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 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. 
 
The rules say that for all services (with two (2) exceptions), the Place of Service (POS) code to be used by the 
physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-
face service. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which 
case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face 
service takes place. You can find this information in the MLN Matters article number MM7631, Revised and 
Clarified Place of Service (POS) Coding Instructions. 
 
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 payment for follow-up inpatient telehealth consultations includes all consultation related 
services furnished before, during, and after communicating with the patient via telehealth. Pre-service activities 
would include, but would not be limited to, reviewing patient data (for example, diagnostic and imaging 
studies, interim lab work) and communicating with other professionals or family members. Intra-service 
activities must include at least two of the three key elements described below for each procedure code. Post-
service activities would include, but would not be limited to, completing medical records or other 
documentation and communicating results of the consultation and further care plans to other health care 
professionals. No additional evaluation and management service could be billed for work related to a follow-up 
inpatient telehealth consultation. 
 
Follow-up inpatient telehealth consultations could be provided at various levels of complexity: Practitioners 
taking a problem focused interval history, conducting a problem focused examination, and engaging in medical 
decision making that is straightforward or of low complexity, would bill a limited service, using code G0406 
(Follow-up inpatient telehealth consultation, limited, physicians typically spend 15 minutes communicating 
with the patient via telehealth). Practitioners taking an expanded focused interval history, conducting an 
expanded problem focused examination, and engaging in medical decision making that is of moderate 
complexity, would bill an intermediate service using code G0407(Follow-up inpatient telehealth consultation, 
intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth). 
Practitioners taking a detailed interval history, conducting a detailed examination, and engaging in medical 
decision making that is of high complexity, would bill a complex service, using code G0408 (Follow-up 
inpatient telehealth consultation, complex, physicians typically spend 35 minutes or more communicating with 
the patient via telehealth). Although follow-up inpatient telehealth consultations are specific to telehealth, these 
services must be billed with POS 02 to identify the telehealth technology used to provide the service. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-104, Chapter 12, Section 190.3. 
 
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.
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 ambulance service claims, institutional-based providers and suppliers must report an 
origin and destination modifier for each ambulance trip provided in HCPCS/Rates.  
 
The first position alpha code equals origin; the second position alpha code equals destination. Origin and 
destination codes and their descriptions are listed below: 
 
D = Diagnostic or therapeutic site other than P or H when these are used as origin codes; 
E = Residential, domiciliary, custodial facility (other than 1819 facility); 
G = Hospital based ESRD facility; 
H = Hospital; 
I = Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport; 
J = Freestanding ESRD facility; 
N = Skilled nursing facility; 
P = Physicians office; 
R = Residence; 
S = Scene of accident or acute event; 
X = Intermediate stop at physicians office on way to hospital (destination code only) 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 15, Section 30. 
 
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 up to 24 one-way routine trips for non-emergency, medical related purposes within a 50-mile limit. You 
can find this information on pages 83-84 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 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. 
 
The rules say that the codes describing bundled payments made to OTPs are Healthcare Common Procedure 
Coding System (HCPCS) codes G2067-G2075. There are add-on codes described by HCPCS codes G2076- 
G2080, HCPCS codes G2215, G2216, and G1028. Only an entity enrolled with Medicare as an Opioid 
Treatment Program (OTP) can bill these codes. Additionally, OTPs are limited to billing only these codes 
describing bundled payments, and may not bill for other codes, such as those paid under the Physician Fee 
Schedule. You can find this rule in Medicare Claims Processing Manual Chapter 39  Opioid Treatment 
Programs (OTPs), Section 30.6. 
  
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 page 34 of the Plan's 2023 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that an "order" is a communication from the treating physician/practitioner requesting that a 
diagnostic test be performed for a beneficiary. While a physician order is not required to be signed, the 
physician must clearly document, in the medical record, his or her intent that the test be performed. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit 
Policy Manual, Chapter 15, Section 80.6.1. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
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 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 $20 copayment for in-network cardiac rehabilitation services. You can 
find this information on page(s) 58 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 Medicare covers services in an emergency department only if the emergency clinic is 
affiliated with a hospital. You can find this rule at SSA 1861, 42 CFR 489.24, and 42 CFR 413.65. 
 
