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 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 11-12 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 the GQ modifier is to be used for asynchronous telecommunications services affiliated with 
a federal telemedicine demonstration program conducted in Alaska or Hawaii. You can find this rule at Centers 
for Medicare and Medicaid Services, Internet-Only Publication 100-04, Medicare Claims Processing Manual 
Chapter 12, Section 190.7. 
 
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 global surgery package for certain codes includes a set of services related to the 
procedure which are considered included in payment for the procedure. Included in the global package are 
follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery. 
Treatment for the underlying condition or an added course of treatment which is not part of normal recovery 
from surgery is not included in this package. Separate payment is allowed for visits and procedures billed with 
modifier "-78," "-79," "-24," "-25," "-57," or "-58. You can find this information in the Centers for Medicare 
and Medicaid Services, Internet-Only Manual, Publication 100-04, Claims Processing Manual, Chapter 12, 
Section 40. 
 
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). 
 
Coverage may be provided for the genetic tests submitted under code 81599 if documentation supports medical 
necessity. You can find this rule in  Local Coverage Article:Billing and Coding: Molecular Pathology 
Procedures (A56199). 
 
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 physicians must report services correctly. This manual discusses general coding principles in 
Chapter I, 
and principles more relevant to other specific groups of HCPCS/CPT codes in the other chapters. There 
are certain types of improper coding that physicians must avoid. You can find this information in the National 
Correct Coding Initiative (NCCI) Chapter 1, A. Introduction. 
 
The rules say 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. 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. HHAs must send the NOA to 
the A/B MAC (HHH) by mail, electronic data interchange (EDI), or direct data entry (DDE). EDI submissions 
require additional data not required by the NOA itself, to satisfy transaction standards. This data is described in 
a companion guide available on the CMS website. HHAs may voluntarily agree to adopt the companion guide 
and use it to submit EDI NOAs at any time. Admission/Start of Care Date Required - The Admission date on 
the NOA must always match the From date. The following data elements are required to submit a claim under 
home health PPS. For billing of home health claims not under an 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. 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. You can find 
this information in the Medicare Claims Processing Manual Chapter 10 - Home Health Agency Billing, 
10.1.10.3 - Submission of the Notice of Admission, 40.1 - Notice of Admission (NOA) and 40.2 - HH PPS 
Claims. 
 
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. 
 
A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. 
There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in 
cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Examples of 
sequela include scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due 
to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes sequenced in the 
following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced 
second. you can find this information in the Centers for Medicare and Medicaid Services, ICD-10-CM Official 
Guidelines for Coding and Reporting FY 2022. 
 
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 group psychotherapy is psychotherapy administered in a group setting with a trained 
therapist simultaneously providing therapy to several patients. Personal and group dynamics are discussed and 
explored in a therapeutic setting allowing emotional catharsis, instruction, insight, and support. To establish 
medical necessity of the service, claims must be submitted with a covered diagnosis. 
 
Group therapy, since it involves psychotherapy, must be led by a person who is authorized by state statute to 
perform this service. This will usually mean a physician, clinical psychologist, clinical social worker, physician 
assistant, certified nurse practitioners, clinical nurse specialist, or other person authorized by the state to 
perform this service. 
 
Group therapy does not include socialization, music therapy, recreational activities, art classes, excursions, 
sensory stimulation or eating together, cognitive stimulation, or motion therapy. 
 
You can find this rule in the Local Coverage Determination (LCD) Psychiatry and Psychology Services 
L34616. 
 
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 pages 3-3 to 3-7 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 in this policy, the term PAP (positive airway pressure) device will refer to both a single-
level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-
up rate (E0470) when it is used in the treatment of obstructive sleep apnea. 
 
    An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A  C are met: 
 
        The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to 
assess the beneficiary for obstructive sleep apnea. 
 
        The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2): 
 
            The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 
events per hour with a minimum of 30 events; or, 
 
            The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a 
minimum of 10 events and documentation of: 
 
                Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
 
                Hypertension, ischemic heart disease, or history of stroke. 
 
        The beneficiary and/or their caregiver has received instruction from the supplier of the device in the 
proper use and care of the equipment. 
 
    If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not 
reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Positive Airway Pressure (PAP) 
Devices for the Treatment of Obstructive Sleep Apnea L33718. 
 
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 44 of the Plan's 2021.
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 a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints 
(L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury 
to or a surgical procedure on the knee(s). This rule is found in Local Coverage Determination (LCD): Knee 
Orthoses (L33318). 
 
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.  
 
There is no separate billing/payment if fixed, swingaway, or detachable non-elevating legrests with or without 
calf pad are provided. Elevating legrests may be billed separately. 
 
You can find this information in the Local Coverage Article Wheelchair Options/Accessories - Policy Article 
A52504. 
 
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 contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
  
  provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
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 160. 
 
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 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 $245 copayment for ambulance services. You can find this information 
on page 43 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 there is no further payment for oxygen equipment during the 5-year reasonable useful 
lifetime (RUL) of the equipment after 36 rental payments have been made. The supplier who provided the 
equipment during the 36th rental month is required to continue to provide the equipment, accessories, contents 
(if applicable), maintenance, and repair of the oxygen equipment during the 5-year reasonable useful lifetime of 
the equipment. You can find this information in the Local Coverage Article: Oxygen and Oxygen Equipment - 
Policy Article (A52514). 
 
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 procedures billed with assistant-at-surgery physician modifiers - 80, -81, -82, or the AS modifier 
for physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant-at-surgery 
policy. Accordingly, pay claims for procedures with these modifiers only if the services of an assistant-at-
surgery are authorized. A/B MACs (B) may not pay assistant-at-surgery for surgical procedures in which a 
physician is used as an assistant-at-surgery in fewer than five percent of the cases for that procedure nationally. 
You can find this information in the Medicare Claims Processing Manual Chapter 12 - 
Physicians/Nonphysician Practitioners: 20.4.3 - Assistant-at Surgery-Services. 
 
The rules say CPT Code 11406-Modifier 80; Assistant Surgeon Indicator - 1- Statutory payment restriction for 
assistants at surgery applies to this procedure. Assistant at surgery may not be paid. You can find this 
information in the 2022 Physician Fee Schedule Search. 
 
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 providers must bill using the appropriate Place of Service (POS) code.  POS code 21 
indicates that the service was provided in an inpatient hospital setting. POS 22 indicates that the service was 
provided in an on-campus 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.