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 outpatient diagnostic tests and therapeutic services 
and supplies.  You can find this information on page(s) 84 to 86 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 $50 copayment for physician/practitioner services, including doctors 
office visits.  You can find this information on page(s) 51 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 fluid used to administer the drug (s) is incidental hydration and is not separately payable. 
You can find this rule in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.5. 
 
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 Medicare pays for ambulance services that meet certain origin and destination requirements. 
Medicare will cover the following ambulance transportation: 
 
1. From any point of origin to the nearest hospital, critical access hospital (CAH), rural emergency hospital 
(REH), or skilled nursing facility (SNF) capable of furnishing appropriate care for a patients illness or injury; 
 
2. From a hospital, CAH, REH, or SNF to a patients home; 
 
3. From a SNF to the nearest supplier of medically necessary services not available at the SNF where the 
patient resides, including the return trip; and 
 
4. For a patient receiving renal dialysis for end stage renal disease, from the patients home to the nearest 
facility that furnishes renal dialysis, including the return trip. You can find these rules at CFR Section 
410.40(f). 
 
The rules also say that for ambulance service claims, institutional-based providers and suppliers must report an 
origin and destination modifier for each ambulance trip provided in HCPCS/Rates. Origin and destination 
modifiers used for ambulance services are created by combining two alpha characters. Each alpha character, 
with the exception of "X", represents an origin code or a destination code. The pair of alpha codes creates one 
modifier. The first position alpha code equals origin; the second position alpha code equals destination. Origin 
and destination codes and their descriptions are listed below: 
 
D = Diagnostic or therapeutic site other than P or H when these are used as origin codes; 
E = Residential, domiciliary, custodial facility (other than 1819 facility); 
G = Hospital based ESRD facility; 
H = Hospital; 
I = Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport; J = Freestanding ESRD facility; 
N = Skilled nursing facility; 
P = Physician's office; 
R = Residence; 
S = Scene of accident or acute event; 
X = Intermediate stop at physician's office on way to hospital (destination code only) 
 
You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, Medicare 
Claims Processing Manual, Chapter 15, Section 30(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 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 and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the 
person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or clinical nurse 
specialist (CNS). Medicare uses the payment policy indicators on the Medicare Physician Fee Schedule 
Database (MPFSDB) to determine if assistant at surgery services are reasonable and necessary for a specific 
Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code. The 
rules say that if the MPFSDB contains an assistant at surgery indicator of 2 for the surgical procedure in 
question, assistant at surgery service may be paid. Payment restrictions do not apply to this procedure. You can 
find these rules in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 4, Sections 250.9, 250.9.1, and 250.9.3. 
 
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 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 $300 copayment for ambulance services.  You can find this information 
on page(s) 40 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 procedures billed with the assistant-at-surgery physician modifiers -80, -81, -82, or the -AS 
modifier for physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant-
at-surgery policy. 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 20.4.3. 
 
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 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 outpatient hospital services.  You can find this 
information on page(s) 63 to 64 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 an Outpatient Prospective Payment System (OPPS) payment status indicator is assigned to 
every Healthcare Common Procedure Coding System (HCPCS) code. The status indicator identifies whether 
the service described by the HCPCS code is paid under the OPPS and if so, whether payment is made 
separately or packaged. The full list of status indicators and their definitions is published in Addendum D1 of 
the OPPS/Ambulatory Surgical Center (ASC) proposed and final rules each year. The status indicator for each 
HCPCS code is shown in OPPS Addendum B. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Pub 100-4, Medicare Claims Processing Manual, Chapter 4, Section 10.1.1. 
 
The rules state the following definition for OPPS payments status indicators: 
 
Indicator Q1: Packaged services subject to separate payment under OPPS payment criteria. 
Indicator V: Clinic or Emergency Department Visit 
 
You can find this rule in Addendum D1  Payment Status Indicators, CMS 1506-P. 
 
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 Grievance Manual, Section 50.12.1. 
 
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. The Plan 
contract also says that there is no charge for in-network or out-of-network providers for home health agency 
care. You can find this information on page 69 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 Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. 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. 
 
The rules say that the Physician Fee Schedule Status Indicator I means that this code is not valid for Medicare 
purposes. 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 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 Durable medical equipment (DME) and related 
supplies. You can find this information on page 54 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say payment for inpatient hospital services is made on the basis of a DRG (diagnosis related group). 
Hospitals must provide proper information about the patient (i.e., age, sex, discharge status, principal and 
secondary diagnoses, and procedures) in order for the correct DRG to be assigned. You can find this rule in the 
Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 3, Section 20.2.1. 
 
The rules say that the circumstances of inpatient admission always govern the selection of principal diagnosis. 
The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition 
established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for 
care. For reporting purposes, the definition for other diagnoses is interpreted as additional conditions that 
affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; 
or extended length of hospital stay; or increased nursing care and/or monitoring. The UHDDS item #11-b 
defines Other Diagnoses as all conditions that coexist at the time of admission, that develop subsequently, or 
that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which 
have no bearing on the current hospital stay are to be excluded. You can find this information in the 
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines 
for Coding and Reporting, Sections II and III. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 $315 copayment for inpatient hospital care. The enrollee must pay a 
$315 copayment per day, for days one to five, for each inpatient hospital stay. There is a $0 copayment for 
additional days after day five. You can find this information on page(s) 64 to 68 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 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 beneficiarys medical 
documentation and confirm that Medicare coverage criteria have been met. You can find this rule in the 
Medicare Program Integrity Manual, Chapter 3, Section 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 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 & 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 116-118 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 sacroiliac joint (SIJ) Denervation (also called RFA) is not considered reasonable and 
necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Sacroiliac Joint Injections and 
Procedures L39402. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.