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 state that germline genetic testing of BRCA1 and BRCA2 is available to identify individuals at 
increased risk for breast and ovarian cancers, as individuals with an inherited cancer syndrome may benefit 
from screening and prevention strategies to reduce their risk. 
 
BRCA1 and BRCA2 genetic testing for susceptibility to breast or ovarian cancer is covered in adults as 
medically reasonable and necessary when there is a personal history of breast cancer (invasive breast cancer or 
ductal carcinoma in situ) and ANY of the following indications: 
- Diagnosed at age 45 or younger; 
- Diagnosed at age 50 or younger with at least one close blood relative with breast cancer at any age; 
- Diagnosed with two breast primaries (includes bilateral disease or cases where there are two or more 
clearly separate ipsilateral primary tumors) when the first breast cancer diagnosis occurred prior to age 
50; 
- Diagnosed at age 60 or younger with a triple negative breast cancer (estrogen receptor [ER] negative, 
progesterone receptor [PR] negative, and human epidermal growth factor receptor 2 [HER2] negative); 
- Diagnosed at any age and there are at least two close blood relatives with pancreatic cancer or prostate 
cancer with Gleason score >7 at any age; 
- Diagnosed at age 50 or younger with a limited family history (e.g., fewer than two first or second 
degree female relatives or female relatives surviving beyond 45 years in the relevant maternal and/or 
paternal lineage); 
- Diagnosed at any age and there are at least two close blood relatives with breast cancer at any age; 
- Diagnosed at any age with at least one close blood relative with breast cancer at age 50 or younger; 
- Diagnosed at any age with at least one close blood relative with epithelial ovarian cancer, fallopian 
tube, or primary peritoneal cancer; 
- Close male blood relative with breast cancer; 
- Individual of Ashkenazi Jewish descent (begin testing with Ashkenazi Jewish founder specific 
mutations). If negative, complete analysis may be considered if ancestry also includes non-Ashkenazi 
Jewish relatives or other criteria for BRCA1/BRCA2 genetic testing are met. 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD): BRCA1 and BRCA2 Genetic testing (L36499). 

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 cover a Power Mobility Device (PMD) (such as a power wheelchair or 
scooter) for a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(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 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. 
 
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 transportation component code R0070 represents the transportation of the equipment to the 
patient. If only one patient is served, R0070 should be reported with no modifier since the descriptor for this 
code reflects only one patient seen. As a contractor priced service, MACs must initially determine a payment 
rate for portable x-ray transportation services that is associated with the cost of providing the service. 
 Carriers must pay a set-up component for each radiologic procedure (other than retakes of the same procedure) 
during both single patient and multiple patient trips under Level II HCPCS code Q0092. You can find this rule 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 13, Section 90.3 and 90.4. 
 
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 shows that the enrollees deductible is $750. Until the enrollee has paid the deductible 
amount, the full cost for most of the covered services must be paid. The deductible does not apply to inpatient 
physician services. You can find this information on page 44 of the Plans 2023 Evidence of Coverage. 
 
The Plan contract says that enrollees must pay a $275 copay per day for days 1-7 for in-network inpatient 
hospital care. Enrollees must pay a 35% coinsurance for out-of-network inpatient hospital care. Enrollees must 
pay a 35% coinsurance for provider services in an out-of-network inpatient hospital. You can find this 
information on pages 59-60 of the Plans 2023 Evidence of Coverage. 
 
The Plan contract says that enrollees must pay a $20 copay for out-of-network physician services in an office 
setting. You can find this information on page 75 of the Plans 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the Place of Service (POS) code is generally used to reflect the actual setting where the 
beneficiary receives the face-to-face service. For example, if the physician's face-to-face encounter with a 
patient occurs in the office, the correct POS code on the claim, in general, reflects the 2-digit POS code 11 for 
office. In these instances, the 2-digit POS code (Item 24B on the claim Form CMS-1500) will match the 
address and ZIP entered in the service location (Item 32 on the 1500 Form) - the physical/geographical location 
of the physician. However, there are two exceptions to this general rule - these are for a service rendered to a 
patient who is a registered inpatient or an outpatient of a hospital. In these cases, the correct POS code, 
regardless of where the face-to-face service occurs, is that of the appropriate inpatient POS code (at a minimum 
POS code 21) or that of the appropriate outpatient hospital POS code. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet-Only Manual, Publication 100-104, Chapter 26, Section 10.6. 
 
