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 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). 
 
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 states that in some cases travel and lodging costs may be covered for enrollees who require an organ 
transplant at an inpatient hospital. This information is found on page 4-34 of the 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 durable medical equipment is equipment which: 
 Can withstand repeated use; 
 Is primarily and customarily used to serve a medical purpose; 
 Generally is not useful to a person in the absence of an illness or injury; and 
 Is appropriate for use in the home. 
 
All requirements of the definition must be met before an item can be considered to be durable medical 
equipment. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-04, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
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 post-operative care is included in the global surgical package. You can find this rule in the 
Center for Medicare Services (CMS) Internet-Only Manual Publication 100-04, Medicare Claims Processing 
Manual, Chapter 12, Section 40.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that for payment of anesthesia services, physicians 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. 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 50 (I). 
 
The rules say that when the physician and the CRNA (or anesthesiologists assistant) are involved in one 
anesthesia case and the services of each are found to be medically necessary, documentation must be submitted 
by both the CRNA and the physician to support payment of the full fee for each of the two providers. The 
physician reports the AA modifier and the CRNA reports the QZ modifier. 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 50. 
 
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 reported as 
the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of 
service. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.6. 
 
The rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other 
supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two 
exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or 
outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You 
can find this information in the MLN Matters article number MM7631, Revised and Clarified Place of Service 
(POS) Coding Instructions. 
 
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 the National Correct Coding Initiative (NCCI) was developed to prevent inappropriate 
payment of services that should not be reported together. NCCI edits are organized in a Column I/Column 2 
table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of an edit 
pair, only the Column 1 code is payable. For edits with a modifier indicator of 0, the Column 2 code cannot be 
paid regardless of whether a modifier is used. You can find this in the NCCI Manual, Chapter I. 
 
The rules say unless otherwise specified, the MAC, RAC and ZPIC/UPIC shall request information from the 
billing provider/supplier. The treating physician, another clinician, provider, or supplier should submit the 
requested documentation. However, because the provider selected for review is the one whose payment is at 
risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the documentation requested by the MAC, CERT, RAC and ZPIC/UPIC. You can find this information in the 
Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, 
Section 3.2.3.3 - Third-party Additional Documentation Request. 
 
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 also 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 rules say that For all beneficiaries receiving home health (HH) services in 2021 whose services will 
continue in 2022, the home health agency (HHA) shall submit an notice of admission (NOA) with a one-time, 
artificial 'admission' date corresponding to the "from" date of the first period of continuing care in 2022. 
For example, if a period of care begins in 2021 and ends on January 10, 2022, the HHA submits and NOA with 
an admission date of January 11, 2022 and then submits a claim when the 30-day period of care is over. The 
HHA should submit the January 11, 2022 admission date on all subsequent claims until the beneficiary is 
discharged and another NOA is required. This is to ensure the claim is matched to the correct NOA and the 
correct receipt date is used for payment. You can find these rules in the Medicare Claims Processing Manual 
Chapter 10, Section 10.1.10.3. 
 
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.
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, 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). 
You can find this rule in National Coverage Determination (NCD) Next Generation Sequencing (NGS) 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 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). 
 
Medicare rules also state that to report a Next Generation Sequencing Lab-Developed Test, providers must 
enter the appropriate DEX Z-Code on the claim. This rule is found in Medicare Local Coverage Article: Billing 
and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and 
Suspected Myeloid Malignancies (A57873). 
 
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 30-day period of care is the unit of payment for the home health prospective payment 
system (HH PPS). The period of care payment is specific to one individual homebound beneficiary. It pays all 
Medicare covered home care that is reasonable and necessary for the patient's care, including routine and 
nonroutine supplies used by that beneficiary during the period of care. It is the only Medicare form of payment 
for such services. Home health agencies (HHAs) shall no longer submit Requests for Anticipated Payment 
(RAPS -Type of Bill 0322) for any HH period of care with a From date on or after January 1, 2022. Instead, 
for each admission to home health, the HHA notifies Medicare systems via submission of a Notice of 
Admission (NOA). For all beneficiaries receiving HH services in 2021 whose services will continue in 2022, 
the HHA shall submit an NOA with a one-time, artificial 'admission' date corresponding to the "From" date of 
the first period of continuing care in 2022. Only one NOA is required for any series of HH periods of care 
beginning with admission to home care and ending with discharge. After a discharge has been reported to 
Medicare, a new NOA is required before the HHA submits any additional claims. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 10, Section 10.1.4 and 10.1.10.3. 
 
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 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 31 of the Pans 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 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 50 one-way, non-emergency trips to Plan-approved locations within the Plan service area. You can find 
this information on page 82 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 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 covered telehealth services include virtual visits, evaluations, communication via telephone, or 
video (computer, smart phone, tablet, online patient portal). Ask one of the Plans network providers if they can 
do virtual visits. Virtual care out-of-network is not covered. You can find this information on page 122 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 both Initial Hospital Care (CPT codes 99221 - 99223) and Subsequent Hospital Care codes 
are per diem services and may be reported only once per day by the same physician or physicians of the same 
specialty from the same group practice. A/B MACs (B) pay for an initial hospital care service if a physician 
sees a patient in the emergency room and decides to admit the person to the hospital. They do not pay for both  
E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date 
of service. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency 
department, physicians office, nursing facility), all services provided by the physician in conjunction with that 
admission are considered part of the initial hospital care when performed on the same date as the admission. 
When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial 
Hospital Care, from CPT code range 99221 - 99223, shall be reported by the physician. The Hospital Discharge 
Day Management service, CPT codes 99238 or 99239, shall not be reported for this scenario. When a patient is 
admitted to inpatient initial hospital care and then discharged on a different calendar date, the physician shall 
report an Initial Hospital Care from CPT code range 99221 -99223 and a Hospital Discharge Day Management 
service, CPT code 99238 or 99239. You can find this information in the Medicare Claims Processing Manual 
Chapter 12 - Physicians/Nonphysician Practitioners; 30.6.8 - Payment for Hospital Observation Services and 
Observation or Inpatient Care Services (Including Admission and Discharge Services) (Rev. 2282, Issued: 08-
26-11, Effective: 01-01-11, Implementation: 11-28-11 and 30.6.9.1 - Payment for Initial Hospital Care Services 
and Observation or Inpatient Care Services (Including Admission and Discharge Services) (Rev. 2282, Issued: 
08-26-11, Effective: 01-01-11, Implementation: 11-28-11). 
 
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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 47-52 of the Plan's 2022 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that gastrointestinal pathogen (GIP) testing is limited to no more than 5 bacterial pathogen 
targets when not testing for Clostridium difficile. Testing for 6-11 pathogens is covered when there is a clinical 
concern for Clostridium difficile colitis, and Clostridium difficile is one of the pathogens being tested. You can 
find this information in Local Coverage Determination (LCD): Foodborne Gastrointestinal Panels Identified by 
Multiplex Nucleic Acid Amplification (NAATs) (L37766). 
 
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 $15 copayment for physician/practitioner service. You can find this 
information on page(s) 58 of the Plan's 2022 Evidence of Coverage.