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.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 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 says that enrollees must pay a $100 copayment for care in a certified ambulatory surgical center. You can find this information on page 102 of the Plan's 2021 Evidence of Coverage (EOC).

The Plan contract also says that enrollees must pay a $30 copayment for each specialist visit. You can find this information on page 102 of the Plan's 2021 Evidence of Coverage (EOC).

The Plan contract does not clearly disclose that the member would be charged a copayment for both a specialist visit and care in a certified ambulatory surgical center.
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 effective for claims with dates of service on or after January 9, 2014, Percutaneous Image-Guided Lumbar Decompression (PILD) is covered by Medicare when provided in a clinical study under section 1862(a)(1)(E) through Coverage with Evidence Development (CED) for beneficiaries with LSS who are enrolled in an approved clinical study and meets the criteria listed in NCD-150.13, Transmittal 167. Effective for claims with dates of service on or after December 7, 2016, Medicare will cover PILD under CED for beneficiaries with LSS who are enrolled in a CMS-approved prospective longitudinal study PILD procedure using and FDA-approved/cleared device that completed a CMS-approved RCT (randomized controlled trial) that met the criteria listed in the January 2014 NCD (see CR 8757, transmittal #2959, dated May 16, 2014). You can find this in the Local Coverage Determination (LCD): Category III Codes (L35490).
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 4Kscore test will be considered medically reasonable and necessary when all the
following are met:
1. When all of the components of the algorithm are present.
2. Testing of men 45 years of age and older, prior to an initial biopsy or following a negative biopsy, who
have a confirmed moderately elevated prostate-specific antigen (PSA) (greater than 3 and less than 10
ng/mL; greater than or equal to 4 and less than 10 ng/mL in men greater than 75 years of age) when
both of the following are present:
- No other relative indication for prostate biopsy including any of the following:
~ Digital Rectal Examination (DRE) suspicious for cancer should be encouraged to
undergo biopsy
~ Persistent and significant increase in PSA should be encouraged to undergo biopsy
~ Positive multiparametric magnetic resonance imaging (MRI) (if done)
~ Other major risk factor for prostate cancer
- No other relative contraindication for prostate biopsy including any of the following:
~ Less than a 10-year life expectancy
~ Benign disease not ruled out.
The following are considered to be not medically reasonable and necessary:
1. Any test that does not contain all of the following components:
- 4 Kallikreins proteins (tPSA, fPSA, iPSA and hK2)
- Clinical information including age
- DRE
- Prior biopsy history
2. Tests performed without evidence of shared decision making between the ordering provider and the
beneficiary.
You can find these rules in Local Coverage Determination (LCD) 4Kscore Test Algorithm (L37992).
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 Outpatient Code Editor (OCE) will return to the provider any claim that reports a code for a device-intensive procedure that does not also report at least one device code required for that procedure. If the claim is returned to the provider for failure to pass the edit, the hospital will need to modify the claim by either correcting the procedure code or ensuring that one of the required device codes is on the claim before resubmission. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 61.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 

Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. 

Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Sections 422.2 and 422.136.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You can find this information on page 74 of the 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 CT scans are covered if there is literature to support its use for the patient's condition and the scan is reasonable and necessary for the patient. You can find this rule in the Centers for Medicare and
Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 220.1(A).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 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). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
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 enrollees must pay 20% coinsurance for Medicare-covered durable medical equipment and supplies. You can find this information on pages 79 to 80 of the Plan's 2021 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 code 38205 - Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic - has an Outpatient Prospective Payment System (OPPS) Status Indicator of "B," indicating that this code is not recognized by OPPS when submitted on an outpatient hospital Part B bill type. You can find this rule in the 2021 OPPS Addendum.
The rules say that effective for claims with dates of service July 1, 2007, and after, the non-Outpatient
Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE.
This integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital
claims, through a single integrated OCE eliminating the need to update two separate OCE software packages
on a quarterly basis. The integrated OCE does not change the current logic that is applied to outpatient bill
types that already pass through the OPPS OCE software. It merely expands the software usage to include nonOPPS hospitals. This new software product will be referred to as the Integrated OCE (I/OCE). The I/OCE
instructions and specifications are provided via Recurring Update Notifications. They are also posted on the
Web at the following address:
https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual,
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 40.1.
Medicare rules state that the I/OCE establishes code edit 62, meaning a code has a status indicator of B. The disposition of this code edit is RTP: Return To Provider. A claim returned to the provider means that the provider can resubmit the claim once the problems are corrected. You can find this rule in the Integrated Outpatient Code Editor (I/OCE) Centers for Medicare and Medicaid Services (CMS) Specifications File, Tables 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 Ambulatory EEG monitoring is a diagnostic procedure for patients in whom a seizure diathesis is suspected but not defined by history, physical or resting EEG. Ambulatory EEG can be utilized in the differential diagnosis of syncope and transient ischemic attacks if not elucidated by conventional studies. Ambulatory EEG should always be preceded by a resting EEG.
Ambulatory EEG monitoring is considered an established technique and covered under Medicare for the above purposes. You can find this rule at Centers for Medicare and Medicaid Services, National Coverage Determination (NCD) 160.22, Ambulatory EEG Monitoring.
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 for services performed on or after January 21, 2020, Medicare will now provide limited coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may be provided by a physician in accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 30.3.3.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan offers additional coverage for acupuncture beyond what is covered by Medicare. This benefit covers acupuncture for the relief of chronic pain or in a place of anesthesia for a surgical or dental procedure covered under the Plan. The person providing the acupuncture must be a physician licensed to perform the service. You can find this on page 3 in the Plan's 2020 Schedule of Cost Sharing in the 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 Section 1833(t) of the Social Security Act (the Act) as amended by Section 4533 of the
Balanced Budget Act (BBA) of 1997, authorizes CMS to implement a Medicare prospective payment system
(PPS) for hospital outpatient services. You can find this rule in the Medicare Claims Processing Manual,
Chapter 4, Section 10.
The rules also say that the outpatient PPS recognizes that Current Procedural Terminology (CPT) code 99153
is a practice expense (PE) only code and are finalizing the proposed PE inputs for CPT code 99153, as well as
finalizing the proposed PE inputs for all other codes in this family without modification. You can find this
information in the Physician's Fee Schedule Final Rule.
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 lists the specific dental services that are covered. Re-evaluation is not listed and therefore is not a covered service. The contract also says that any services that are not listed are not covered. You can find this information on pages 4-66 to 4-77 of the Plan's 2021 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 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 37 to 38 of the Plan's 2021 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 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 in Chapter 3, on pages 37-38 of the Plan's 2021 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 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). 

The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.

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 enrollees must pay a $40 copayment for lab services provided in the outpatient hospital setting. You can find this information on page 76 of the Plan's 2021 Evidence of Coverage (EOC).