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 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 Section 1833(t)(1)(B)(i) of the Act allows CMS to define the services for which payment 
under the OPPS is appropriate and the Secretary has determined that the services designated to be inpatient 
only services are not appropriate to be furnished in a hospital outpatient department. Inpatient only services 
are generally, but not always, surgical services that require inpatient care because of the nature of the 
procedure, the typical underlying physical condition of patients who require the service, or the need for at least 
24 hours of postoperative recovery time or monitoring before the patient can be safely discharged. An example 
of an inpatient only service is CPT code 33513, Coronary artery bypass, vein only; four coronary venous 
grafts. The designation of services to be inpatient-only is open to public comment each year as part of the 
annual rulemaking process. Procedures removed from the inpatient only list may be appropriately furnished 
in either the inpatient or outpatient settings and such procedures continue to be payable when furnished in the 
inpatient setting. 
 
There is no payment under the OPPS for services that CMS designates to be inpatientonly services. These 
services have an OPPS status indicator of C in the OPPS Addendum B and are listed together in Addendum 
E of each years OPPS/ASC final rule. For the most current Addendum B and for Addendum E published with 
the OPPS notices and regulations, see http://www.cms.gov/Medicare/Medicare-Fee-for-
ServicePayment/HospitalOutpatientPPS/index.html. 
 Excluding the handful of exceptions discussed below, CMS does not pay for an inpatient-only service 
furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient 
hospital bill type (TOB 13X). CMS also does not pay for all other services on the same day as the inpatient 
only procedure.  
 
You can find these rules in the Medicare Claims Processing Manual, Chapter 4, Section 180.7. 
 
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 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 the positioning/safety belt (Column II) is included in the allowance for the power wheelchair 
(Column I) when provided at the same time. 
 
A power standing feature (E2301) is non-covered because it is 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 standing feature, it will be denied as non-covered. 
 
If an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be 
denied as non-covered. You can find this information in Local Coverage Article: Wheelchair 
Options/Accessories - Policy Article (A52504). 
 
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 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.  
 
The rules also say that effective for dates of service on and after July 1, 2011, A/B Medicare Administrative 
Contractors (MACs) shall automatically deny claim line(s) items submitted with a GZ modifier. A/B MACs 
shall not perform complex medical review on claim line(s) items submitted with a GZ modifier. All MACs 
shall make all language published in educational outreach materials, articles, and on their Web sites, consistent 
to state all claim line(s) items submitted with a GZ modifier shall be denied automatically and will not be 
subject to complex medical review. You can find this information in the CMS Internet only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
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 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 up to 72 one-way trips with each one-way trip not exceeding 50 miles of driving distance. You can find 
this information on pages 99-100 of the Plans 2023 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 when a Health Insurance Prospective Payment System (HIPPS) rate code of RUAxx, 
RUBxx , RUCxx, RULxx and/or RUXxx is present, a minimum of two rehabilitation therapy ancillary codes 
are required (revenue code 042x and/or, 043x and/or, 044x). When a HIPPS rate code of RHAxx, RHBxx, 
RHCxx, RHLxx, RHXxx, RLAxx, RLBxx, RLXxx, RMAxx, RMBxx, RMCxx, RMLxx, RMXxx, RVAxx, 
RVBxx, RVCxx, RVLxx, and/or RVXxx is present, a minimum of one rehabilitation therapy ancillary revenue 
code is required (revenue code 042x, 043x, or 044x. Bills that are missing required rehabilitation therapy 
ancillary revenue codes are to be returned to the SNF for resubmission. You can find this rule at Centers for 
Medicare and Medicaid Services, Internet-Only Publication 100-04, Medicare Claims Processing Transmittal 
2239, Change Request 7339,  
 
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).  
 
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 that there is a $300 deductible which applies to certain items and services. The Plan 
deductible applies to outpatient diagnostic tests and therapeutic services. You can find this information on page 
1 of the Plan's 2023 Schedule of Cost Sharing. 
 
The Plan contract also says that enrollees pay a $0 copayment after meeting the deductible for outpatient lab 
services. You can find this information on pages 20-21 of the Plans 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 that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
requested item or service but is limited to four D6245/D6740 per year. This benefit includes one D5225 every 
five years. You can find this information on pages 125-135 of the Plan's 2023 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 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 rule in Medicare Claims Processing Manual Chapter 26, Section 10.6. 
 
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. 
 
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 does not include D6240 
when associated with implants. This benefit does not include D6056, D6058 or D6010. You can find this 
information on pages 103-110 of the Plans 2023 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 say that procedures billed with the 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. 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 
20.4.3. 
 
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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code that 
describes the services performed. A HCPCS/CPT code may be reported only if all services described by that 
code have been 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). 
 
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 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 up to 24 one-way trips with each one-way trip not exceeding 50 miles of driving distance. You can find 
this information on pages 87-88 of the Plans 2023 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 anesthesia codes describe a general anatomic area or service which usually relates to a 
number of surgical procedures, often from multiple sections of the CPT Manual. For Medicare purposes, 
only one anesthesia code is reported unless the anesthesia code is an Add-on Code (AOC). You can find this 
rule in the National Correct Coding Initiative Policy Manual, Chapter 2 (B). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 code 0202U is non-covered. You can find this information in Local Coverage Article 
(LCA): Billing and Coding: Respiratory Pathogen Panel Testing (A58741). 
 
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 the supply allowance (A4595) includes electrodes (any type), conductive paste or gel (if 
needed, depending on the type of electrode), tape or other adhesive (if needed, depending on the type of 
electrode), adhesive remover, skin preparation materials, batteries (any type, single use or rechargeable), and a 
battery charger (if rechargeable batteries are used). One unit of service includes all necessary supplies for one 
months prescribed use of the device. You can find this rule in Local Coverage Article Transcutaneous 
Electrical Joint Stimulation Devices (TEJSD) - Policy Article A52713. 
 
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.