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 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 a list of 
covered services when rendered by a participating provider. This benefit also includes a list of covered dental 
procedure codes. Dental codes D9120, D6010 and D6064 are not listed and therefore not covered by the Plan's 
dental benefit. You can find this information on pages 58 to 59 and on pages 100 to 101 of the Plans 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 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).

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 you can continue to sell OTC COVID-19 tests to patients, including those enrolled in Part B 
or Medicare Advantage (MA) plans. But, starting on May 12, 2023, Medicare will not cover or pay for OTC 
COVID-19 tests for Medicare Part B patients. 
 Only give patients OTC COVID-19 tests when they request them, and inform patients (or their 
caregivers) that Medicare does not cover or pay for these tests. 
 You can voluntarily give the patient an Advanced Beneficiary Notice of Non-Coverage (ABN) before 
you give them an OTC COVID-19 test. The ABN is not required, but it tells the patient that Medicare 
does not cover OTC COVID-19 tests and lets them know they will pay out-of-pocket for the tests. 
 
You can find these rules in the Centers for Medicare and Medicaid Services (CMS) online article, COVID-19 
Over-the-Counter Tests (https://www.cms.gov/files/document/covid-over-counter-test-coverage.pdf). 
 
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 the usual maximum frequency of replacement for a lithium-based battery (E2397) is one 
every 3 years. Only one battery is allowed at any one time. 
 
The rules also say that adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the 
beneficiary requires an arm height that is different from that available using nonadjustable arms and the 
beneficiary spends at least 2 hours per day in the wheelchair. 
 
You can find these rules in the Local Coverage Determination (LCD) for Wheelchair Options/Accessories 
(L33792). 
 
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 botulinum toxins (Botox, Dysport, Xeomin, and Myobloc), will be considered medically 
reasonable and necessary when administered for treatment of Food & Drug Administration (FDA)-labeled 
indications and Off-label indications (as applicable) below: 
1. FDA indications for Botox as noted on the FDA website 
2. Off-Label indications for onabotulinumtoxinA (Botox) may be considered medically reasonable and 
necessary in patients for the following conditions: 
- Esophageal achalasia in adults who are considered poor surgical candidates 
- Chronic anal fissure for patients with inadequate response to conservative or pharmacologic 
treatment 
- Essential hand tremor for patients with a high amplitude tremor that disrupts activities of daily 
living and have had inadequate response to oral pharmacotherapy such as propranolol and 
primidone 
- Focal limb dystonia 
- Hemifacial spasm in adults (cranial nerve VII disorder) 
- Isolated oromandibular dystonia in adults 
- Laryngeal dystonia (spastic dysphonia) for adductor type (ADSD) 
- Bothersome simple motor tics in adolescents and adults when the benefits of treatment outweigh 
the risks 
- Severely disabling or aggressive vocal tics in older adolescents and adults when the benefits of 
treatment outweigh the risks 
 
You can find these rules in Local Coverage Determination (LCD) Botulinum Toxins (L38809). 
 
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 does not cover chiropractic maintenance care. When further clinical improvement 
cannot be reasonably expected from ongoing care, the care is considered maintenance. You can find this rule in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 15, Section 240.1.3. 
 
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 the only covered chiropractic service is manual manipulation of the spine to correct 
subluxation. You can find this information on page 48 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 20% coinsurance for Medicare Part B prescription drugs. There is no 
additional cost for the administration of Part B drugs. You can find this information on page 63 of the Plan's 
2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that home health agencies (HHAs) must report where home health services were provided. The 
following codes are used for this reporting: 
- H5001: Home health care provided in patients home/residence 
- H5002: Home health care provided in assisted living facility 
- H5009: Home health care provided in place not otherwise specified 
 
The location where services were provided must always be reported along with the first visit reported on the 
claim. In addition to reporting a visit line using the G codes as described above, HHAs must report an 
additional line item with the same revenue code and date of service, reporting one of the three Q codes (Q5001, 
Q5002, and Q5009), one unit and a nominal covered charge (e.g., a penny). If the location where services were 
provided changes during the period of care, the new location should be reported with an additional line 
corresponding to the first visit provided in the new location. You can find these rules in Medicare Claims 
Processing Manual Chapter 10, 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 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% coinsurance for Part B chemotherapy. You can find this 
information on page 87 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 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 physicians in the same group practice who are in the same specialty must bill 
and be paid as though they were a single physician. If more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or 
more than one physician in the same specialty in the same group, only one evaluation and management 
service may be reported unless the evaluation and management services are for unrelated problems. 
Instead of billing separately, the physicians should select a level of service representative of 
the combined visits and submit the appropriate code for that level. You can find this rule at 
Medicare Claims Processing Manual Chapter 12 - Section 30.6.5.

