). You can find this rule at Local Coverage 
Determination (LCD) L35936: Facet Joint Interventions for Pain Management (eff. 2/10/22). 
 
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 if a laboratory assays two or more genes in a patient in parallel, then those two or more 
genes will be considered part of the 
same panel. A panel constitutes a single procedural service, so one procedure code must be submitted for the 
panel. This information is found in the Medicare NCCI Coding Policy Manual  Chapter 10  CPT Codes  
80000-89999, Section F, number 8. 
 
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. 
 
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 must pay for ambulance services when an emergency exists or when other means of 
transport would endanger the patients health. An emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. You can 
find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, 
Medicare Managed Care Manual, Chapter 4, Sections 20.1 and 20.2. 
 
Ambulance services are separately reimbursable only under Part B. Once a beneficiary is admitted to a 
hospital, critical access hospital (CAH), or skilled nursing facility (SNF), it may be necessary to transport the 
beneficiary to another hospital or other site temporarily for specialized care while the beneficiary maintains 
inpatient status with the original provider. This movement of the patient is considered "patient transportation" 
and is covered as an inpatient hospital or CAH service and as a SNF service when the SNF is furnishing it as a 
covered SNF service and payment is made under Part A for that service. (If the beneficiary is a resident of a 
SNF and must be transported by ambulance to receive dialysis or certain other high-end outpatient hospital 
services, the ambulance transport may be separately payable under Part B. Also, if the beneficiary is a SNF 
resident and not in a Part A covered stay and must be transported by ambulance to the nearest supplier of 
medically necessary services not available at the SNF, the ambulance transport, including the return trip, may 
be covered under Part B.) Because the service is covered and payable as a beneficiary transportation service 
under Part A, the service cannot be classified and paid for as an ambulance service under Part B. You can find 
this rule in the Medicare Claims Processing Manual, Chapter 15, 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 diagnostic breath analyses are tests performed to measure either the hydrogen or carbon 
dioxide content of the breath after the ingestion of certain compounds. The analyses are performed to diagnose 
certain gastrointestinal disease states. 
 
The following breath test is covered: lactose breath hydrogen to detect lactose malabsorption. 
 
The following breath tests are excluded from coverage: lactulose breath hydrogen for diagnosing small bowel 
bacterial overgrowth and measuring small bowel transit time, CO2 for diagnosing bile acid malabsorption 
and/or CO2 for diagnosing fat malabsorption. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, National Coverage Determinations (NCD) Manual: Diagnostic Breath Analyses (100.5). 
 
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 Medicare has started a new initiative on April 4, 2022, that will cover up to eight over-the-
counter COVID-19 tests each calendar month, at no cost to you. Medicare will cover these tests if you have 
Part B, including those enrolled in a Medicare Advantage plan. If you are in a Medicare Advantage (MA) plan, 
the tests covered under this initiative will be covered outside of your existing plans coverage, and in addition 
to any over-the-counter tests that may be covered under the plan as a supplemental benefit. You can get over-
the-counter COVID-19 tests at any pharmacy or health care provider that participates in this initiative. 
Enrollees cannot submit a claim for these tests to Medicare or their MA plan (unless covered by a supplemental 
benefit) for reimbursement under this initiative. The participating provider would bill Medicare directly for 
reimbursement of the tests provided to the enrollee. You can find this information on the Centers for Medicare 
and Medicaid Services website at  https://www.cms.gov/newsroom/fact-sheets/medicare-covers-over-counter-
covid-19-tests.  
 
Medicare does not reimburse separately for sales tax. You can find this the Centers for Medicare and Medicaid 
Services, Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 23, 
Section 80.3.1. 
 
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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing 
information (such as copayments, deductibles and coinsurance). 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 the enrollee has a $750 deductible. You can find this information on page 59 of the 
Plan's 2022 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 ambulance services are only covered when the patient's clinical condition is such that other 
methods of transport are contraindicated. You can find this rule at 42 CFR Section 410.40(e). 
 
The rules say that, generally, items and services provided outside of the United States (US) are not covered. 
The only exceptions are emergency hospital services when the emergency occurred within the US, 
emergency/non-emergency hospital services when the foreign hospital is substantially closer or more 
accessible than the US hospital, or services provided on a ship docked at a US port or within US Territorial 
waters. You can find this information in the Medicare Benefit Policy Manual, Chapter 16, Section 60. 
 
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 you must pay all costs to return to your service area. You can find this information on 
page 62 of the Plan's 2022 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 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 molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage when ALL 
of the following criteria are met: 
 Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are 
unavailable or results are clearly equivocal; AND 
 Availability of a clinically valid test, based on published peer reviewed medical literature; AND 
 Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed 
test) or LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) of 
analytical validity and clinical utility; AND 
 Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND 
 For testing panels, including but not limited to, multiple genes or multiple conditions, and in cases 
where a tiered approach/method is clinically available, testing would be covered ONLY for the number 
of genes or test that are reasonable and necessary to obtain necessary information for therapeutic 
decision making; AND 
 Individual has not previously received genetic testing for the disease/condition. (In general, diagnostic 
genetic testing for a disease should be performed once in a lifetime.) Exceptions include clinical 
scenarios whereby repeat testing of somatically-acquired mutations (for example, pre- and post- 
therapy) may be required to inform appropriate therapeutic decision-making. You can find these rules in Local Coverage Determination (LCD) Molecular Pathology Procedures L35000. 
 
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 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. A HCPCS code with a status indicator of "B" is a code that is not recognized 
by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x). An alternate code that is 
recognized by OPPS may be available. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 4, Section 
10.1.1. 
 
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.