The rules state that Licensed independent freestanding emergency departments (EDs) may participate in 
Medicare and Medicaid to help address the urgent need to increase hospital capacity during the COVID-19 
Public Health Emergency to provide additional care to patients in the following ways: 
 
 As hospital-affiliated ED under the 1135 emergency waiver;  
 As Medicaid-certified clinics under the states clinic benefit; and  
 As a Medicare-certified hospital by temporarily enrolling in Medicare as a hospital via a specific attestation 
process. 
 
You can find this rule at Centers for Medicare and Medicaid Services, Memorandum QSO-20-27-Hospital 
entitled "Guidance for Licensed Independent Freestanding Emergency Departments (EDs) to Participate in 
Medicare and Medicaid During the COVID-19 Public Health Emergency.". 
 
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 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 $95.45 deductible for Physician/Practitioner services, including doctor's 
office visits. You can find this information on pages 45-46 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-
CM) has two types of excludes notes. Each type of note has a different definition for use, but they are all 
similar in that they indicate that codes excluded from each other are independent of each other. An Excludes1 
note indicates that the code excluded should never be used at the same time as the code above the Excludes1 
note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an 
acquired form of the same condition. An exception to the Excludes1 definition is the circumstance when the 
two conditions are unrelated to each other. You can find this rule in the ICD-10-CM Official Guidelines for 
Coding and Reporting, FY 2023. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the following is a list of suppliers who frequently attempt to enroll in Medicare but are not 
eligible to do so. (This list is not all-inclusive, however.). If the contractor receives an enrollment application 
from any of these individuals or entities, the contractor shall deny the application with the exception of entities 
eligible to enroll using the Form CMS-20134, which is specific to the furnishing of MDPP services. 
     Drug and Alcohol Rehabilitation Counselor  
You can find this rule in the Medicare Program Integrity Manual Chapter 10.2.8 - Providers/Suppliers Not 
Eligible to Enroll. 
 
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 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 $50 copayment for diagnostic procedures and tests. You can find this 
information on pages 76-78 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $20 copayment for each specialist office visit. You can 
find this information on pages 81-82 of the Plans 2022 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 Thermography is the measurement of self-emanating infrared radiation that reveals 
temperature variations at the surface of the body. The thermographic device senses body temperature and 
demonstrates areas of differing heat emission by producing brightly colored patterns. Each color represents a 
specific temperature level. Interpretation of these color patterns according to designated anatomic distribution 
is thought to aid in diagnosing a vast array of diseases. Indications and Limitations of Coverage: 
 
Thermography for any indication (including breast lesions which were excluded from Medicare coverage on 
July 20, 1984) is excluded from Medicare coverage because the available evidence does not support this test as 
a useful aid in the diagnosis or treatment of illness or injury. Therefore, it is not considered effective. This 
exclusion was published as a CMS Final Notice in the "Federal Register" on November 20, 1992. You can find 
this rule at the Medicare National Coverage Determination (NCD) 220.11: Thermography. 
 
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 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 $5,900 out-of-pocket for in-network covered Part A and Part B services. 
The amounts you pay for copayments and coinsurance for in-network covered services count toward this 
maximum out-of-pocket amount. You can find this information on page 56 of the Plan's 2022 Evidence of 
Coverage (EOC).  
 
The Plan contract say that enrollees must pay a 20% coinsurance for Medicare Part B Covered Drugs at 
primary care provider's (PCP's) office, specialist's office and pharmacy for home infusion therapy. You can 
find this information pages 66 to 67 of the Plans 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 urgently needed services. You can find this 
information on page(s) 81 of the Plan's 2023 Evidence of Coverage.