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 Modifiers GN, GO, and GP refer only to services provided under plans of care for physical 
therapy, occupational therapy and speech-language pathology services. They should never be used with codes 
that are not on the list of applicable therapy services. For example, respiratory therapy services, or nutrition 
therapy services shall not be represented by therapy codes which require GN, GO, and GP modifiers. 
Contractors edit institutional claims to ensure the following: 
 that a GN, GO or GP modifier is present for all lines reporting revenue codes 
042X, 043X, or 044X. 
 that no more than one GN, GO or GP modifier is reported on the same service 
line. 
 that revenue codes and modifiers are reported only in the following combinations: 
o Revenue code 42x (physical therapy) lines may only contain modifier GP 
o Revenue code 43x (occupational therapy) lines may only contain modifier GO 
o Revenue code 44x (speech-language pathology) lines may only contain 
modifier GN. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.1. 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 46-49 of the Plan's 2022 
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 for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity
Manual Chapter 3, 3.3.2.1.
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 for all beneficiaries receiving home health services in 2021 whose services will continue in 
2022, the home health agency (HHA) shall submit a Notice of Admission (NOA) with a one-time, artificial 
'admission' date corresponding to the "From" date of the first period of continuing care in 2022. For example, if 
a period of care begins in 2021 and ends on January 10, 2022, the HHA submits and NOA with an admission 
date of January 11, 2022, and then submits a claim when the 30-day period of care is over. The HHA should 
submit the January 11, 2022, admission date on all subsequent claims until the beneficiary is discharged and 
another NOA is required. This is to ensure the claim is matched to the correct NOA and the correct receipt date 
is used for payment. You can find this information in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.1.10.3. 
 
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.
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 Oncotype DX Breast genetic testing was developed for patients with the following findings: 
 
1. estrogen-receptor positive, node-negative carcinoma of the breast 
2. estrogen-receptor positive micrometastases of carcinoma of the breast, and 
3. estrogen-receptor positive breast carcinoma with 1-3 positive nodes. 
 
This information is found in Local Coverage Article: Billing and Coding: MolDX: Oncotype DX Breast Cancer 
Assay (A54480). 
 
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 if a Medically Unlikely Edits (MUE) value is listed as 0 (zero), the procedure code is 
invalid, not covered, bundled, not separately payable, statutorily excluded, or not reasonable and necessary. 
This rule is found in the Medicare Claims Processing Manual Chapter 23, Section 20.9.3.2- Medically Unlikely 
Edits (MUEs). 
 
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 provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules state that definitive drug testing is indicated when: 
1. The results of the screen are presumptively positive. 
2. Results of the screen are negative, and this negative finding is inconsistent with the patient's medical history. 
3. This test may also be used, when the coverage criteria of the policy are met AND there is no presumptive 
test available, locally and/or commercially, as may be the case for certain synthetic or semi-synthetic opioids. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD): Drug Testing (L34645). 
 
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 $40 copayment for urgent care services. You can find this information 
on page(s) 4-53 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 a Pneumatic Compression Device (PCD) that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a 
preventative service or function are excluded from coverage under the Medicare DME benefit. A PCD coded as 
E0675 to treat peripheral arterial disease is not eligible for reimbursement. There is insufficient evidence to 
demonstrate that reimbursement is justified. Claims for E0675 will be denied as not reasonable and necessary. 
You can find this information in the Local Coverage Article: Pneumatic Compression Devices - Policy Article 
(A52488) and in the Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829). 
 
The rules say that CMS does not pay any provider or supplier other than the facility or hospital for services 
furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary 
either directly or under arrangements. You can find this rule in 42 CFR 409.32. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 home health agencies (HHAs) must send the notice of admission (NOA) to the A/B MAC by 
mail, electronic data interchange (EDI), or direct data entry (DDE). EDI submissions require additional data 
not required by the NOA itself, to satisfy transaction standards. This data is described in a companion guide 
available on the Centers for Medicare and Medicaid Services website. HHAs may voluntarily agree to adopt 
the companion guide and use it to submit EDI NOAs at any time. 
 
The rules say that the admission date on the NOA must always match the From date. 
 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Claims Processing Manual, Chapter 10, Section 40.1. 
 
