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 includes one 
D5225 every 60 floating months. You can find this information on page 108 of the Plan's 2023 Dental Quick 
Reference Guide.
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 custodial care is not covered. Custodial care is personal care for a person who does not need 
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of 
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, 
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also 
custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
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 
says that members can receive up to 60 hours per year of in-home support services including light house help, 
companionship services, grocery shopping, technology lessons, and social transportation. You can find this 
information on page 71 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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). 
 
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
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility 
limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices L33789 (eff 1/1/17). 
 
The rules say that under the circumstances specified below, payment may be made for repair, maintenance, and 
replacement of medically required DME, including equipment which had been in use before the user enrolled 
in Part B of the program. However, do not pay for repair, maintenance, or replacement of equipment in the 
frequent and substantial servicing or oxygen equipment payment categories. In addition, payments for repair 
and maintenance may not include payment for parts and labor covered under a manufacturers or suppliers 
warranty. You can find this rule in Medicare Benefit Policy Manual: Chapter 15, 110.2 - Repairs, Maintenance, 
Replacement, and Delivery. 
 
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 several Healthcare Common Procedural Coding System (HCPCS) modifiers are used to 
signify a specific line item is either not covered or not payable by Medicare, for many different reasons. There 
is a chart that lists those modifiers, many more commonly used on professional claims, for services not covered 
or not payable by Medicare. Modifiers not payable on professional claims are also not payable on institutional 
claims and will be denied if submitted on such claims. Providers are liable for these denials, UNLESS a 
specific modifier (see second table in this section) or indicator on the claim (i.e., occurrence code 32) 
specifically assigns liability to the beneficiary. You can find this rule in the Centers for Medicare & Medicaid 
Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 
60.4.2. 
 
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 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 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. The periodontal scaling and root planing is covered by the Plan's dental benefits. You can find 
this information on pages 51 to 52 of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the dollar amount of the limitations (caps) on outpatient therapy services is established by 
statute. The updated amount of the caps is released annually via Recurring Update Notifications and posted on 
the CMS Website www.cms.gov/TherapyServices, on contractor Websites, and on each beneficiarys Medicare 
Summary Notice. Section 50202 of the Bipartisan Budget Act of 2018 repeals application of the Medicare 
outpatient therapy caps but retains the former cap amounts as a threshold of incurred expenses above which 
claims must include a modifier as a confirmation that services are medically necessary as justified by 
appropriate documentation in the medical record. This is termed the KX modifier threshold. Along with this 
KX modifier threshold, the new law retains the targeted medical review process but at a lower threshold 
amount of $3,000.  
 
The beneficiary may qualify for use of the cap exceptions process at any time during the episode when 
documented medically necessary services exceed caps. All covered and medically necessary services qualify 
for exceptions to caps. All requests for exception are in the form of a KX modifier added to claim lines.  
 
You can find these rules in the Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 5, Section 10.2 and 10.3.1. 
 
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 say that presumptive drug testing may be reported with CPT codes 80305-80307. These codes differ 
based on the level of complexity of the testing methodology. Only one code from this code range may be 
reported per date of service. You can find this rule in the National Correct Coding Initiative (NCCI) Manual, 
Chapter 10, Section E. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP) is covered in patients with 
osteoporotic vertebral compression fracture (VCF) when BOTH the following: 
 
Inclusion criteria (ALL are required): 
Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5), based on symptom onset, and 
documented by advanced imaging (bone marrow edema on magnetic resonance imaging (MRI) or bone-
scan/single-photon emission computerized tomography (SPECT)/computed tomograohy (CT) uptake) 
Symptomatic (ONE): 
Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score = 8)  
Non-hospitalized with moderate to severe pain (NRS or VAS =5) despite optimal non-surgical management 
(NSM) (ONE): 
Worsening pain 
Stable to improved pain (but NRS or VAS still =5) (with = 2 of the following): 
Progression of vertebral body height loss 
> 25% vertebral body height reduction 
Kyphotic deformity 
Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) >17 
Continuum of care (10) (Both are required) 
All patients presenting with VCF should be referred for evaluation of bone mineral density (BMD) and 
osteoporosis education for subsequent treatment as indicated. 
All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program. 
Exclusion criteria (Can have NONE of the following): 
 
Absolute contraindication 
Current back pain is not primarily due to the identified acute or subacute VCF(s). 
Osteomyelitis, discitis or active systemic or surgical site infection 
Pregnancy 
Relative contraindication 
Greater than three vertebral fractures per procedure Allergy to bone cement or opacification agents 
Uncorrected coagulopathy 
Spinal instability 
Myelopathy from the fracture 
Neurologic deficit 
Neural impingement 
Fracture retropulsion/canal compromise 
Vertebral augmentation and Kyphoplasty for vertebral compression fractures with intractable spinal pain 
secondary not relieved with medical therapy will be covered for osteolytic vertebral metastatic disease or 
myeloma involving a vertebral body. 
 
You can find these rules 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 state that the Type of Bill code is a 4-digit alphanumeric code that gives two pieces of information. 
The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this bill in this 
particular period of care. The acceptable 4th digit options are as follows: 7 (to indicate a replacement of a prior 
claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a final claim). You can find this rule at Centers 
for Medicare and Medicaid Services, Internet-Only Publication 100-04, Medicare Claims Processing Manual 
Chapter 10, 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 state that for services performed in the Hospital Outpatient Department (Type of Bill 13X) or an 
Ambulatory Surgical Center (ASC): ASC facilities and Outpatient Prospective Payment System (OPPS) 
hospital outpatient departments should report Healthcare Common Procedure Coding System (HCPCS) code 
G0260 for sacroiliac joint injections. G0260 should be reported with an imaging code specific to the imaging 
modality employed. Report Current Procedural Terminology (CPT) 77002 for fluoroscopic guidance or CPT 
77012 for computed tomography (CT) guidance in the ASC and the hospital outpatient department. You can 
find this information in the Local Coverage Article (LCA): Billing and Coding: Sacroiliac Joint Injections and 
Procedures (A59233). 
 
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 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). 
 
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 the Plan will reimburse members for certain services not covered by Original Medicare. Under 
the Wellness Wallet, the Plan will reimburse up to $300 each year in total for Fitness (Membership), 
Naturopathic Services, Acupuncture, Nutrition/Dietary Education, Weight Management Programs, and Face 
Masks. You can find this information on page 111 of the Plans 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules also say interpret the phrase new patient to mean a patient who has not received any professional 
services, for example, evaluation and management (E&M) service or other face-to-face service (such as a 
surgical procedure) from the physician or physician group practice (same physician specialty) within the 
previous 3 years. You can find this information in the Centers for Medicare & Medicaid Services, Internet-
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.7. 
 
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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers 50 one-way trips to Plan approved locations per year. You can find this information on page 75 of the 
Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that physicians bill for the anesthesia services associated with multiple bilateral surgeries by 
reporting the anesthesia procedure with the highest base unit value with the multiple procedure modifier "-51." 
They report the total time for all procedures in the line item with the highest base unit value. If the same 
anesthesia CPT code applies to two or more of the surgical procedures, billers enter the anesthesia code with 
the "-51" modifier and the number of surgeries to which the modified CPT code applies. Payment can be made 
under the fee schedule for anesthesia services associated with multiple surgical procedures or multiple bilateral 
procedures. Payment is determined based on the base unit of the anesthesia procedure with the highest base 
unit value and time units based on the actual anesthesia time of the multiple procedures. See 40.6-40.7for a 
definition and appropriate billing and claims processing instructions for multiple and bilateral surgeries. You 
can find this information in the Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 12, Section 50E. 
 
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.