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 starting January 15, 2022, most people with a health plan can go online, or to a pharmacy or
store to purchase an at-home over the counter COVID-19 diagnostic test authorized by the U.S. Food and Drug
Administration (FDA) at no cost, either through reimbursement or free of charge through their insurance. The
test will either be free directly at the point of sale, if the health plan provides for direct coverage, or by
reimbursement if you are charged for your test. The plans may cover this as a
supplemental benefit starting January 15, 2022, on the specific benefits offered by the Plan. You can find this
information on the Centers for Medicare and Medicaid Services website at https://www.cms.gov/how-to-getyour-
at-home-OTC-COVID-19-test-for-free.
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 $195 copayment for all other diagnostic and nuclear medicine radiological 
services. You can find this information in Chapter 4 on page 54 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 starting January 15, 2022, most people with a health plan can go online, or to a pharmacy or
store to purchase an at-home over the counter COVID-19 diagnostic test authorized by the U.S. Food and Drug
Administration (FDA) at no cost, either through reimbursement or free of charge through their insurance. The
test will either be free directly at the point of sale, if the health plan provides for direct coverage, or by
reimbursement if you are charged for your test. The plans may cover this as a
supplemental benefit starting January 15, 2022, on the specific benefits offered by the Plan. You can find
this information on the Centers for Medicare and Medicaid Services website at https://www.cms.gov/how-toget-
your-at-home-OTC-COVID-19-test-for-free.
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 addendum states that the Plan began to provide supplemental coverage for home COVID-19 test kits
on February 1, 2022.
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 starting January 15, 2022, most people with a health plan can go online, or to a pharmacy or
store to purchase an at-home over the counter COVID-19 diagnostic test authorized by the U.S. Food and Drug
Administration (FDA) at no cost, either through reimbursement or free of charge through their insurance. The
test will either be free directly at the point of sale, if the health plan provides for direct coverage, or by
reimbursement if you are charged for your test. The plans may cover this as a
supplemental benefit starting January 15, 2022, on the specific benefits offered by the Plan. You can find this
information on the Centers for Medicare and Medicaid Services website at https://www.cms.gov/how-to-getyour-
at-home-OTC-COVID-19-test-for-free.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plans 2022 contract addendum states that the Plan will cover home COVID-19 tests as a supplemental
benefit beginning on February 1, 2022.
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 one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report CPT code 81479 
(Unlisted molecular pathology procedure) with one unit of service. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, National Correct Coding Initiative (NCCI) 
Manual, Chapter 10, Section F(8). 
 
The rules say that the Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied.   
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. Codes with an MAI of 2 have been rigorously reviewed and vetted within 
CMS and obtain this MAI designation because units of service on the same date of service (DOS) in excess of 
the MUE value would be considered impossible because it was contrary to statute, regulation, or subregulatory 
guidance. 
 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(V).  
 
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information within the Plan's 2022 Medicare Part B Preferred drug list.
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 starting January 15, 2022, most people with a health plan can go online, or to a pharmacy or
store to purchase an at-home over the counter COVID-19 diagnostic test authorized by the U.S. Food and Drug
Administration (FDA) at no cost, either through reimbursement or free of charge through their insurance. The
test will either be free directly at the point of sale, if the health plan provides for direct coverage, or by
reimbursement if you are charged for your test. The plans may cover this as a supplemental
benefit starting January 15, 2022, on the specific benefits offered by the Plan. You can find this information on
the Centers for Medicare and Medicaid Services website at https://www.cms.gov/how-to-get-your-at-home-
OTC-COVID-19-test-for-free
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 starting January 15, 2022, most people with a health plan can go online, or to a pharmacy or
store to purchase an at-home over the counter COVID-19 diagnostic test authorized by the U.S. Food and Drug
Administration (FDA) at no cost, either through reimbursement or free of charge through their insurance. The
test will either be free directly at the point of sale, if the health plan provides for direct coverage, or by
reimbursement if you are charged for your test. The plans may cover this as a supplemental
benefit starting January 15, 2022, on the specific benefits offered by the Plan. You can find this information on
the Centers for Medicare and Medicaid Services website at https://www.cms.gov/how-to-get-your-at-home-
OTC-COVID-19-test-for-free.
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 addendum says that home COVID-19 test kits began to be covered as a supplemental benefit starting
February 1, 2022.
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 an Outpatient Prospective Payment System (OPPS) payment status indicator is assigned to 
every Healthcare Common Procedure Coding System (HCPCS) code. The status indicator identifies whether 
the service described by the HCPCS code is paid under the OPPS and if so, whether payment is made 
separately or packaged. The status indicator may also provide additional information about how the code is 
paid under the OPPS or under another payment system or fee schedule. For example, services with status 
indicator A are paid under a fee schedule or payment system other than the OPPS. Services with status 
indicator N are paid under the OPPS, but their payment is packaged into payment for a separately paid service. 
Services with status indicator T are paid separately under OPPS but a multiple procedure payment reduction 
applies when two or more services with a status indicator of T are billed on the same date of service. You can 
find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Section 10.1.1. 
 
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 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 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 Plan 
contract says that enrollees must pay a $15 copayment per service during the visit for covered routine dental 
services when provided by an in-network provider. You can find this information on page 61 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a 20% coinsurance for Medicare-covered prosthetic devices. You can find 
this information in Chapter 4 on page 87 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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules say that for anesthesia services/claims, physicians must report the appropriate modifier to denote 
whether the service meets the requirements for payment at the personally performed rate, medically directed 
rate, or medically supervised rate. The modifiers are as follows: 
 
AA - Anesthesia Services performed personally by the anesthesiologist 
AD - Medical Supervision by a physician; more than 4 concurrent anesthesia procedures 
G8 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical 
procedures 
G9 - Monitored anesthesia care for patient who has a history of severe cardio- pulmonary condition 
QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals 
QS - Monitored anesthesia care service 
QY - Medical direction of one qualified nonphysician anesthetist by an anesthesiologist 
GC - These services have been performed by a resident under the direction of a teaching physician. 
 
You can find this information in The Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Transmittal 3747, Section I. Anesthesia Claims 
Modifiers. 
 
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 $250 copayment for an injection. You can find this information in 
Chapter 4, on page 40, 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 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). 
 
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 does not clearly disclose how much enrollees should expect to pay for dental services.
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 only the 
items and services listed in the Covered Routine Dental Benefits chart. Gingival irrigation (D4921) is not 
covered by the Plan's routine dental benefits. You can find this information on pages 4-59 to 4-74 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 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, for days 1-20: a $0 copayment per day, per admission. Day 21-100: $160 
copayment per day, per admission. You can find this information on pages 198 to 200 of the Plan's 2021 
Evidence of Coverage (EOC) and on pages 210 to 212 of the Plan's 2022 EOC.