The rules say that HHAs shall no longer submit a Request for Anticipated Payment (RAP) for any home health 
(HH) period of care with a From date on or after January 1, 2022. Instead, for each admission to home health, 
the HHA notifies Medicare systems via submission of an NOA.  
 
HHAs shall send the NOA to the A/B MAC by mail, electronic data interchange (EDI), or direct data entry 
(DDE). EDI submissions require additional data not required by the NOA itself, to satisfy transaction 
standards. This data is described in a companion guide available on the CMS website. HHAs may voluntarily 
agree to adopt the companion guide and use it to submit EDI NOAs at any time.  
 For all beneficiaries receiving HH services in 2021 whose services will continue in 2022, the HHA shall submit 
an NOA with a one-time, artificial 'admission' date corresponding to the "From" date of the first period of 
continuing care in 2022. For example, if a period of care begins in 2021 and ends on January 10, 2022, the 
HHA submits and NOA with an admission date of January 11, 2022 and then submits a claim when the 30-day 
period of care is over. The HHA should submit the January 11, 2022 admission date on all subsequent claims 
until the beneficiary is discharged and another NOA is required. This is to ensure the claim is matched to the 
correct NOA and the correct receipt date is used for payment. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Claims Processing Manual, Chapter 10, Section 10.1.10.3. 
 
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.
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 composite ambulatory payment classifications (APCs) provide a single payment for a 
comprehensive diagnostic and/or treatment service that is defined, for purposes of the APC, as a service 
typically reported with multiple codes. When codes that meet the criteria for payment of the composite APC 
are billed on the same date of service, CMS makes a single payment for all of the codes as a whole, rather than 
paying individually for each code.  
 
A service that is assigned to a composite APC is a major component of a single episode of care. The 
hospital receives one payment through a composite APC for multiple major separately identifiable services. 
Services mapped to composite APCs are assigned status indicator Q3.  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Sections 10.2.1 and 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 that breast reconstruction of the affected and the contralateral unaffected breast following a 
medically necessary mastectomy is covered. You can find this rule in the Local Coverage Determination 
(LCD) - Cosmetic and Reconstructive Surgery (L39051) - Effective November 14, 2021. 
 
The rules say that reconstructive surgery is performed on abnormal structures of the body, caused by congenital 
defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally 
performed to improve function, may also be done to approximate a normal appearance, and may be covered as 
surgery is considered reconstructive in nature. Cosmetic surgery is performed to reshape normal structures of 
the body in order to improve the patient's appearance and self-esteem. You can find this rule in the Local 
Coverage Determination (LCD) - Cosmetic and Reconstructive Surgery (L39051) - Effective November 14, 
2021. 
 
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 $40 copayment for an x-ray. You can find this information in Chapter 4 
on pages 55-56 of the Plan's 2022 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 STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. You 
can find this rule at Centers for Medicare and Medicaid Services, Internet-Only Publication 100-04, Medicare 
Claims Processing Manual, Chapter 4, Section 10.4.(C)(2). 
 
The rules say that a service that is assigned to a composite Ambulatory Payment Classification (APC) is a 
major component of a single episode of care. The hospital receives one payment through a composite APC for 
multiple major separately identifiable services. Services mapped to composite APCs are assigned status 
indicator Q3. You can find this rule at Centers for Medicare and Medicaid Services, Internet-Only Publication 
100-04, Medicare Claims Processing Manual, Chapter 4, Section 10.4.(C)(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 state that providers must enter the correct date of service into item 24A of the 1500 Form. This is a 
required field that must be completed accurately. You can find this rule at Centers for Medicare and Medicaid 
Services, Internet-Only 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 $225 copayment for advanced imaging services. You can find this 
information on pages 107-108 of the Plan's 2022 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 when services or supplies are rendered by a non-contracting, original Medicare, participating 
provider, there is no balance billing paid by either the Plan or the enrollee. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 4, 170.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that providers are not allowed to balance bill you. You only have to pay your cost sharing 
amount when you get services that are covered by the Plan. The contract says never paying more than your cost 
sharing amount applies even if the Plan pays the provider less than the provider charges for a service. The 
contract says if you believe a provider has balance billed you, you can call the Plans Customer Care Center. 
You can find this information on pages 40-41 of the Plans 2022 Evidence of Coverage (EOC).