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. The contract also says that 
enrollees may be billed by the out-of-network provider for any charged amount greater than the payment made 
by the Plan. You can find this information on pages 115 to 136 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 Medicare contractors may not make adjustments in fee schedule amount provided by 
Medicare for codes billed with modifier -76 (repeat procedure by same physician). The global surgical package 
includes all additional medical or surgical services required of the surgeon during the postoperative period of 
the surgery because of complications which do not require additional trips to the operating room. Clearly 
distinct surgical procedures during the postoperative period which are not re-operations or treatment for 
complications are not included in the global surgical period. Unrelated procedures or visits during the 
postoperative period should be billed with modifier -79 for a procedure or -24 for an evaluation and 
management service. You can find these rules in Medicare Claims Processing Manual Chapter 12, Sections 
20.5, 40.1(A), and 40.1(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.
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 long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of 
stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).   
 
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need 
medical care. You can find this rule in the Centers for Medicare and Medicaid Services(CMS), Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the following data elements are required to submit a claim under home health Prospective 
Payment System (PPS). For billing of home health claims not under an HH plan of care (not under HH PPS), 
see Section 90. Home health services under a plan of care are paid based on a 30-day period of care.  
 
Home health agencies (HHAs) submit a Notice of Admission (NOA) at the beginning of an admission and then 
submit one claim for each 30-day period of care. Claims submitted before an NOA has been received for the 
beneficiary will be returned to the provider. 
 
Type of Bill 
Required - This 4-digit alphanumeric code gives two pieces of information. The first three digits indicate the 
base type of bill. The fourth digit indicates the sequence of this bill in this particular episode of care. 
The types of bills accepted for HH PPS claims are: 
 
032x - Home Health Services under a Plan of Treatment 
4th Digit  Definition 
 
7 - Replacement of Prior Claim - HHAs use to correct a previously submitted bill. Apply this code for the 
corrected or new bill. These adjustment claims must be accepted at any point within the timely filing period 
after the payment of the original claim. 
8 - Void/Cancel of a Prior Claim - HHAs use this code to indicate this bill is an exact duplicate of an incorrect 
bill previously submitted. A replacement claim must be submitted for the period of care to be paid. 
 
9 - Final Claim for an HH PPS Period  This code indicates an HH original bill to be processed following the 
submission of an HH PPS Notice of Admission (Type of Bill (TOB) 032A) HHAs must submit HH PPS claims 
with the 4th digit of 9. These claims may be adjusted with code 7 or cancelled with code 8. A/B MACs (HHH) do not accept late charge bills, submitted with code 5, on HH PPS claims. To add services within the 
period of a paid HH claim, the HHA must submit an adjustment. 
 
You can find this information in the Medicare Claims Processing Manual Chapter 10 - Home Health Agency  
Billing, 40.2 - HH PPS Claims. 
 
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 $260 copayment for ambulance services. You can find this information 
on page(s) 35-36 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 50% of the allowed amount for out-of-network physician services. You 
can find this information on page 106 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 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 
preventive and comprehensive services. Osseous surgery (D4261), a bone replacement graft (D4263) and 
guided tissue regeneration (D4266) are excluded from this benefit. You can find this information on pages 140 
to 154 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 state that wireless capsule endoscopy of the small bowel is considered medically reasonable and 
necessary when the following conditions have been met:  
 documented continuous blood loss and anemia secondary to obscure bleeding of the small bowel; 
 the site of bleeding could not be previously identified by colonoscopy, or endoscopy, or;  
 radiographic exams of the small bowel have failed to reveal a source, or; 
 intraoperative enteroscopy is being considered, or; 
 initial diagnosis of suspected Crohns Disease when there is no evidence provided by conventional 
diagnostic tests such as small bowel follow-through (SBFT), and upper and lower endoscopy. 
Wireless capsule endoscopy of the esophagus is considered medically reasonable and necessary for the 
following condition, if the criteria have been met: 
 Patient diagnosed with portal hypertension who requires immediate evaluation of esophageal varices  
 AND the esophageal capsule endoscopy is performed in lieu of conventional endoscopy because the 
provider who would perform the endoscopy has determined that the patients current medical condition 
prohibits a conventional endoscopy.  
 AND the medical record clearly reflects why the patient was not a candidate for conventional 
endoscopy and how the capsule endoscopy would contribute to the patients care. 
You can find this information in the Local Coverage Determination (LCD) for Wireless Capsule Endoscopy 
(L33774). 
 
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 $35 copayment for Physician/Practitioner services, including doctors 
office visits. You can find this information on page(s) 100 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 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 
preventive and comprehensive services. Intraoral - comprehensive x-rays (D0210) are excluded from this 
benefit. You can find this information on page 56 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 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). 
 
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 urgently needed services are covered by the Plan. When you are outside the service area 
and cannot get care from a network provider, our plan will cover urgently needed services that you get from 
any provider. 
 
Our plan covers worldwide emergency, urgent care, and ambulance services outside the United States under the 
following circumstances: 
 
 Unforeseen medical illness 
 Injury, or 
 condition that requires immediate medical care. 
 
You can find this information on pages 53 to 54 of the Plan's 2021 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 if a laboratory assays two or more genes in a patient in parallel, then those two or more 
genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS 
codes must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit 
claims for genes individually. The order by the treating clinician must reflect whether the treating clinician is 
ordering a panel or single genes, and additionally, the patients medical record must reflect that the service 
billed was reasonable and necessary. You can find this rule in the Local Coverage Article Billing and Coding: 
MolDX: Testing of Multiple Genes, A57880 
 
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 there is no separate payment for mounting hardware for a seat or back cushion. You can find 
this rule in the Local Coverage Article for Wheelchair Seating - Policy Article (A52505). 
 
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 molecular or predisposition genetic testing. You 
can find this information on page 91 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 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 clinical 
crown lengthening  hard tissue (D4249). This service requires prior authorization. You can find this 
information on pages 73-74 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 Chronic Wounds are defined as wounds that do not respond to standard wound treatment for 
at least a 30-day period during organized comprehensive conservative therapy. A Failed Response is defined as 
an ulcer or skin deficit that has failed to respond to documented appropriate wound-care measures, has 
increased in size or depth, or has not changed in baseline size or depth and has no indication that improvement 
is likely (such as granulation, epithelialization or progress towards closing). 
 
Medicare covers application of skin substitutes to Ulcers or Wounds with Failed Response that are: 
 Partial- or full-thickness ulcers, not involving tendon, muscle, joint capsule or exhibiting exposed bone 
or sinus tracts, with a clean granular base; 
 Skin deficit at least 1.0 square centimeter (cm) in size; 
 Clean and free of necrotic debris or exudate; 
 Have adequate circulation/oxygenation to support tissue growth/wound healing as evidenced by 
physical examination (e.g., Ankle-Brachial Index [ABI] of no less than 0.60, toe pressure greater than 30 
millimeters of mercury [mmHg]); 
 For diabetic foot ulcers, the patients medical record reflects a diagnosis of Type 1 or Type 2 Diabetes 
and also reflects medical management for this condition. 
 
You can find this information in the Local Coverage Determination (LCD): Application of Bioengineered Skin 
Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041). 
 
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.