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 transportation, including transportation by ambulance, to and from another hospital or 
freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where 
the patient is an inpatient is covered under Part A. Consequently, transportation is covered by the prospective 
payment rate or reimbursed as reasonable costs under Part A to hospitals excluded from the prospective 
payment system (PPS). You can find this information in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, 10.4. 
 
The rules say that hospital bundling rules exclude payment to independent suppliers of ambulance services for 
beneficiaries in a hospital inpatient stay. The Common Working File (CWF) performs reject edits to incoming 
claims from independent suppliers of ambulance services. The CWF searches paid claim history and compares 
the line item service date on an ambulance claim to the admission and discharge dates on a hospital inpatient 
stay. The CWF rejects the line item when the ambulance line item service date falls within the admission and 
discharge dates on a hospital inpatient claim. Based on CWF rejects, the A/B MAC (B) must deny line items 
for ambulance services billed by independent suppliers that should be bundled to the hospital. 
 
Upon receipt of a hospital inpatient claim, CWF searches paid claim history and compares the period between 
the hospital inpatient admission and discharge dates to the line item service date on an ambulance claim billed 
by an independent supplier. The CWF shall generate an unsolicited response when the line item service date 
falls within the admission and discharge dates of the hospital inpatient claim. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 3, 10.5. 
 
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 pages 42 and 43 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). 
 
An Implantable (or Insertable Loop) Recorder (ILR) is used when syncope is thought to be cardiac-related, but 
is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom MLR. You can find 
this information in the National Coverage Determination (NCD) (20.15) Electrocardiographic Services. 
 
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 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. 
 
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 to send us your request for payment, along with your bill and documentation of any payment 
you have made. You can find this information on page 99 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 certain conditions have both an underlying etiology and multiple body system manifestations 
due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the 
underlying condition be sequenced first, if applicable, followed by the manifestation. In most cases the 
manifestation codes will have in the code title, in diseases classified elsewhere. Codes with this title are a 
component of the etiology/ manifestation convention. The code title indicates that it is a manifestation code. 
In diseases classified elsewhere does are never permitted to be used as first listed or principal diagnosis 
codes. There are manifestation codes that do not have in diseases classified elsewhere in the title. For such 
codes, there is a use additional code note at the etiology code and a code first note at the manifestation 
code, and the rules for sequencing apply. You can find this rule in the ICD-10-CM Official Guidelines for 
Coding and Reporting FY 2021. 
 
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 $40 copayment for Medicare Part B Prescription Drugs. You can find this 
information on pages 4-39 to 4-41 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay $150 copayment for Outpatient surgery and other medical 
services provided at hospital outpatient facilities and ambulatory surgical centers. You can find this information 
on pages 4-39 to 4-41 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules state that payment may be made under the physician fee schedule for the professional component of 
physician laboratory or physician pathology services furnished to hospital inpatients or outpatients. Payment is 
not made under the physician fee schedule for technical component (TC) services furnished in institutional 
settings where the TC service is bundled into the facility payment, e.g., hospital inpatient and outpatient 
settings. For services furnished on or after July 1, 2012, an independent laboratory may not bill the Medicare 
contractor (and the Medicare contractor may not pay) for the TC of a physician pathology service furnished to 
a hospital inpatient or outpatient. You can find this information in the Centers for Medicare and Medicaid 
Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 
60. 
 
The rules say that professional component (PC)/technical component (TC) indicator of 1 identifies codes that 
describe diagnostic tests. These codes generally have both a professional and technical component. Modifiers 
26 and TC can be used with these codes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 
50.6.  
 
The rules say that if the same physician or other supplier entity does not furnish both the TC and PC of the 
diagnostic service, or if the same physician or other supplier entity furnishes both the TC and PC but the 
professional interpretation was furnished in a different payment locality from where the TC was furnished, the 
professional interpretation of a diagnostic test must be separately billed with modifier -26 by the interpreting 
physician. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 13, Section 150(E).  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. 
 
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 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 in accordance with current Medicare conditions of participation and Medicare coverage 
guidelines governing home health, the patients plan of care must reflect the physician or allowed practitioner 
ordered services that the home health agency provides either directly or under arrangement. 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 10.10E. 
 
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 when your primary care physician (PCP) thinks that you need specialized treatment, he/she can give you a 
referral to see a specialist or certain other providers in the plan's network. If you are seeing a network specialist 
for your care, you may need to return to your PCP for a referral for additional services. For some types of 
services, your PCP may need to get approval in advance from our plan (this is called getting "prior 
authorization"). See Chapter 4, Section 2.1 for information about which services require prior authorization. 
You can find this information on page 33 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 Medicare Part B prescription drugs. You can find 
this information in Chapter 4 on page 84 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay $100 copayment for diagnostic radiology services. You can 
find this information in Chapter 4 on page 87 of the Plans 2022 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 Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet all of the following criteria:  
 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
You can find this information in the Local Coverage Determination (LCD) for Facet Joint Interventions for 
Pain Management (L35936). 
 
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 state that Medicare law contains a restriction that miles beyond the closest available facility cannot be 
billed to Medicare. Non-covered miles beyond the closest facility are billed with HCPCS procedure code 
A0888 ("non-covered ambulance mileage per mile, e.g., for miles traveled beyond the closest appropriate 
facility"). These non-covered line items can be billed on claims also containing covered charges. Ambulance 
claims may use the -GY modifier on line items for such non-covered mileage, and liability for the service will 
be assigned correctly to the beneficiary. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 15, Section 30.2.4. 
 
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 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. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for an intraoral - periapical first radiographic image (D0220); and an intraoral - periapical each 
additional radiographic image (D0230) but is limited to one procedure code per calendar year. This benefit also 
includes coverage for core buildup (D2950), a porcelain/ceramic crown (D2740), and a porcelain/ceramic 
retainer crown (D6740) but is limited to two procedure codes per calendar year. You can find this information 
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 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 Medicare coverage for outpatient cardiac telemetry is limited to patients who have 
demonstrated a specific need for this type of cardiac telemetry service. The ordering physician must have 
determined and documented that patients who require this service are at low risk for a life-threatening cardiac 
event. In addition, the medical record must clearly demonstrate that the results of this testing will provide 
diagnostic and/or treatment information useful in the ongoing management of the patient. 
 
The following uses of real-time, outpatient cardiac telemetry are considered medically reasonable and 
necessary: 
 
    1. Detection, characterization and documentation of symptomatic transient or paroxysmal dysrhythmia when  
    the frequency of the symptoms is limited and the use of a 24-hour ambulatory ECG is documented in the 
    medical record to be unlikely to capture and record the dysrhythmia, or 
    2. Other testing and/or monitoring/recording/telemetry has been unrevealing. The ordering physician must 
    document the prior testing performed and the results. This information must be maintained in the patients  
    medical record and be available upon request, or 
    3. Prolonged monitoring is required specifically to ensure the absence of atrial fibrillation prior to the  
    discontinuation of anticoagulation therapy. 
 
You can find this information in the Local Coverage Determination (LCD): Real-Time, Outpatient Cardiac 
Telemetry (L34997). 
 
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.