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

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
The rules say that clinical diagnostic laboratory tests (CDLTs) making use of high throughput technologies (as 
defined in this Ruling) and administered during the ongoing emergency period defined in paragraph (1)(B) of 
section 1135(g) of the Act beginning on or after March 18, 2020, for the detection of SARS-CoV-2 or the 
diagnosis of the virus that causes Covid-19, are new and involve high throughput machines (which are highly 
sophisticated equipment) which require more intensive technician training (to ensure the role of extremely 
skilled personnel) and more time intensive processes (to assure quality). These tests are a type of CDLT 
currently paid for under Medicare Part B using codes U0003 and U0004. You can find this rule in the Centers 
for Medicare & Medicaid Services, Ruling Number CMS-2020-01-R. 
 
The rules say that beginning January 1, 2021, CMS will establish a new add-on payment of $25 as identified by 
HCPCS code U0005. As required by the HCPCS code U0005 descriptor, this add-on payment may be billed 
with either HCPCS code U0003 or HCPCS code U0004 when the applicable test is completed within 2 
calendar days of the specimen being collected. You can find this ruling in the Centers for Medicare and 
Medicaid Services, Ruling Number CMS-2020-1-R2. 
 
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 page(s) 24-30 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 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 three 
crowns every 12 months. This benefit does not include D2950. You can find this information on pages 59-61 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 the Type of Bill (TOB) code is a required data element for home health prospective 
payment system (PPS) claims. The first three digits must be 032. The fourth digit indicates the sequence of this 
bill in the particular period of care. The types of bill accepted for home health PPS claims are: 
- 0327  Replacement of a prior claim 
- 0328  Void/Cancel of a prior claim 
- 0329  Final claim for a home health PPS period 
 
You can find this rule 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 that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. 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 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 58-59 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 does not include 
coverage for dental service codes D7953 and D5140. You can find this information in Chapter 4 on pages 58-
59 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 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 does not include 
D2751. You can find this information on pages 59-61 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 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. You can find this information 
on pages 54-57 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 to report a molecular syndromic panel for infectious disease pathogen identification, the 
following claim information must be submitted: 
- The appropriate procedure code 
~ If the panel being used does not have its own proprietary code, select the appropriate code and 
follow the additional instructions for the given panel in the relevant grouping paragraph. If no 
specific code exists for the test submitted, bill with code 87999. 
- Codes that are not billed with the appropriate accompanying diagnosis code will be denied. Tests with 
other indicated uses may therefore submit for a Z-Code and undergo a technical assessment (TA) by 
MolDX. Tests using code 87999 will also require a Z-Code and TA. 
- Tests that are Food & Drug Administration (FDA) approved/cleared and performed in ways consistent 
with their intended use labelling directions do not require a Z-Code when billed with an appropriate 
accompanying diagnosis code. However, the performance of multiple FDA-approved/cleared molecular 
infectious disease pathogen identification tests on the same date of service (DOS) for the same intended 
use on the same patient sample is considered as one distinct service and requires a Z-Code and a TA. If 
an existing code does not identify the service, it requires the use of code 87999. 
- Add modifier -59 for different species or strains reported by the same code, as allowed by policy. 
- Enter 1 unit of service. 
- If applicable, enter the appropriate Z-Code identifier adjacent to the procedure code in the 
comment/narrative field. 
- The appropriate diagnosis code(s). 
 
You can find this rule in Local Coverage Article (LCA) Billing and Coding: MolDX: Molecular Syndromic 
Panels for Infectious Disease Pathogen Identification Testing (A58710). 
 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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that as of January 1, 2013, for most evaluation and management (E&M) visit 
families, practitioners will select visit level based on the level of medical decision making (MDM) or the 
amount of time spent by the physician or non-physician practitioner. For some types of visits (such as 
emergency department visits and critical care), in accordance with their CPT codes, practitioners do not have 
this choice and will use only MDM or only time to bill. It would not be medically necessary or appropriate to 
bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation 
should not be the primary influence upon which a specific level of service is billed. Documentation should 
support the level of service reported. You can find this rule in the Centers for Medicare & Medicaid Services 
(CMS), Internet Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Section 
30.6.1. 
 
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 state that a manual wheelchair for use inside the home is covered if: 
- Criteria A, B, C, D, and E are met; and 
- Criterion F or G is met. 
A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, 
grooming, and bathing in customary locations in the home. A mobility limitation is one that: 
1. Prevents the beneficiary from accomplishing an MRADL entirely, or 
2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality 
secondary to the attempts to perform an MRADL; or 
3. Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
B. The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately 
fitted cane or walker. 
C. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for 
use of the manual wheelchair that is provided. 
D. Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in 
MRADLs and the beneficiary will use it on a regular basis in the home. 
E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the 
home. 
F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities 
needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. 
Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or 
absence of one or both upper extremities are relevant to the assessment of upper extremity function. 
G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the 
wheelchair. 
 
A high strength lightweight wheelchair (K0004) is covered when a beneficiary meets the criteria in (1) or (2): 
1. The beneficiary self-propels the wheelchair while engaging in frequent activities in the home that 
cannot be performed in a standard or lightweight wheelchair. 2. The beneficiary requires a seat width, depth, or height that cannot be accommodated in a standard, 
lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair. 
 
A high strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is 
less than three months (e.g., post-operative recovery). You can find these rules in Local Coverage 
Determination (LCD) Manual Wheelchair Bases (L33788). 
 
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 to repair means to fix or mend and to put the equipment back in good condition after 
damage or wear. Repairs to equipment which a beneficiary owns are covered when necessary to make the 
equipment serviceable. However, do not pay for repair of previously denied equipment or equipment in the 
frequent and substantial servicing or oxygen equipment payment categories. If the expense for repairs exceeds 
the estimated expense of purchasing or renting another item of equipment for the remaining period of medical 
need, no payment can be made for the amount of the excess. You can find this information in the Centers for 
Medicare & Medicaid Services, Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, 
chapter 15, sectioon 110. 
 
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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the report home health (HH) visits, the home health agency (HHA) reports one of the 
following Healthcare Common Procedure Coding System (HCPCS) codes to represent a visit by each HH care 
discipline: 
 
Occupational Therapy (revenue code 043x)  
G0152 Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 
minutes.  
G0158 Services performed by a qualified occupational therapist assistant in the home health or hospice setting, 
each 15 minutes.  
G0160 Services performed by a qualified occupational therapist, in the home health setting, in the 
establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes.  
G2169 Services performed by an occupational therapist assistant in the home health setting in the delivery of a 
safe and effective occupational therapy maintenance program, each 15 minutes.  
 
You can find this rule in the Centers for Medicare & Medicaid Services (CMS), Internet Only Manual, Pub 
100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.2. 
 
The rules say that Medicare systems may return to the provider Low Utilization Payment Adjustment (LUPA) 
claims if the claim meets the criteria for a LUPA add-on payment, but it contains no qualifying skilled service. 
In these cases, the HHA may add the skilled visit to the claim if it was omitted in error and re-submit the claim. 
You can find this rule in the Centers for Medicare & Medicaid Services (CMS), Internet Only Manual, Pub 
100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.2. 
 
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.