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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up-to 24 one-way routine trips for non-emergency, medical-related purposes such as doctor visits; 
appointments for dental, vision, hearing, and behavioral health services; and visits to pharmacies to pick up 
prescription drugs within a 50-mile limit. Destination must always be plan-approved. Mode of transportation 
could include van, medical transport, wheelchair van, or car at the discretion of the plan. You can find this 
information on page 82 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 painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those 
that have not responded to non-surgical medical management (e.g. narcotic and/or non- narcotic medication, 
physical therapy modalities) with and without methods of immobility (e.g. rest, bracing). 
 
You can find these rules in Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L35130). 
 
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 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 
coverage for specific items or services, but only when they are received from an in-network provider. You can 
find this information on pages 75-77 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 an ambulance transport is covered to the nearest appropriate facility to obtain necessary 
diagnostic and/or therapeutic services. Only local transportation by ambulance is covered, and therefore, only 
mileage to the nearest appropriate facility equipped to treat the patient is covered. However, if two or more 
facilities that meet the destination requirements can treat the patient appropriately and the locality of each 
facility encompasses the place where the ambulance transportation of the patient began, then the full mileage to 
any one of the facilities to which the beneficiary is taken is covered. 
 
The term "locality" with respect to ambulance service means the service area surrounding the institution to 
which individuals normally travel or are expected to travel to receive hospital or skilled nursing services. The 
MACs have the discretion to define locality in their service areas. 
 
The term "appropriate facilities" means that the institution is generally equipped to provide the needed hospital 
or skilled nursing care for the illness or injury involved. In the case of a hospital, it also means that a physician 
or a physician specialist is available to provide the necessary care required to treat the patient's condition. The 
fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient 
does not warrant a finding that a closer institution does not have "appropriate facilities." Such a finding is 
warranted, however, if the beneficiary's condition requires a higher level of trauma care or other specialized 
service available only at the more distant hospital. An institution is also not considered an appropriate facility if 
there is no bed available. The contractor, however, will presume that there are beds available at the local 
institutions unless the claimant furnished evidence that none of these institutions had a bed available at the time 
the ambulance service was provided. 
 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.3, 10.3.5, and 10.3.6. 
 
  
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 $15 copayment for periodontal maintenance. You can find this 
information in the 2023 Dental Benefits Chart.
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 Gastrointestinal Pathogen (GIP) test panel is a single service with a single unit of service 
(UOS=1). A GIP test panel must not be unbundled and billed as individual components regardless of the fact 
that the GIP test panel reports multiple individual pathogens and/or targets. You can find this rule in the Local 
Coverage Article Billing and Coding: Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid 
Amplification Techniques (NAATs), A56642. 
 
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. 
 
Medicare guidance says 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 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 
unspecified preventive procedure and resin fillings. You can find this information in Chapter 4 on page 105 of 
the Plans 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare does not pay for hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract provides supplemental (extra) coverage for hearing aids. This benefit includes coverage for hearing aids purchased through the Plan's select hearing aid provider. Hearing aids ordered through providers other than the Plan's select hearing aid provider are not covered. This information can be found on pages 4-28 to 4-29 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. 
 
Medicare guidance says 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 $20 copayment for Medicare-covered x-rays. You can find this 
information on page 62 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 the global surgery package of procedures with a global period of 10 or 90 days 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, follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery, among other related services. In order to report an unrelated evaluation and management (EM) service by same physician during a postoperative period, modifier -24 must be used. Services submitted with the -24 modifier must be sufficiently documented to establish that the visit was unrelated to the surgery. Not included in the global surgery payment are clearly distinct surgical procedures during the postoperative period which are not re-operations or treatment for complications. These services should be billed with modifier -79. You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.1.
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 an expandable controller is capable of accommodating one or more of the following 
additional functions: 
 
- Other types of proportional input devices (such as, mini-proportional or compact joysticks, touchpads, chin 
control, head control, and so on) 
- Non-proportional input devices (such as, sip and puff, head array, and so on) 
- Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating 
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) 
 
An expandable controller may also be able to operate one or more of the following: 
 
- A separate display (for example, for alternate control devices) 
- Other electronic devices (such as, control of an augmentative speech device or computer through the chair's 
drive control) 
- An attendant control 
 
You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective 
January 1, 2020. 
 
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.
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 $120 copayment for each emergency room visit. You can find this 
information on page 52 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that the Centers for Medicare & Medicaid Services (CMS) has determined that Percutaneous Image-Guided Lumbar Decompression (PILD) will be covered by Medicare when provided in a clinical study under section 1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED) for beneficiaries with lumbar spinal stenosis (LSS) who are enrolled in an approved clinical study that meets the criteria. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual Section 150.13.
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.