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 24 Ambulatory Surgical Center- A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis. You can find this information in the Medicare Claims Processing Manual Chapter 26 - Completing and Processing Form CMS -1500 Data Set, 10.5 - Place of Service Codes (POS) and Definitions. The rules say that professional Component (PC)/Technical Component (TC) Indicator 3 = Technical component only codes: This indicator identifies stand-alone codes that describe the technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the professional component of the diagnostic-only tests. It also identifies codes that are covered only as diagnostic tests and therefore, do not have a related professional code. The total RVUs for technical component only codes include values for practice expense and malpractice expense only. You can find this information in Medicare's Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements, Section 50.6 -Physician Fee Schedule Payment Policy Indicator File Record Layout. The rules say that the work (or professional) component of physician's services refers to the resources used in furnishing the service that reflect physician time and intensity. The technical component (or practice expense [PE]) refers to the portion of resources involved in furnishing services (such as equipment costs, office rent, and wages of personnel). As part of the CY 2017 Final Rule, CPT code 99153 was established as a PE-only code meaning there is no work component RVU associated with that service.
The CY 2017 Final Rule established CPT codes 99151, 99152 and 99155- 99157 as representative of the work component for moderate sedation services. This is further reflected in the 2021 National Physician Fee Schedule Relative Value File April Release with CPT code 99153 assigned a PC/TC indicator of 3 and a work RVU of 0.00. You can find this information in the CY 2017 Final Rule.
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.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information in Chapter 3 of the Plan's 2018 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 a $45 copayment for specialist services. You can find this information on pages 4-54 to 4-60 of the Plan's 2021 Evidence of Coverage (EOC).

The Plan contract says that enrollees must pay a $30 copayment for outpatient diagnostic tests, including electrocardiograms (EKG's). You can find this information on pages 4-39 to 4-45 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 the HCPCS Level II Manual states that "R" codes are used for the transportation of portable x-ray equipment. By the code description, "R" codes are designation by location and per patient. (HCPCS) The OIG supports the HCPCS Level II Manual instructing portable x-ray suppliers to bill the technical and professional components in the same manner as other diagnostic imaging providers. The reimbursement for the transportation and the setup of x-ray equipment as well as the x-ray performed is allowed. Bringing the x-ray equipment to the patient's location, setting up the equipment and preparing for use is also separately reimbursable. However, the transportation of portable x-ray equipment is not reimbursable when the portable set-up services were not performed. (OIG) The CMS supports the HCPCS Manual and OIG directing that the transportation of portable x-ray equipment is only reimbursable when the set-up of x-ray equipment is reported in conjunction with the radiology codes when the x-ray equipment was actually transported to the location where the x-ray was taken. (CMS). You can find this guidance in the Center for Medicare & Medicaid Services Claims Processing Manual (CMS) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf and Healthcare Common Procedure Coding System Level II Manual. (HCPCS) Office of the Inspector General (OIG) https://oig.hhs.gov/oei/reports/oei-12-10-00190.pdf.

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. The Plan contract says that you may see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. You can find this information on page 62 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 certain codes may be grouped together for reimbursement as a "composite" Ambulatory Payment Classification (APC) when they occur together on the same claim with the same date of service (SI = Q3). When the composite criteria for a group are met, the primary code is assigned the composite APC and status indicator for payment; non-primary codes, and additional primary codes from the same composite group, are assigned status indicator N and packaged into the composite APC. You can find this information in Integrated OCE (IOCE) CMS Specifications V14. 2 - Effective July 1, 2013.   The rules say that i multiple imaging procedures from the same family are performed on the same date of service (DOS), a multiple imaging composite APC is assigned to the first eligible code encountered; all other eligible imaging procedures from the same family on the same day are packaged (the status indicator is changed to N). You can find this information in 5.5.10 Multiple Imaging Composite Assignment Rules & Criteria.  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 resin-based composite of one surface (D2391), resin-based composite of two surfaces (D2392), and resin-based composite of three surfaces (D2393). The Plan contract also says that you must pay a 50% coinsurance for each of these services. You can find this information on page 99 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 a power wheelchair is covered if use of a power wheelchair will significantly improve the beneficiary's ability to participate in mobility-related activities of daily living (MRADLs) and the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver. You can find this rule and full criteria for coverage in Local Coverage Determination (LCD): Power Mobility Devices (L33789).  

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 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 57 to 58 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 state that a Pneumatic Compression Device coded E0651 is covered when the following criteria are met: 1. There is edema in the affected lower extremity 2. One or more venous stasis ulcer(s) 3. The ulcer(s) have failed to heal after a six-month trial of conservative therapy directed by the treating practitioner. These rules can be found in Local Coverage Determination (LCD) for Pneumatic Compression Devices (L33829).
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 screening tests are excluded from coverage. The only exceptions are for the following services:
1. screening mammography,
2. colorectal cancer screening tests,
3. screening pelvic exams,
4. prostate cancer screening tests,
5. glaucoma screening exams,
6. ultrasound screening for abdominal aortic aneurysms (AAA),
7. cardiovascular disease screening tests,
8. diabetes screening tests, and
9. screening electrocardiograms, and
10. certain other testing recommended by the United States Preventive Services Task Force and approved by the Centers for Medicare and Medicaid Service.
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64.
The rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. You can find this rule in 42 CFR, Section 410.32
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 when completing the 1500 claim form, providers must enter the correct Place of Service (POS) code in section 24B.  Invalid or incorrect POS codes will be denied and returned to the provider. If the physician bills for lab services performed in his/her office, the POS code for "Office" is shown.  If the physician bills for a lab test furnished by another physician, who maintains a lab in his/her office, the code for "Other" is shown.  If the physician bills for a lab service furnished by an independent lab, the code for "Independent Laboratory" is used.  Items 21 and 22 on the Form CMS-1500 must be completed for all laboratory work performed outside a physician's office.  If an independent lab bills, the place where the sample was taken is shown.  An independent laboratory taking a sample in its laboratory shows "81" as place of service.  If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on campus-outpatient hospital (POS code 22), respectively. You can find this rule at Medicare Claims Processing Manual Chapter 26 Section 10.6.  

The rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I.  

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 find this rule at 42 CFR Section 424.5.  

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 state that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of service. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.6.

 The rules say that for all services (with two (2) exceptions), the 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 Medicare Learning Network (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 SelectMDx testing is covered in males with previous negative prostate biopsy who are being considered for repeat biopsy. This rule can be found in Medicare Local Coverage Determination MolDx: ConfirmMDx Epigenetic Molecular Assay (L36327).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract lists the specific dental services that are covered. This benefit includes comprehensive oral evaluation, complete series x-ray, and panoramic x-ray once every 3 plan years. This benefit also includes crowns and core build up once per tooth every 5 plan years. Oral or facial photographic images are not listed and therefore are not covered services. The contract also says any services not listed are not covered. You can find this information on pages 4-64 to 4-77 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that 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 for an MA-plan, non-contracting, non-participating DME supplier, the MAO must pay the
non-contracting non-participating (non-par) DME supplier the difference between the enrollee's cost-sharing
and the DME supplier's bill; the enrollee only pays plan-allowed cost-sharing. The coinsurance percentage is
multiplied by the total provider bill, if the MAO uses a coinsurance method for its cost-sharing. Note that the
total provider bill may include permitted balance billing. You can find this information in the Centers for
Medicare and Medicaid Services, Internet-Only Manual, Publication 100-16, Medicare Managed Care Manual,
Chapter 4, 170.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.