Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that for claims with dates of service on or after January 1, 2001, providers must report revenue 
code 0540 and one of the following HCPCS codes for each ambulance trip provided during the billing period:  
A0426; A0427; A0428; A0429; A0430; A0431; A0432; A0433; or A0434.  
 
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, 30.2(D). 
 
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 $250 copayment for outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers. You can find this information in Chapter 4 on 
page 81 of the Plan's 2021 Evidence of Coverage (EOC). 
 
The Plan contract also says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs. 
You can find this information in Chapter 4 on page 76 of the Plan's 2021 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 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 the following conditions are met (42 CFR 422.100(l)): 
 
 The MA plan provides all categories of DME covered under original Medicare Part B; 
 The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
 The MA plans contracted suppliers provide access to all preferred DME brands; 
 During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 
90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year; 
 Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
 The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
 The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the Evidence of Coverage and Annual Notice of Change and on its website; and 
 The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by CMS to require full coverage. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS) Medicare Managed 
Care Manual Chapter 4, Section 10.12.2- Specifying Brands or Manufacturers of DME. 
 
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 we exclusively cover diabetic supplies made by OneTouch/LifeScan. Specifically, we 
cover the OneTouch Verio, OneTouch Ultra and OneTouch UltraMini glucose monitors and test strips. We also cover OneTouch/LifeScan lancets, solutions and lancing devices. We generally will not cover other 
brands of monitors and test strips unless you or your provider requests a medical exception. If the exception is 
approved, a 20% cost-share will apply. You can find this information on page 66 of the Plan's 202 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 for Medicare payment to occur, interactive audio and video telecommunications must be 
used, permitting real-time communication between the distant site physician or practitioner and the Medicare 
beneficiary. As a condition of payment, the patient must be present and participating in the telehealth visit. 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, 190.4. 
 
The rules say that pursuant to authority granted under the CARES Act, CMS is waiving the requirements of 
section 1834(m)(1) of the ACT and 42 CFR  410.78(a)(3) for use of interactive telecommunications systems 
to furnish telehealth services, to the extent they require use of video technology, for certain services. This 
waiver allows the use of audio-only equipment to furnish services described by the codes for audio-only 
telephone evaluation and management services, and behavioral health counseling and educational services (see 
designated codes https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes). 
Unless provided otherwise, other services included on the Medicare telehealth services list must be furnished 
using, at a minimum, audio and video equipment permitting two-way, real-time interactive communication 
between the patient and distant site physician or practitioner. 
 
You can find this information in the COVID-19 Emergency Declaration Blanket Waivers for Health Care 
Providers. 
 
 
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 home health care services under a prospective payment system (HH PPS). 
Home health services under a plan of care are paid based on a 60-day episode of care. Payment for home health 
care episodes is usually made in two parts. To receive the first part of the HH PPS split payment, the home 
health agency must submit a Request for Anticipated Payment (RAP). Specific data elements are required to 
submit a RAP. The home health agency must enter the claim - Outcome and Assessment Information Set 
(OASIS) matching key output by the Grouper software. This is known as the Treatment Authorization Code. 
You can find this rule, a list of the data elements, and instructions for the Treatment Authorization Code in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 10, Section 40.1. 
 
The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid 
information for all of these elements may be returned as unprocessable. You can find this rule in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 1, Section 80.3.1. 
 
The rules say that 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 rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 10, Section 40.1. 
 
  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. 
 
Medicare guidance says to Lower the Medicare Fee- For- Service Paid Claims Error Rate, CMS has established 
units of service edits referenced to as Medically Unlikely Edit(S)(MUEs). An MUE for a HCPCS/CPT code is 
the maximum number of units of service (UOS) under most circumstances allowable by the same provider for 
the same beneficiary on the same date of service. The ideal MUE value for a HCPCS/ CPT code is the unit of 
service that allows the vast majority of appropriately coded claims to pass the MUE. 
 
