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 visits by the same physician on the same day as a minor surgery or endoscopy are included in 
the payment for the procedure, unless a significant, separately identifiable service is also performed. Modifier 
"-25" is used to facilitate billing of evaluation and management services on the day of a procedure for which 
separate payment may be made. It is used to report a significant, separately identifiable evaluation and 
management service by same physician on the day of a procedure. 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, Sections 40.1(C) and 40.2.A(8). 
 
The rules state that Medicare requires that services provided/ordered/certified be authenticated by the persons 
responsible for the care of the beneficiary in accordance with Medicare's policies. The method used shall be a 
handwritten or electronic signature. Stamped signatures are not acceptable. Providers should not add late 
signatures to the medical record, (beyond the short delay that occurs during the transcription process) but 
instead should make use of the signature authentication process. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, 3.3.2.4. 
 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.
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 more than one general anesthesia codes is submitted on same date of service by same 
provider without a modifier to distinguish it as a separate surgical session or encounter, it will be denied. This 
rule is found in the National Correct Coding Initiative Policy Manual for Medicare services, Chapter 2, 
Anesthesia. 
 
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 power seat elevation equipment used with a power wheelchair raises and lowers users while 
they remain in the seated position. This equipment uses an electromechanical lift system to provide varying 
amounts of vertical seat to floor height. It does not change the seated angles or the seats angle relative to the 
ground. 
 
Complex rehabilitative power-driven wheelchairs are defined in 42 CFR 414.202. 
 
Effective for services performed on or after May 16, 2023, power seat elevation equipment is reasonable and 
necessary for individuals using complex rehabilitative power-driven wheelchairs, when the following 
conditions are met: 
 
1. The individual has undergone a specialty evaluation that confirms the individuals ability to safely operate 
the seat elevation equipment in the home. This evaluation must be performed by a licensed/certified medical 
professional such as a physical therapist (PT), occupational therapist (OT), or other practitioner, who has 
specific training and experience in rehabilitation wheelchair evaluations; and, 
2. At least one of the following apply: 
The individual performs weight bearing transfers to/from the power wheelchair while in the home, using either 
their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a sit to 
stand transfer. Transfers may be accomplished with or without caregiver assistance and/or the use of assistive 
equipment (e.g. sliding board, cane, crutch, walker, etc.); or, 
The individual requires a non-weight bearing transfer (e.g. a dependent transfer) to/from the power wheelchair 
while in the home. Transfers may be accomplished with or without a floor or mounted lift; or, 
The individual performs reaching from the power wheelchair to complete one or more mobility related 
activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in customary 
locations within the home. MRADLs may be accomplished with or without caregiver assistance and/or the use 
of assistive equipment. 
 
You can find these rules in the National Coverage Determination (NCD) Seat Elevation Equipment (Power 
Operated) on Power Wheelchairs 280.16. If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 18 of the 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 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 when billing multiple units of a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code, providers must enter the actual number of units 
provided on the claim form. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.4. 
 
The rules state that an "order" is a communication from the treating physician/practitioner requesting that a 
diagnostic test be performed for a beneficiary. While a physician order is not required to be signed, the 
physician must clearly document, in the medical record, his or her intent that the test be performed. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit 
Policy Manual, Chapter 15, Section 80.6.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 PGx tests must demonstrate analytical validity, clinical validity, and clinical utility to be 
considered reasonable and necessary for coverage. This is demonstrated through a required technical 
assessment of the test. PGx tests are considered germline tests and must adhere to other relevant germline 
testing policies published by this contractor. You can find this rule in Local Coverage Determination (LCD)  
MolDX: Pharmacogenomics Testing L38294. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that In order to constitute a Medicare claim, services submitted for payment must be submitted to 
the appropriate Medicare contractor (Section 70.2.1), in a proper claim format Section 70.2.2), and in 
accordance with these CMS claim completion instructions. Services submitted for payment in a manner not 
complete and consistent according to these instructions will not be accepted into Medicare's electronic claims 
processing system and will not be considered filed for purposes of determining timely filing. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual Chapter 1, Section 70.3.2. 
 
