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 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 says that when services are provided by an out-of-network provider, the enrollee is responsible for 100% of the cost. You can find this information on page 85 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 SelectMDx has been deemed investigational due to lack of independent validation, false
negatives, short follow-up, lack of randomized trials, lack of cut-point standardization, undetected cancers (up
to 25%) with a single negative prostate biopsy, and the potential for upgrading (32%-49) that occurs in patients
with Gleason 6 at biopsy. The concern implicit in the last two issues is that biomarker validations studies,
which correlate biomarker test results only with initial biopsy findings, may be underestimating the risk of
missing clinically significant cancer, hence the need for longer follow-up. You can find this rule in Local
Coverage Determination (LCD): Biomarker Testing (Prior to Initial Biopsy) for Prostate Cancer Diagnosis
(L37733).
The rules also say that code 81479 is not considered medically necessary when used for SelectMDx. You can
find this rule in Local Coverage Article: Billing and Coding: Biomarker Testing (Prior to Initial Biopsy) for
Prostate Cancer Diagnosis (A56609).
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.
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. 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 290(3).
With the exception of the situations described above, orthopedic footwear billed using codes L3260 will be
denied as noncovered. You can find this information in the Local Coverage Article - Orthopedic Footwear -
Policy Article (A52481).
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 enrollees must pay a $35 copayment for each visit to a specialty physician office.
You can find this information on page 83 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 DME must be for use in the patient's residence other than a healthcare institution and payment cannot be made for equipment for use in an institution. You can find this information in Medicare's Medicare Claims Processing Manual Chapter 20, section 10.1 and 10.2. The rules say that a Pneumatic Compression Device (PCD) that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a preventative service or function are excluded from coverage under the Medicare DME benefit. A PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. There is insufficient evidence to demonstrate that reimbursement is justified. Claims for E0675 will be denied as not reasonable and necessary. You can find this information in the Local Coverage Article: Pneumatic Compression Devices - Policy Article (A52488) and in the Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).
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 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 that providers 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 (NCCI) Policy
Manual for Medicare Services, Chapter I(A).
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. 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 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 modifier -59 is used to indicate a distinct procedural service. This may represent a different session or patient encounter, different procedure or surgery, different site, or organ system, separate incision/excision, or separate injury. 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 20.9.1.1B.

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 use of the following CPT/HCPCS Codes for these treatments is inappropriate and will be denied: CPT code 76942- ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation. You can find this information in Medicare's Local Coverage Article Billing and Coding: Nerve Blocks for Peripheral Neuropathy (A57589).
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 a $200 copayment for each one-way ground ambulance trip. You can find this information on page 40 of the Plan's 2020 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 providers 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 all providers are required to furnish necessary information to the health plan when requested. You can find this information in the Medicare Managed Care Manual, Chapter 4 Benefits and Beneficiary Protections, 20.3 (MAO Responsibility), 110.1 (Access and Availability Rule), Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services 20.0-40.4 Physician Services and Physician/Practitioner.
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 that treatment for lower urinary tract symptoms/benign prostatic hyperplasia will be considered
reasonable and necessary when performed ONCE in patients with the following:
1. Indications including ALL of the following:
a. Age less than 80
b. Prostate volume of 30-150 cc by transrectal ultrasound (TRUS)
c. Persistent moderate to severe symptoms despite maximal medical management including ALL of the
following:
i. International Prostate Symptom Score (IPSS) =12
ii. Maximum urinary flow rate (Qmax) of =15 mL/s (voided volume greater than 125 cc)
iii. Failure, contraindication, or intolerance to at least three months of conventional medical therapy for
LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride)
2. Only treatment using an FDA approved/cleared device will be considered reasonable and necessary.
You can find this rule in the Local Coverage Determination (LCD) - Fluid Jet System in the Treatment of
Benign Prostatic Hyperplasia (BPH) (L38378) - Effective March 25, 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 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). Medicare rules say that Medicare does not pay for services that are not provided within the United States. You can find this information in Section 10 of Chapter 16 of the Medicare Benefit Policy Manual.

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 health plan contract says that they provide a supplemental benefit for services outside the United States. Coverage is limited to $100,000 for emergency services, urgent services, and emergency transportation outside the United States. You can find this information in Chapter 4 on page 57 of the plan's 2021 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 (CMS), Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. Oral appliances generally are classified as dental devices and are not classified as Durable Medical Equipment (DME). The following items (not all-inclusive) are considered to be dental devices and will be denied as non-covered, not DME: - Oral occlusal appliances used to treat temporomandibular joint (TMJ) disorders - Tongue retaining devices used to treat OSA and/or snoring - All oral appliances used only to treat snoring without a diagnosis of OSA - Oral appliances used to treat other dental conditions - Oral appliances that require repeated fitting and/or adjustments, beyond the first 90-days, in order to maintain fit and/or effectiveness This information can be found in CMS Policy Article (A52512) - Oral Appliances for Obstructive Sleep Apnea.
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. However, dental splints, dental prosthesis, or any dental treatment for the teeth, gums, or jaw or dental treatment related to temporomandibular joint syndrome (TMJ) are not covered under any condition. You can find this information on page 116 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 39 to 40 of the Plan's 2021 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 definitive urine drug testing (UDT) is reasonable and necessary in order to: 1. Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT; 2. Definitively identify specific drugs in a large family of drugs; 3. Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, meperidine, synthetic cannabinoids and other synthetic/analog drugs; 4. Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., discontinuation of THC use according to a treatment plan); 5. Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patient's self-report, presentation, medical history, or current prescribed pain medication plan; 6. Rule out an error as the cause of a presumptive UDT result; 7. Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 8. Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. You can find this rule in the Local Coverage Determination (LCD) - Controlled Substance Monitoring and Drugs of Abuse Testing (L35006) - Effective October 17, 2019. The rules say that definitive urine drug testing may be reasonable and necessary based on patient specific indications, including historical use, medication response, and clinical assessment, when accurate results are necessary to make clinical decisions. The clinician's rationale for the definitive urine drug testing and the tests ordered must be documented in the patient's medical record. You can find this rule in the Local Coverage Determination (LCD) - Controlled Substance Monitoring and Drugs of Abuse Testing (L35006) - Effective October 17, 2019. The rules say that the frequency of testing beyond the baseline presumptive urine drug testing must be based on individual patient needs substantiated by documentation in the patient's medical record. The patient's medical record must include an appropriate testing frequency based on the stage of screening, treatment, or recovery; the rationale for the drugs/drug classes ordered; and the results must be documented in the medical record and used to direct care.
The frequency of testing must be based on a complete clinical assessment of the individual's risk potential for abuse and diversion using a validated risk assessment interview or questionnaire and should include the patient's response to prescribed medications and the side effects of medications. You can find this rule in the Local Coverage Determination (LCD) - Controlled Substance Monitoring and Drugs of Abuse Testing (L35006) - Effective October 17, 2019.
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. Services are covered with providers in the Plan's PPO Network only. You can find this information on page 74 of the Plan's 2021 Evidence of Coverage (EOC).