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 Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. You can find this rule in 
the Centers for Medicare & 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 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 (CMS), Medicare National Correct Coding Initiative Policy 
Manual for Medicare Services, Chapter I(A). 
 
The rules say that all line items for the same beneficiary, same NPI, and same date of service shall be subject to 
NCCI Procedure-to-Procedure (PTP) edits. If the correct coding modifier indicator (CCMI) of a PTP edit is 
"0", the Column Two code is not eligible for payment even if an NCCI PTP-associated modifier is 
appropriately appended to one of the codes. If the CCMI of a PTP edit is "1", the edit may be bypassed, and the 
Column Two code of the edit may be eligible for payment if an NCCI PTP-associated modifier is appropriately 
appended to one of the codes. You can find this rule in the Centers for Medicare & Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9.1.1. 
 
The rules say that CMS issued replacement files for NCCI Procedure to Procedure (PTP) edits for the October 
1, 2023, files (PRA and OPH). Effective July 1, 2023, CMS implemented NCCI PTP edits between Column 
One codes 80305, 80306, and 80307 for presumptive test(s), and Column Two codes G0480  G0483, and 
G0659 for definitive test(s). CMS will withdraw these edits retroactive to July 1, 2023, in a replacement file for 
the 4th quarter of 2023. The MACs will adjust those claims with dates of service between July 1, 2023, and 
October 1, 2023, to allow payment as appropriate under existing payment and coverage policies. Alternatively, 
a laboratory may also choose to use the MAC appeals process if it does not wish to wait for the automatic 
adjustment to occur, or it can wait to submit its claims until CMS implements the change. You can find this in 
the Centers for Medicare & Medicaid Services (CMS), Medicare National Correct Coding Initiative Edits 
Replacement Files. 
 
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 in order to receive payment for covered items or services from either Medicare or a 
Medicare beneficiary, a provider or supplier must be enrolled in the Medicare program. You can find this rule 
in 42 Code of Federal Regulations (CFR), Section 424.505. 
 
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 you can get your care from an out-of-network provider, however, in most cases that provider must 
be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who has opted out 
of or been excluded or precluded from the Medicare Program. If you receive care from a provider who is not 
eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. You can 
find this information on page 46 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 medically necessary services are those that are reasonable and necessary for the 
diagnosis or treatment of an illness or injury. Medically necessary services include services to 
improve the functioning of a malformed body member. You can find this rule in the Social Security 
Act, Section 1862(a)(1)(A).

The rules also say that a power seat elevation feature (E2300) and power standing feature (E2301) 
are noncovered because they are not primarily medical in nature. If a wheelchair has an electrical 
connection device described by code E2310 or E2311 and if the sole function of the connection is 
for a power seat elevation or power standing feature, it will be denied as non-covered. You can 
find this rule in the Local Coverage Article (LCA) for Wheelchair Options/Accessories - Policy 
Article (A52504).

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 medically necessary services are those that are reasonable and necessary for the 
diagnosis or treatment of an illness or injury. Medically necessary services include services to 
improve the functioning of a malformed body member. You can find this rule in the Social Security 
Act, Section 1862(a)(1)(A).

The rules say that services that are not medically necessary are not covered. The rules also say 
that experimental and investigational devices are not covered. You can find this rule at 42 CFR 
Sections 411.15 and 411.15(o).

The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a 
medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of 
equipment that are clearly used for medical purposes. Medicare will not pay for:

1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners;
2. Equipment used for a patient's comfort or for the convenience of a person caring for the 
patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help 
devices such as grab bars. You can find these rules in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100- 02, Medicare Benefit Policy Manual, Chapter 15, 
Section 110.1.

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 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 crowns 
(D2750), provisional crowns (D2799), and core build-ups (D2950). You can find this information on pages 75 
to 76 of the Plans 2023 Evidence of Coverage (EOC).