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 $200 copayment for ambulance services/per groundambulance 
transport.  You can find this information on page(s) 54 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 for Pigmented Lesion Assay to be covered, the lesion tested must meet the following 
characteristics: 
 
1. The lesion must meet one or more ABCDE criteria (Asymmetry, Border, Color, Diameter, Evolving) 
2. Primary melanocytic skin lesions between 5mm and 19mm 
3. Lesions where the skin is intact (i.e. non-ulcerated or non-bleeding lesions) 
4. Lesions that do not contain a scar or were previously biopsied 
5. Lesions not located in areas of psoriasis, eczema or similar skin conditions 
6. Lesions not already clinically diagnosed as melanoma or for which the clinical suspicion is sufficiently high 
that the treating clinician believes melanoma is a more likely diagnosis than not 
7. Lesions in areas other than palms of hands, soles of feet, nails, mucous membranes and hair covered areas 
that cannot be trimmed. 
 
This information is found in Local Coverage Determination (LCD): MolDX: Pigmented Lesion Assay 
(L38151). 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9.  
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
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.  
 
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).   
 
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 $10 copayment for each Medicare-covered chiropractic service. 
Enrollees must also pay a $10 copayment for each non-Medicare covered chiropractic routine visit. The 
deductible applies to non-Medicare covered x-rays services performed by an out-of-network chiropractor. As a 
member of the Plan, the most you will have to pay out-of-pocket for out-of-network covered services in 2023 is 
$3,200. The amounts you pay for deductibles, copayments, and coinsurance for out-of-network covered 
services count toward this maximum out-of-pocket amount. Additionally, Medicare-covered services include 
manual manipulation of the spine to correct a subluxation. Office visits and x-rays related to a Medicare-
covered service are not covered. Non-Medicare covered routine visits can be used for conditions including, but 
not limited to, back pain, neck pain, and headaches. You can find this information on page 62 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 $10 copayment for outpatient diagnostic tests/lab serices.  You can find 
this information on page(s) 73 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 state that the ambulance must have customary patient care equipment and first aid supplies, including 
reusable devices and equipment such as backboards, neck boards, and inflatable leg and arm splints. These are 
all considered part of the general ambulance service and payment for them is included in the payment rate for 
the transport. You can find this rule in the Centers for Medicare and Medicaid Services (CMS) Internet-Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.1.5. 
 
The rules say that payment for items and services is included in the fee schedule payment. Such items and 
services include but are not limited to oxygen, drugs, extra attendants, and EKG testing - but only when such 
items and services are both medically necessary and covered by Medicare under the ambulance benefit. You 
can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 15, 30.1. 
 
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 state that the test panel is a single test with multiple components and is characterized by a single unit 
of service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact 
that the test reports multiple individual pathogens and/or targets. If additional organisms are not included in a 
panel, testing for those organisms separately may be reasonable and necessary when ordered in addition to the 
panel and supported by documentation in the medical record. You can find this information in Local Coverage 
Article (LCA): Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen 
Identification Testing (A58761). 
 
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 for air ambulance services only if the enrollees medical condition is such that 
transportation by either basic, the provision of medically necessary supplies and services or advanced life 
support, an emergency medical technician (EMT) intermediate or EMT-Paramedic ground ambulance is not 
appropriate. Air ambulance services may be covered only if: 
 
1. certain vehicle and crew requirements are met; 
 
2. the enrollees medical condition needed immediate and rapid ambulance transport that could not have been 
provided by ground ambulance; and  
 
3. either the point of pickup is not accessible by ground vehicle or great distances, or other obstacles are 
involved in getting the patient to the nearest hospital with appropriate facilities. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 10, Sections 10.4, and 10.4.1, and 30.1.1. 
 
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 outpatient diagnostic test/lab services.  You can find 
this information on page(s) 70 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 state that repairs to equipment which a beneficiary owns are covered when necessary to make the 
equipment serviceable. If the expense for repairs exceeds the estimated expense of purchasing or renting 
another item of equipment for the remaining period of medical need, no payment can be made for the amount 
of the excess. You can find this information in the Centers for Medicare and Medicaid Services (CMS), 
Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2. 
 
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 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 Chapter 3 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 Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. 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, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. You can find this rule at 42 CFR Section 422.111(a) and (b). 
 
The rules say that If the patient's condition requires bed side rails, they can be covered when an integral part of, 
or an accessory to, a hospital bed. You can find this rule in National Coverage Determination (NCD) Hospital 
Bed 280.7. 
 
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. The Plan 
contract also says that the Plan will not cover other brands and manufacturers unless your doctor or other 
provider tells us that the brand is appropriate for your medical needs. You can find this information on page 56 
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 global surgery package of procedures with a global period of 10 or 90 days includes all 
additional medical or surgical services required of the surgeon during the postoperative period of the surgery 
because of complications which do not require additional trips to the operating room, follow-up visits during 
the postoperative period of the surgery that are related to recovery from the surgery, among other related 
services. In order to report an unrelated evaluation and management (EM) service by same physician during a 
postoperative period, modifier -24 must be used. Services submitted with the -24 modifier must be sufficiently 
documented to establish that the visit was unrelated to the surgery. Not included in the global surgery payment 
are clearly distinct surgical procedures during the postoperative period which are not re-operations or treatment 
for complications. These services should be billed with modifier -79. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 12, Section 40.1. 
 
The rules say that the Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. MUEs for codes with an MAI of 3 are per day edits based on clinical 
benchmarks. Codes with an MAI of 3 are based on criteria combined with data such that it would be 
possible, but medically unlikely, that higher values would represent correctly reported medically necessary 
services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, 
were correctly coded, and were medically necessary.  
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(V). 
 
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 $45 copayment for physician/practitioner services/specialist 
telemedicine visit.  You can find this information on page(s) 81 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 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 39 to 40 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 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. Crowns, core buildup, and bridges are covered by the Plan's dental benefits. You can find this 
information on pages 81 to 82 of the Plans 2023 Evidence of Coverage (EOC).