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. Although the Plan has a Point-of-Service (POS) option to cover certain out-of-network services, this benefit only applies to covered routine dental services. You can find this information on page 32 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 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, effective for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally for somatic (acquired) cancer, when performed in a 
Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating 
physician, and when all of the following requirements are met: 
 
   a. Patient has: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
   b. The diagnostic laboratory test using NGS must have: 
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
iii. results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, National Coverage Determinations (NCD) Manual: Next Generation Sequencing (NGS) 
NCD 90.2. 
 
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 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. Although the Plan has a Point-of-Service (POS) option to cover 
certain out-of-network services, this benefit only applies to covered routine dental services. You can find this 
information on page 27-28 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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64.  
 
The rules also state that screening services such as pre-symptomatic genetic tests and services used to detect an 
undiagnosed disease or disease predisposition are not a benefit and are not covered. Similarly, the costs of 
tests/examinations that assess the risk of a condition unless the risk assessment clearly and directly effects the 
management of the patient may not be reimbursed. You can find this information in Local Coverage 
Determination (LCD): Molecular Pathology Procedures (L34519). 
 
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 if an independent lab bills for services, the place where the sample was taken is shown as 
the Place of Service (POS). For example, an independent laboratory taking a sample in its laboratory reports 81 
as place of service. You can find this rule in Medicare Claims Processing Manual Chapter 26, Section 10.6. 
 
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 comprehensive oral evaluation, intraoral x-ray, periodontal scaling and root planing but are limited to once per 3 plan years. This benefit does not include gingival irrigation services. You can find this information on pages 65-67 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 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 A/B Medicare Administrative Contractor (MACs) shall automatically deny claim line(s) 
items submitted with a GZ modifier. A/B MACs shall not perform complex medical review on claim line(s) 
items submitted with a GZ modifier. All MACs shall make all language published in educational outreach 
materials, articles, and on their Web sites, consistent to state all claim line(s) items submitted with a GZ 
modifier shall be denied automatically and will not be subject to complex medical review. 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 20.9.1.1. 
 
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 modifier XU may be used to bypass a National Correct Coding Initiative (NCCI) Procedure-
to-Procedure (PTP) as long as the proper criteria for use of the modifier is met. Medical documentation must 
support the use of the modifier. The XU modifier is used to indicate Unusual Non-Overlapping Service, the 
use of a service that is distinct because it does not overlap usual components of the main service."  You can 
find this rule at Centers for Medicare and Medicaid Services, MedLearn MLN Matters Fact Sheet entitled 
"Proper Use of Modifiers 59, XE, XP, XS, and XU." 
 
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 if the Medicare Fee Schedule Database contains an assistant at surgery indicator of 0 for a 
surgical procedure, assistant at surgery services are generally not medically necessary. Assistant at surgery 
services will not be paid unless supporting documentation is submitted to establish medical necessity. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 12, Section 40.8(D). 
 
The rules say that carriers process assistant at surgery claims for services furnished in teaching hospitals on the 
basis of the following certification by the assistant, or through the use of modifier -82 which indicates that a 
qualified resident surgeon was not available. This certification is for use only when the basis for payment is the 
unavailability of qualified residents. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 100.1.7. 
 
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 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 procedure code E2311 describes the electronic components that allow the beneficiary to 
control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or 
non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power 
leg elevation, power seat elevation, power standing. 
 
The rules also say that a harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. 
that are required for the operation of an expandable controller. It also includes all the necessary fasteners, 
connectors, and mounting hardware. Code E2313 is separately billable in addition to an expandable controller 
both at initial issue and with complete replacement of the expandable controller. Code K0108 must not be used 
for any component or feature of an expandable controller at the time of initial issue. The reimbursement for any 
type of complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. 
 
You can find this information in the Local Coverage Article for Wheelchair Options/Accessories - Policy 
Article (A52504). 
 
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.