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 $100 copayment for ambulance services.  You can find this information 
on page(s) 56 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 a $375 copayment for outpatient surgery.  You can find this information 
on page(s) 101 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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that definitive urine drug testing (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 rule in the Local Coverage 
Determination for Controlled Substance Monitoring and Drugs of Abuse Testing, L35006. 
 
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 $65 copayment for inpatient hospital care. The enrollee must pay a $65 
copayment per day for days 1-5 and a $0 copayment for days 6-90. You can find this information on page(s) 75 
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 Home Health Aide (HHA) services may be covered only if the enrollee needs one or more of 
the following qualified skilled services:  
 
1. Skilled nursing care;  
2. Physical therapy;  
3. Occupational therapy; or  
4. Speech pathology services.  
 
HHA services are no longer covered for enrollees once the qualifying skilled service has ended. To be covered, 
home health aide services must be reasonable and necessary. You can find this rule at 42 CFR Sections 409.44 
and 409.45. 
 
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 & Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 $240 copayment for inpatient hospital care. The enrollee must pay a 
$240 copayment per day for days 1-5 and a $0 copayment for days 6 and beyond. You can find this information 
on page(s) 63 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 the evaluation and management services on the day before major surgery or on the day of 
major surgery that result in the initial decision to perform the surgery are not included in the global surgery 
payment for the major surgery and, therefore, may be billed and paid separately. In addition to the Current 
Procedural Terminology (CPT) evaluation and management code, modifier "-57" (decision for surgery) is used 
to identify a visit which results in the initial decision to perform surgery. You can find this information in the 
Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 12, Section 40.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator N means that this code is not covered by 
Medicare. Medicare uses another code for reporting of, and payment for, these services. You can find this 
information in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare & Medicaid 
Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and 
Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) are categorized 
into payment classes, such as capped rental items. The CMS determines the category that applies to each 
HCPSC code and issues instructions when changes are appropriate. You can find this rule in the Centers for 
Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 20, Section 30. 
 
The rules say that claims must specify whether equipment is rented or purchased. Modifier -RR indicates a 
rental. Use the -RR modifier when the durable medical equipment is to be rented. Modifier -KH indicates the 
initial claim for the first month rental of a DMEPOS item. Modifier -KI indicates a DMEPOS item in the 
second or third month of rental. Modifier -KJ indicates a DMEPOS capped rental in months four to fifteen. 
You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 20, Section 130.9. 
 
The rules say that in all of the situations describing use of the KX modifier, if all of the coverage criteria have 
not been met, the GA or GZ modifier must be added to a claim line for the PAP equipment and accessories. 
When there is an expectation of a reasonable and necessary denial, suppliers must enter the GA modifier on the 
claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if 
they have not obtained a valid ABN. Claim lines billed without a GA, GZ or KX modifier will be rejected as 
missing information. You can find this rule in the Local Coverage Article for Positive Airway Pressure (PAP) 
Devices for the Treatment of Obstructive Sleep Apnea, A52467. 
 
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 50% coinsurance for physician/practitioner services, including doctors 
office visits.  You can find this information on page(s) 108 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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2.  
 
The rules say that a Licensed Professional Counselor is not eligible to participate in Medicare. You can find 
this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-08, 
Medicare Program Integrity Manual, Chapter 10, Section 10.2.8 
 
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 ineligible mental health and substance abuse providers, such as a Licensed 
Professional Counselor (LPC), are not covered under any condition. You can find this information on page 98 
of the Plans 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 outpatient surgery, including services provided at 
ambulatory surgical centers. You can find this information on page 78 of the Plan's 2023 Evidence of Coverage 
(EOC).  
 
The Plan contract also says that enrollees in-network maximum out-of-pocket (MOOP) amount is $3,600. You 
can find this information on page 42 of the Plan's 2023 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 20% coinsurance for outpatient diagnostic tests and therapeutic services 
and supplies.  You can find this information on page(s) 78 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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that the continuous glucose monitor (CGM) supply allowance includes all items necessary for the 
use of the device and includes, but is not limited to, CGM sensors and transmitters. Only one (1) month, thirty 
(30) days of the supply allowance may be billed to the DME MAC at a time; however, suppliers may dispense 
up to a ninety (90) day supply. You can find this rule in the Local Coverage Article for Glucose Monitors, 
A52464. 
 
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 outpatient diagnostic tests and therapeutic services 
and supplies.  You can find this information on page(s) 91 to 94 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 payment may be made for services furnished by an opt-out physician or practitioner who 
has not signed a private contract with a Medicare beneficiary for emergency or urgent care items and services 
furnished to, or ordered or prescribed for, such beneficiary on or after the date the physician opted out. 
 
Where a physician or practitioner who has opted out of Medicare treats a beneficiary with whom the physician 
or practitioner does not have a private contract in an emergency or urgent care situation, the physician or 
practitioner may not charge the beneficiary more than the Medicare limiting charge for the service and must 
submit the claim to Medicare on behalf of the beneficiary for the emergency or urgent care. Medicare payment 
may be made to the beneficiary for the Medicare covered services furnished to the beneficiary. 
 
In this circumstance the physician or practitioner must submit a completed Medicare claim on behalf of the 
beneficiary with the appropriate Healthcare Common Procedure Coding System (HCPCS) code and HCPCS 
modifier that indicates the services furnished to the Medicare beneficiary were emergency or urgent care 
services and the beneficiary does not have a private contract with the physician or practitioner. If the physician 
or practitioner did not submit the GJ national HCPCS modifier, then the Medicare contractor must deny the 
claim so that the beneficiary can appeal. 
 
Modifier GJ (opt-out physician/practitioner emergency or urgent services) must be used on claims for services 
rendered by an opt-out physician/ practitioner for an emergency/urgent care service. The use of this modifier 
indicates that the service was furnished by an opt-out physician/practitioner who has not signed a private 
contract with a Medicare beneficiary for emergency or urgent care items and services furnished to, or ordered 
or prescribed for, such beneficiary on or after the date the physician/practitioner opted out. 
 
You can find this rule in the Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 15, Section 40.28.  
 
 
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).  
 
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 there is a $525 deductible which applies to certain items and services. The Plan 
deductible applies to the inpatient hospital stay. You can find this information on page 48 of the Plan's 2023 
Evidence of Coverage (EOC).   
 
The Plan contract also says that enrollees must pay 10% coinsurance per stay, for in-network Medicare-covered 
hospital stays. You can find this information on page 82 of the Plan's 2023 EOC.  
 
The Plan contract also says that the maximum out-of-pocket (MOOP) amount for medical services for calendar 
year 2023 is $2,300. You can find this information on page 50 of the Plan's 2023 EOC.