The rules say that any independent laboratory performing tests covered by the Clinical Laboratory 
Improvements Amendments of 1988 (CLIA) must submit the CLIA number on the claim. Laboratory claims 
submitted without the required CLIA number are returned as unprocessable. If the CLIA number is submitted 
on the claim, but is inconsistent with the CLIA format, the A/B MAC (B) returns the claim as unprocessable. If 
more than one CLIA number is submitted on the claim, except when a reference laboratory is on the same 
claim, the A/B MAC (B) returns the claim as unprocessable. You can find this rule in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, 
Chapter 16, Section 70.10. 
 
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 beginning January 1, 2022, home health agencies (HHAs) will no longer submit Requests for 
Anticipated Payment (RAPs). Instead, for each admission to home health the HHA notifies Medicare systems 
via submission of a Notice of Admission (NOA). The NOA is a one-time submission to establish that the 
beneficiary is under a home health period of care and trigger home health consolidated billing edits. The NOA 
covers contiguous 30-day periods of care until the individuals is discharged from Medicare home health 
services. This rule is found in Medicare Claims Processing Manual Chapter 10, sec 40.2 - HH PPS Claim. 
 
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
2. The services require the skills or direct supervision of a therapist,  
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. 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 220.2. 
 
The local Medicare Administrative Contractor has published its interpretation of the various outpatient therapy 
rules which provide more specific criteria for certain services. You can find this information in the Local 
Coverage Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566). 
 
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 certain data elements are required. Any claim with incomplete, missing, or invalid 
information for all of these elements may be returned as unprocessable. You can find this rule in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 1, Section 80.3.1. 
 
The following data elements are required to submit a claim under home health PPS. For billing of home health 
claims not under a home health (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 an 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. 
 
The rules also say that HHAs must report where home health services were provided. The following codes are 
used for this reporting: 
Q5001: Hospice or home health care provided in patients home/residence 
Q5002: Hospice or home health care provided in assisted living facility 
Q5009: Hospice or home health care provided in place not otherwise specified 
The location where services were provided must always be reported along with the first visit reported on the 
claim. In addition to reporting a visit line using the G codes as described above, HHAs must report an 
additional line item with the same revenue code and date of service, reporting one of the three Q codes (Q5001, 
Q5002, and Q5009), one unit and a nominal covered charge (e.g., a penny). If the location where services were 
provided changes during the period of care, the new location should be reported with an additional line 
corresponding to the first visit provided in the new location. 
 
You can find these rules in the Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 10, Section 40.2.  
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that if a mobile unit is serving an entity for which another POS code already exists, providers 
should use the POS code for that entity. This rule is found in the Medicare Claims Processing Manual Chapter 
26, Section 10.5, Special Considerations for Mobile Unit Settings. 
 
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 the rate, facility or non-facility, that a physician service is paid under the Medicare 
Physician Fee Schedule (MPFS) is determined by the Place of service (POS) code that is used to identify the 
setting where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner 
(NPP) or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the 
face-to-face service and determines whether the facility or non-facility payment rate is paid. You can find this 
information at the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 12, Section 20.4.2. 
 
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). 
 
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 payment for the substance use counseling is included in the bundled payment rates made
to Opioid Treatment Programs (OTPs); therefore, the practitioner furnishing the service should not bill
separately for the service. You can find this rule in the Medicare Claims Processing Manual Chapter 39, Opioid
Treatment Programs (OTPs), Section 50, Institutional Opioid Treatment Services.

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).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 26 of the Plan's 2023 
Member Handbook.
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 state that providers must bill the appropriate Place of Service (POS) code for services.  POS code 21 
indicates that the services were performed in an inpatient hospital setting. POS code 22 indicates that the 
services were performed in an outpatient hospital setting. You can find this rule at Centers for Medicare and 
Medicaid Services, Internet-Only Publication 100-04, Medicare Claims Processing Manual Chapter 26, Section 
10.5. 
 
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.