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 a professional component (PC)/technical component (TC) indicator of 8 identifies 
professional component of clinical laboratory codes for which separate payment may be made only if the 
physician interprets an abnormal smear for hospital inpatient. This applies only to code 85060. No TC billing is 
recognized because payment for the underlying clinical laboratory test is made to the hospital, generally 
through the prospective payment system (PPS) rate. You can find this rule in the Centers for Medicare and 
Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, 
Chapter 23, Section 50.6. 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 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 $345 per day for days 1-5 and $0 per day for days 6-365 for each inpatient 
admission at an out-of-network facility. You can find this information on pages 75-77 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 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 37 and 41-42.
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 $40 copayment for each eye exam service. You can find this 
information on pages 91-92 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 20% coinsurance for each Medicare-covered medical supply. You can 
find this information on page 4-33 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 does not include 
dental services provided by an out-of-network provider. You can find this information on pages 85-86 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 the term interface in the code narrative and definitions describes the mechanism for 
controlling the movement of a power wheelchair. Examples of interfaces include, but are not limited to, 
joystick, sip and puff, chin control, head control, etc.  The term controller describes the microprocessor and 
other related electronics that receive and interpret input from the joystick (or other drive control interface) and 
convert that input into power output which controls speed and direction. A high-power wire harness connects 
the controller to the motor and gears.  
 
An expandable controller is capable of accommodating one or more of the following additional functions: 
 Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin 
control, head control, etc.) 
 Non-proportional input devices (e.g., sip and puff, head array, etc.) 
 Operate 3 or more powered seating actuators through the drive control. 
 A separate display (i.e., for alternate control devices) 
 Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's 
drive control) 
 An attendant control 
 
A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are 
not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or 
E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will 
be denied as non-covered. You can find this rule in the Local Coverage Article for Wheelchair 
Options/Accessories, 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.
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 only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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. The Plan 
contract also says that the only covered chiropractic service is manual manipulation of the spine to correct 
subluxation. You can find this information on page 63 of the Plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that purified natural hyaluronans have been approved by the FDA for the treatment of pain 
associated with osteoarthritis of the knee in patients who have failed to respond adequately to conservative 
nonpharmacologic therapy and simple analgesics. The synovial fluid's capacity to lubricate and absorb shock is 
typically reduced in joints affected by osteoarthritis. These changes are partly due to a reduction in the 
concentration and size of hyaluronic acid molecules that are naturally present in synovial fluid. In addition to 
the FDA approved use, hyalurons have been recognized as a therapeutic option in osteoarthritis of the shoulder. 
This article defines coverage criteria for the injection of the knee or shoulder with either sodium hyaluronate 
(Hyalgan, Supartz or Visco-3TM, EuflexxaTM, MonoviscTM, GelSyn-3TM, GenVisc 850, Durolane, 
TriViscTM, SynojoyntTM, TriluronTM), hylan G-F 20 (Synvisc, Synvisc-One TM), hyaluronic acid (Gel-One), 
high molecular weight hyaluronan (Orthovisc) or high molecular weight viscoelastic hyaluronan 
(Hymovis). 
 
The dose and frequency of administration should be consistent with the FDA approved labeling. 
 
It is expected that an injection (Synvisc-One TM, Gel-One, Durolane) or course of the injections (Synvisc, 
Hyalgan, Supartz or Visco-3TM, EuflexxaTM, Orthovisc, GelSyn-3TM, GenVisc 850, Hymovis, 
TriViscTM, SynojoyntTM, TriluronTM) will not be repeated within six months time. 
 
A repeat series of injections may be allowed when: 
 
    The indications continue to be met; and 
    Significant improvement in pain and functional capacity from the prior series of injections is documented in 
the medical record; and 
    The last injection (in a prior course) was given at least six (6) months ago. 
 
Repeat injections for shoulder arthritis are limited to a single repeat course. 
 
You can find this information in the Local Coverage Article Billing and Coding Billing and Coding: 
Hyaluronans Intra-articular Injections of A52420. 
 
