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 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 each outpatient rehabilitation visit. You can find this 
information on page 75 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 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 $30 copayment for Medicare-covered urgent care facility visits. You can 
find this information on page(s) 107 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 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 $0 copayment for days 1 to 20 and a $100 copayment per day for days 21 
to 100 for SNF care. You can find this information on page 121 of the Plan's 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 that the following are examples of wound care items which are non-covered under the surgical 
dressing benefit because they do not meet the statutory definition of a dressing (not all-inclusive): 
 
Skin sealants or barriers (A6250) 
Wound cleansers (A6260) or irrigating solutions 
Solutions used to moisten gauze (e.g., saline) 
Silicone gel sheets (A6025) 
Topical antiseptics 
Topical antibiotics 
Enzymatic debriding agents 
Gauze or other dressings used to cleanse or debride a wound but not left on the wound 
First-aid type adhesive bandage (A6413) 
Any item listed in the latest edition of the Orange Book (e.g., an antibiotic-impregnated dressing which 
requires a prescription 
Gradient compression stockings (A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, 
A6541, A6544, A6549) 
Surgical stockings (A4490, A4495, A4500, A4510) 
Non-elastic binder for an extremity (A4465) 
Small adhesive bandages (e.g., Band-Aid or similar product) are not primarily used for the treatment of wounds 
addressed in the Surgical Dressings policy. 
These dressings are noncovered under the surgical dressing benefit. 
 
Collagen Dressing Or Wound Filler (A6010, A6011, A6021-A6024) 
 
A collagen-based dressing or wound filler is covered for full thickness wounds (e.g., stage 3 or 4 ulcers), 
wounds with light to moderate exudate, or wounds that have stalled or have not progressed toward a healing goal. They can stay in place up to 7 days. Collagen based dressings are not covered for wounds with heavy 
exudate, third-degree burns, or when an active vasculitis is present. 
 
Gauze, Non-Impregnated (A6216-A6221, A6402-A6404, A6407) 
 
Non-impregnated gauze dressing change is up to 3 times per day for a dressing without a border and once per 
day for a dressing with a border. It is usually not reasonable and necessary to stack more than 2 gauze pads on 
top of each other in any one area. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Surgical Dressings 
(L33831). 
 
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 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 CMS does not pay any provider or supplier other than the facility or hospital for services 
furnished to the beneficiary while an inpatient. The facility or hospital must furnish all necessary covered 
services to the beneficiary either directly or under arrangements made between the facility and hospital and 
outside providers.  You can find this information in 42 CFR 409.10.  
 
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 39 of the Plan's 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 that home health agencies (HHAs) must report where home health services were provided. The 
following codes are used for this reporting: 
Q5001: Hospice or home health care provided in patients home/residence 
Q5002: Hospice or home health care provided in assisted living facility 
Q5009: Hospice or home health care provided in place not otherwise specified 
The location where services were provided must always be reported along with the first visit reported on the 
claim. In addition to reporting a visit line using the G codes as described above, HHAs must report an 
additional line item with the same revenue code and date of service, reporting one of the three Q codes (Q5001, 
Q5002, and Q5009), one unit and a nominal covered charge (e.g., a penny). If the location where services were 
provided changes during the period of care, the new location should be reported with an additional line 
corresponding to the first visit provided in the new location. You can find this information in the Medicare 
Claims Processing Manual, Chapter 10 - Home Health (HH) Agency Billing, Section 40.2. 
 
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 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 the 
surgical placement of implant body (D6010) but is limited to two every calendar year; 1 per tooth every 5 
calendar year. This benefit also includes a bone graft at time of implant placement (D6104) but is limited to 2 
every calendar year. You can find this information on pages 95 and 98 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 definitive UDT is reasonable and necessary for the following circumstances: 
 
    -Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT screen; 
    -Definitively identify specific drugs in a large family of drugs; 
    -Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, 
Meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
    -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); 
    -Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients self- 
report, presentation, medical history, or current prescribed pain medication plan; 
    -Rule out an error as the cause of an unexpected presumptive UDT result; 
    -Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 
    -Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
 
Definitive UDT 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 clinicians rationale for the definitive UDT and the tests ordered must be documented in the patients 
medical record. You can find this information in Local Coverage Determination (LCD): Controlled Substance 
Monitoring and Drugs of Abuse Testing (L36393). 
 
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 20% coinsurance for in-network Medicare Part B covered drugs  
Primary Care Providers (PCP) office  Specialists office - Pharmacy. You can find this information on page 
61 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 say that the rate, facility or nonfacility, that a physician service is paid under the Medicare Physician 
Fee Schedule (MPFS) is determined by the Place of service (POS) code that is used to identify the setting 
where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner (NPP) 
or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the face-to-
face service and determines whether the facility or nonfacility payment rate is paid. However, for a service 
rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS codes 
19 or 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred. 
For the professional component (PC) of diagnostic tests, the facility and nonfacility payment rates are the same 
 irrespective of the POS code on the claim. See chapter 13, section 150 of this manual for POS instructions for 
the PC and technical component of diagnostic tests. 
 
The list of settings where a physicians services are paid at the facility rate include: 
 
 Inpatient Hospital (POS code 21); 
 Outpatient Hospital-On campus (POS code 22); 
 Emergency Room-Hospital (POS code 23); 
 
You can find this information in the Medicare Claim Processing Manual, Chapter 12, Section 20.4.2 - Site of 
Service Payment Differential. 
 
The rules say the following is the current national POS code set, with facility and  nonfacility designations 
noted for Medicare payment for services on  the Physician Fee Schedule: 23 - Emergency Room-Hospital 
A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided. You can find 
this information in the Medicare Claims Processing Manual, Chapter 26 - Completing and Processing Form 
CMS-1500 Data Set, Section 10.5 - Place of Service Codes (POS) and Definitions.  
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 417.414. 
 
The rules say that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 27 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 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 following types of tests are examples of services that are not relevant to a Medicare 
beneficiary, are not considered a Medicare benefit (statutorily excluded), and therefore will be denied as 
Medicare Excluded Tests: 
 Tests considered screening in the absence of clinical signs and symptoms of disease that are not 
specifically identified by the law 
 Tests performed to determine carrier screening 
 Tests performed for screening hereditary cancer syndromes 
 Prenatal diagnostic testing 
 Tests performed on patients without signs or symptoms to determine risk for developing a disease or 
condition 
 Tests performed to measure the quality of a process 
 Tests without diagnosis specific indications 
 Tests identified as investigational by available literature and/or the literature supplied by the developer 
and are not a part of a clinical trial 
Screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or 
disease predisposition are not a Medicare benefit and are not covered. You can find these rules in Local 
Coverage Article Billing and Coding: Molecular Pathology and Genetic Testing A58917. 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 32 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 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 $350 copayment for outpatient diagnostic test. You can find this 
information on page(s) 79 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The Plan contract says that for all women: Pap tests and pelvic exams are covered once every 24 months. If you 
are at high risk of cervical or vaginal cancer or you are of childbearing age and have had an abnormal Pap test 
within the past 3 years: one Pap test every 12 months. You can find this information in Chapter 4 on page 62 of 
the Plan's 2022 Evidence of Coverage. 
 
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 20% coinsurance for each Medicare-covered Part B drug. You can find 
this information on page 97 of the Plan's 2022 Evidence of Coverage (EOC).