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 certain conditions have both an underlying etiology and multiple body system manifestations 
due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the 
underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a 
combination exists, there is a use additional code note at the etiology code, and a code first note at the 
manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology 
followed by manifestation. You can find this information in the ICD-10-CM Official Guidelines for Coding 
and Reporting FY2021. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 $325 copayment per day for days 1-6 for an in-network inpatient 
hospital stay. The contract also says that there is a $0 copayment for additional days after day 6. You can find 
this information on page 91 of the Plan's 2021 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 all of the following criteria must be met for a power mobility device to be covered. 
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. 
B. The beneficiarys mobility limitation cannot be sufficiently and safely resolved by the use of an 
appropriately fitted cane or walker. 
C. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-
configured manual wheelchair in the home to perform MRADLs during a typical day. 
A. The beneficiary is able to: 
 Safely transfer to and from a POV, and 
 Operate the tiller steering system, and 
 Maintain postural stability and position while operating the POV in the home. 
B. The beneficiarys mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) 
are sufficient for safe mobility using a POV in the home. 
C. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for 
the operation of the POV that is provided. 
D. The beneficiarys weight is less than or equal to the weight capacity of the POV that is provided and 
greater than or equal to 95% of the weight capacity of the next lower weight class POV  
E. Use of a POV will significantly improve the beneficiarys ability to participate in MRADLs and the 
beneficiary will use it in the home. 
A. The beneficiary has not expressed an unwillingness to use a POV in the home. 
 
If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable 
and necessary. You can find this rule in the Local Coverage Determination for Power Mobility Devices, 
L33789 (eff 01/01/20). 
 
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 Group 3 PWC with no power options (K0848, K0849, K0850, K0851, K0852, K0853, 
K0854, K0855) is covered if:  
A. All of the coverage criteria (a)-(e) for a PWC are met; and 
B. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital 
skeletal deformity; and 
C. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical 
professional, such as a PT or OT, or practitioner who has specific training and experience in 
rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and 
its special features (see Documentation Requirements section). The PT, OT, or practitioner may have no 
financial relationship with the supplier; and 
D. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology 
Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the 
wheelchair selection for the beneficiary. 
If a Group 3 PWC is provided and if criteria (IV)(A)  (IV)(D) are not met, it will be denied as not reasonable 
and necessary. 
  A Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with Multiple Power 
Options (K0861, K0862, K0863, K0864) is covered if:  
A. The Group 3 criteria IV(A) and IV(B) are met; and 
B. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] 
and III[B]) (respectively) are met. 
If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or (V)(B) 
is not met, it will be denied as not reasonable and necessary. You can find this rule at Local Coverage 
Determination (LCD) L33789: Power Mobility Devices (eff. 1/1/20). 
 If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1.  
 
The rules also say that Telephone Alert Systems are emergency communications systems and do not serve a 
diagnostic or therapeutic purpose. You can find this information in the National Coverage Determination 
(NCD) 280.1, Durable Medical Equipment Reference List. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 $325 copayment for Outpatient hospital services. You can find this 
information on page 99 of the Plan's 2021 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 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 all other drugs covered under Medicare Part B. 
You can find this information in Chapter 4 on pages 84 to 86 of the Plan's 2021 Evidence of Coverage (EOC). 
 
The Plan contract also says that enrollees must pay a $35 copayment for Physician specialist services 
(including surgery second opinion, telehealth, and urgently needed services). You can find this information in 
Chapter 4 on pages 95 to 98 of the Plan's 2021 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 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 each Medicare-covered and non-Medicare-covered 
podiatry visit. You can find this information on page 98 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative (NCCI) Policy 
Manual for Medicare Services, Chapter I(A). 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules say that physicians in the same group practice who are in the same specialty must bill and be paid as 
though they were a single physician. If more than one evaluation and management (face-to-face) service is 
provided on the same day to the same patient by the same physician or more than one physician in the same 
specialty in the same group, only one evaluation and management service may be reported unless the 
evaluation and management services are for unrelated problems. Instead of billing separately, the physicians 
should select a level of service representative of the combined visits and submit the appropriate code for that 
level. You can find this information in the Medicare's Claim Processing Manual, Chapter 12, Section 30.6.5. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 effective January 1, 2011, Section 153b of the Medicare Improvements for Patients and 
Providers (MIPPA) requires the implementation of End Stage Renal Disease Prospective Payment System 
(ESRD PPS). The ESRD PPS provides a single payment to ESRD facilities that will cover all of the resources 
used in furnishing an outpatient dialysis treatment, including supplies and equipment used to administer 
dialysis (in the ESRD facility or at a patient's home), drugs, biologicals, laboratory tests, training, and support 
services. You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, 10. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 B: Payment for covered services are always bundled into payment for other services not 
specified. There will be no RVUs or 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 (an example is a telephone call from a hospital nurse regarding care of a patient). You can find this 
information in the CMS Manual System; Pub 100-04 Medicare Claims Processing; Transmittal 1005. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 $250 copayment for in-network outpatient surgery at an outpatient 
hospital. You can find this information on pages 4-56 and 4-57 of the Plan's 2021 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 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. 
 
The rules say that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic 
preparations will be considered medically reasonable and necessary when ALL of the following conditions are 
met: 
 
1. The patient is symptomatic. Such symptoms may include pain which interferes with the activities of daily 
living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness. 
2. The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space 
narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. 
3. If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, 
laboratory and imaging studies (i.e., the pain and functional disability is not considered likely to be due to a 
diagnosis other than osteoarthritis of the knee). 
4. The patient has failed at least three months of conservative therapy. Conservative therapy is defined as: 
 
-Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss, 
physical therapy if indicated); and 
-If not contraindicated, simple analgesics and (e.g., acetaminophen) or NSAIDS per hyaluronan product 
prescribing information. 
 
5. The patient has failed to respond to aspiration of the knee when effusion is present and intra-articular 
corticosteroid injection therapy when inflammation is a significant component of the patients symptoms and 
intra-articular corticosteroids are not contraindicated. 
 
You can find this rule in the Local Coverage Determination (LCD) - Hyaluronan Acid Therapies for 
Osteoarthritis of the Knee (L35427) - Effective October 1, 2019. 
 
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 eligible Professionals Medicare recognizes these Part B providers as eligible to provide 
diagnostic and BHI or SBIRT services, 
as permitted under state law: 
 Physicians (Medical Doctors [MDs] and Doctors of Osteopathy [DOs]), particularly Psychiatrists 
 Clinical Psychologists (CPs) 
 Clinical Social Workers (CSWs) 
 Clinical Nurse Specialists (CNSs) 
 Nurse Practitioners (NPs) 
 Physician Assistants (PAs) 
 Certified Nurse-Midwives (CNMs) 
 Independently Practicing Psychologists (IPPs). You can find this information in Centers for Medicare & 
Medicaid Services (CMS) Medicare Mental Health Medicare Learning Network MLN Booklet on page 7. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 62 and 84-85 of the 
Plan's 2021 EOC.