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 This section applies to UPICs. This section is applicable to DME MACs, RACs, SMRC, and 
CERT MR contractors, as noted in Ch. 5, Section 5.8. Suppliers are required to maintain proof of delivery 
documentation in their files. Proof of delivery documentation must be maintained in the suppliers files for 
seven years (starting from the date of service). Section 1833(e) grants Medicare contractors the authority to 
request any information necessary to determine the amounts due. This includes proof of delivery in order to 
verify that the beneficiary received the DMEPOS item and thus to determine the amounts due to the provider. 
Proof of delivery is also one of the supplier standards as noted in 42 CFR Section 424.57(c)(12). If the UPIC 
has reason to be concerned that Medicare was billed for an item that was not received (such as a complaint 
from a beneficiary about non-receipt), the UPIC shall request proof of delivery from the supplier. Proof of 
delivery documentation must be made available, within the prescribed timeframes, to the UPIC upon request. 
For any items that do not have proof of delivery from the supplier, such claimed items shall be denied by the 
UPIC and overpayments recovered. Suppliers that consistently do not provide documentation to support that 
their items were delivered may be referred to the OIG or NSC for investigation and/or imposition of sanctions. 
You can find this information in the Medicare Program Integrity Manual Chapter 4: 100-08. Ch. 4, Section 
4.7.3.1; Supplier Proof of Delivery Documentation Requirements. 
 
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). 
 
Effective January 1, 2002, new modifiers were developed to allow practitioners and suppliers to bill Medicare 
for items and services that are statutorily non-covered or do not meet the definition of a Medicare benefit and 
items and services not considered reasonable and necessary by Medicare.  
 
1. Definitions of the GA, GY, and GZ Modifiers. The modifiers are defined below:  
 
GA - Waiver of liability statement on file.  
GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit.  
GZ - Item or service expected to be denied as not reasonable and necessary.  
 
The GZ modifier must be used when physicians, practitioners, or suppliers want to indicate that they expect 
that Medicare will deny an item or service as not reasonable and necessary, and they have not had an Advance 
Beneficiary Notification (ABN) signed by the beneficiary. You can find this information in CMS Manual 
system, Pub 100-04 Medicare Claims Processing, Transmittal 2148, Change Request 7228.  
 
Effective for dates of service on and after July 1, 2011, A/B Medicare Administrative Contractors (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 information in the CMS Internet only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, Section 20.9.  
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 has a new initiative that will cover up to eight over-the-counter COVID-19 tests each calendar 
month, at no cost to you. Medicare coverage and payment begins on April 4, 2022, and is available for up to 
eight over-the-counter COVID-19 tests per calendar month you receive from a participating pharmacy or health 
care provider after the initiative starts. Medicare will not provide payment for over-the-counter COVID-19 tests 
obtained prior to April 4, 2022. You can find this information in https://www.cms.gov/newsroom/fact-
sheets/medicare-covers-over-counter-covid-19-tests 
 
Medicare guidance says status code N Not valid for Medicare purposes. You can find this guidance in the 
2022 National Physician Fee Schedule. 
 
The rules say that sales taxes where appropriate were included in the calculation of reasonable charges 
computed. They were also accounted for in the calculation of the base fee schedules for durable medical 
equipment (DME) and orthotic/prosthetic devices. The Consumer Price Index used to update fee schedules also 
accounts for sales tax. Therefore, Medicare Administrative Contractor (MACs) do not make any additional 
payment for sales taxes and do not make adjustments in fees to reflect local changes in tax rates. You can find 
this rule in the Medicare Claim Processing Manual, Chapter 23- Fee Schedule Administration and Coding, 
80.3.1- Calculating Customer Charge. 
 
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 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 60 one-way transportation trips when each one-way trip does not exceed 75 miles. You can find this 
information on pages 4-83 to 4-84 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 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 MolDX will review all new test/assay clinical information to determine if a test meets 
Medicares reasonable and necessary requirement. Labs must submit a comprehensive dossier on each new 
test/assay prior to claim submission. MolDX will only cover and reimburse tests that demonstrate analytical 
and clinical validity, and clinical utility at a level that meets the Medicare reasonable and necessary 
requirement. You can find this rule in Local Coverage Determination (LCD) MolDX: Molecular Diagnostic 
Tests (MDT) L35025. 
 
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 when services or supplies are rendered by a non-contracting, original Medicare, participating 
provider, there is no balance billing paid by either the Plan or the enrollee. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 4, 170.2. 
 
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.