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 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 $175 copayment for advanced radiology services.  You can find this 
information on page(s) 90 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 a $15 copayment for each Medicare-covered podiatry visit.  You can find 
this information on page(s) 101 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 that Medicare will pay for an inpatient rehabilitation facility (IRF) admission when the services
are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary
approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one
therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must
need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program.
This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at
least five days per week. The patient does not need to be expected to achieve complete independence in selfcare
nor be expected to return to his or her prior level of functioning. The patient must need supervision by a
rehabilitation physician. The physician must see the patient at least three days per week throughout the stay.
You can find these rules in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication
100-02, Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622.

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 Centers for Medicare & 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." MUEs for codes with an MAI of 3 are "per day edits based on clinical
benchmarks." Codes with an MAI of "3" are based on criteria combined with data such that it would be
possible, but medically unlikely, that higher values would represent correctly reported medically necessary
services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided,
were correctly coded, and were medically necessary. You can find this rule in the Centers for Medicare &
Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter
I(V).

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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for
Medicare Services, Chapter I(A).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 claims processing systems contain edits which identify exact duplicate claims and 
suspect duplicate claims. All exact duplicate claims or claim lines are auto-denied or rejected. Some claims that 
appear to be duplicates are actually claims or claim lines that contain an item or service, or multiple instances 
of an item or service, for which Medicare payment may be made. Correct coding rules applicable to all billers 
of health care claims encourage the appropriate use of condition codes or modifiers to identify claims that may 
appear to be duplicates, but, in fact, are not. You can find this rule in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, 
Section 120.1.  

The rules say that if more than one evaluation and management (face-toface) service is provided on the same 
day to the same patient by the same physician or more than one physician in the same specialty in the same 
group, only one evaluation and management service may be reported unless the evaluation and management 
services are for unrelated problems. You can find this rule in the Centers for Medicare and Medicaid Services 
(CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 
30.6.5. 
 
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.
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 an expandable controller can accommodate one or more of the following additional
functions:
- Other types of proportional input devices (such as, mini-proportional or compact joysticks, 
touchpads, chin control, head control, and so on) - non-proportional input devices (such as, sip 
and puff, head array, and so on)
- Operate 3 or more powered seating actuators through the drive control. (Note: Control of the 
power seating actuators though the Control Input Device would require the use of an additional 
component, E2310 or E2311.) An expandable controller may also be able to operate one or more of the 
following: - A separate display (for example, for alternate control devices)
- Other electronic devices (such as, control of an augmentative speech device or computer through 
the chair's drive control)
- An attendant control

You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective
January 1, 2020.

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 $175 copayment for advanced radiology services.  You can find this 
information on page(s) 90 of the Plan's 2023 Schedule of Cost Sharing.
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 power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered. 
 
The rules state that an expandable controller is capable of accommodating one or more of the following 
additional functions: 

1. Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin 
control, head control, etc.) 
2. Non-proportional input devices (e.g., sip and puff, head array, etc.) 
3. Operate three (3) or more powered seating actuators through the drive control. (Note: Control of the 
power seating actuators though the Control Input Device would require the use of an additional 
component, E2310 or E2311.) 
An expandable controller may also be able to operate one or more of the following: 
1. A separate display (i.e., for alternate control devices) 
2. Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's 
drive control) 
3. An attendant control 

The rules state that a power tilt and recline seating system (E1006, E1007, E1008) includes: a solid seat 
platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height 
armrests; fixed or swingaway detachable legrests; fixed or flip-up footplates; two motors and related 
electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface. 
 
The rules state that a power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related 
electronics with or without variable speed programmability which allows the legrest to be raised and lowered 
independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not 
be integrated with the power tilt and/or recline control(s). 
 
You can find these rules in the Local Coverage Article for Wheelchair Options/Accessories - Policy Article, 
A52504. 
 
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 $50 copayment for outpatient diagnostic tests and therapeutic services 
and supplies.  You can find this information on page(s) 82 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 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 & 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 D6750 
and D6240 once per 60 months. Pre-operative x-rays are required documentation. Bridges are covered to 
replace only one upper anterior tooth or only two adjacent lower anterior teeth. There cannot be any missing 
posterior teeth in the arch. You can find this information on pages 103 to 109 of the Plans 2023 Evidence of 
Coverage (EOC), in the Plan's Dental Benefit Limitations and Exclusions Guide and in the Office Reference 
Manual maintained by the Plan's dental benefit administrator.
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 & 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 the Plan has a Point-of-Service (POS) option to cover certain out-of-network services. Not all 
services are covered out-of-network under this benefit. You can find this information on page 39 of the Plan's 
2023 Evidence of Coverage (EOC).  
 
The Plan contract also says that an in-network provider must be used for out-of-network telehealth services 
under the POS benefit. You can find this information on pages 101-107 of the Plans 2023 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 services that do not have Food and Drug Administration (FDA)-cleared/approved indicated 
uses, as well as FDA-approved tests performed in ways not consistent with their intended-use labeling 
directions, will require registration with Molecular Diagnostic Services Program (MolDX) and a Technical 
Assessment (TA) to demonstrate compliance of the service with this policy. Similarly, tests (and CPT codes) 
for which there are no accompanying ICD-10 codes in the associated Billing and Coding Article will require 
registration with MolDX and a TA to demonstrate compliance of the service with this policy. You can find this 
rule in Local Coverage Determination (LCD) MolDX: Molecular Syndromic Panels for Infectious Disease 
Pathogen Identification Testing L38988.    
 
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 20% coinsurance for Medicare Part B drugs.  You can find this 
information on page(s) 88 to 89 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 a $75 copayment for each emergency room visit. You can find this 
information on page 10 of the Plan's 2023 Schedule of Cost Sharing. 
 
The Plan contract also says that enrollees must pay a $15 copayment for Medicarecovered physician specialist 
services. You can find this information on page 24 of the Plan's 2023 Schedule of Cost Sharing.
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 $35 copayment for specialist office or telehealth visit. The Plan contract 
also says that the Plan will cover one screening for depression per year. The screening must be done in a 
primary care setting that can provide follow-up treatment and/or referrals. You can find this information on 
pages 67 and 106 of the Plan's 2023 Evidence of Coverage (EOC).