Prior to April 1, 2013, each line of a claim was adjudicated separately against the MUE value for the 
HCPCS/CPT code reported on that claim line. If the UOS on that claim line exceeded the MUE value, the 
entire claim line was denied. The MUE files on the CMS NCCI website display an "MUE Adjudication 
Indicator" (MAI) for each HCPCS/ CPT code An MAI of "1" indicates that the edit is a claim line MUE. An 
MAI of "2" or "3" indicates that the edit is a DOS MUE. You can find this guidance in the NCCI Policy 
Manual for Medicare Services, Chapter 1, Section V - Medically Unlikely Edits (MUES). 
 
Per review of CMS MUE Practitioner Services 2020 File shows 88321 has the MUE value of "1" with MUE 
Adjudication Indicator as "2 Date of Service Edit" and per NCCI Chapter 1 Section "V" it states: MUES for 
HCPCS codes with an MAI of "2" are absolute date of service edits. These are "per day edits based on policy". 
HCPCS codes with an MAI of "2" have been rigorously reviewed and vetted within CMS and obtain this MAI 
designation because UOS on the same date of service (DOS) in excess of the MUE value would be considered 
impossible because it was contrary to statue, regulation, or subregulatory guidance. This subregulatory 
guidance includes clear correct coding policy that is binding on both providers and CMS claims processing 
contractors. Limitations created by anatomical, or coding limitations are incorporated in correct coding policy, 
both in the HIPAA mandated coding descriptors and CMS approved coding guidance as well as specific 
guidance in CMS and NCCI manuals.  
 
 As a result, claims processing contractors are instructed that an MAI of "2" denotes a claims processing 
restriction for which override during processing, reopening, or redetermination would be contrary to CMS 
policy. You can find this guidance in the NCCI Policy for Medicare Services Chapter 1 General Correct 
Coding Policies Section V and CMS MUE Table. 
 
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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $50 copayment for outpatient diagnostic testing, including 
echocardiograms. You can find this information on pages 95-97 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 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 $295 copayment for Medicare-covered surgery or other services 
provided to you at an outpatient hospital. You can find this information in Chapter 5 on pages 38 to 40 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 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 $35 copayment for an outpatient diagnostic test. You can find this 
information on page 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/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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules also say that when reporting an "unlisted procedure code" or a "not otherwise classified" (NOC) 
code, include a narrative description in claim form item 19 if a coherent description can be given within the 
confines of that box. Otherwise, an attachment shall be submitted with the claim. This is a required field. 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 10.4. 
 
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 $280 copayment for days 1-6 for inpatient hospital care. You can find 
this information in Chapter 4 on page 22 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 state that a review of the available evidence found five combinatorial pharmacogenomics (PGx) tests 
for which outcome data has been published. These studies focus on testing for drug selection for psychiatric 
and neurological use and include the Genesight Psychotropic assay. A review of the published clinical studies 
performed demonstrated that, despite showing some promising findings, these studies had several shortcomings 
in that they failed to meet their primary endpoints, were not representative of the Medicare population, or had 
other significant shortcomings such as a possible biased sample population. While there are some large PGx 
studies, the Medicare contractor is not aware of large high-quality studies that used a clear evidence-based 
prescribing approach in the control arm. As a number of prominent psychiatrists with expertise in the biological 
underpinnings of mental health have pointed out, it is not clear that PGx testing is a better tool for drug 
selection than using a standardized evidence-based protocol which does not rely on genetics, or a consultation 
from a knowledgeable provider. In summary, the present evidence does not clearly demonstrate that routine 
PGx testing for the purpose of medication selection offers a benefit over selection of medications based on 
contemporary evidence-based medication selection protocols. You can find this information in the Local 
Coverage Determination (LCD): MolDX: Pharmacogenomics Testing (L38394). 
 
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 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 says that enrollees must pay a $40 copayment for a diagnostic hearing evaluation from a specialty 
provider. You can find this information on page 66 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 state that Plans may provide transplant services at a location further away than the normal community 
patterns of care for that service. In any circumstance in which an MA plan provides transplant services at a 
more distant location, the MA plan must provide reasonable transportation and accommodations for the 
enrollee and a companion. 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, Section 10.11. 
 
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.