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 many surgical procedures may be performed bilaterally. bilateral surgical procedures be 
reported using modifier 50 with one unit of service unless the code descriptor defines the procedure as 
bilateral. You can find this guidance in the National Correct Coding Initiative (NCCI) Policy Manual, 
Chapter 1  General Correct Coding Policies, Section A. Introduction and Section V. Medically Unlikely Edits 
(MUEs). 
 
The rules say that bilateral surgeries are procedures performed on both sides of the body during the same 
operative session or on the same day. B. Billing Instructions for Bilateral Surgeries - If a procedure is not 
identified by its terminology as a bilateral procedure (or unilateral or bilateral), physicians must report the 
procedure with modifier -50. They report such procedures as a single line item. (NOTE: This differs from the 
Current Procedural Terminology (CPT) coding guidelines which indicate that bilateral procedures should be 
billed as two line items.) If a procedure is identified by the terminology as bilateral (or unilateral or bilateral), 
as in codes 27395 and 52290, physicians do not report the procedure with modifier -50. You can find this 
guidance in the Medicare Claims Processing Manual, Chapter 12  Physicians/Nonphysician Practitioners, 
Section 40.7  Claims for Bilateral Surgeries. 
 
Medicare guidance says, 50: Bilateral Procedure - Modifier 50 is used to report bilateral procedures that 
are performed on both sides of the body at the same operative session. Do not report modifiers right (RT) and 
left (LT) when modifier 50 applies. Do not submit two line items to report a bilateral procedure using modifier 
50. Report one line with modifier 50 using one unit of service. Modifier 50 applies to any bilateral procedure 
performed on both sides at the same operative session. The bilateral modifier 50 is restricted to operative 
sessions only. Modifier 50 may not be used: To report surgical procedures identified by their terminology as 
bilateral, or To report surgical procedures identified by their terminology as unilateral or bilateral. The unit 
entry to use when modifier 50 is reported is one unit. You can find this guidance in the Medicare Claims Processing Manual, Chapter 4  Part B Hospital (Including Inpatient Hospital Part B and Outpatient 
Prospective Payment System (OPPS), Section 20.6.2  Use of Modifiers -50, -LT, and -RT. 
 
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 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 also say that a non-expandable controller may have the ability to control up to 2 power seating 
actuators through the drive control (for example, seat elevator and single actuator power elevating legrests). 
(Note: Control of the power seating actuators though the Control Input Device would require the use of an 
additional component, E2310 or E2311.) You can find this information 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 $255 copayment for ambulance services. You can find this information on 
page 49 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 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 a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered
because they are not primarily medical in nature. You can find this rule 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 that ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure (BiPAP) device is 
made based upon the specifics of each persons medical condition. There must be enough detailed information 
in the medical record to justify the treatment selected. Ventilators fall under the Frequent and Substantial 
Servicing (FSS) payment category, and payment policy requirements preclude FSS payment for devices used to 
deliver continuous and/or intermittent positive airway pressure, regardless of the illness treated by the device. 
This means that products currently classified as Healthcare Common Procedure Coding System (HCPCS) code 
E0465, E0466, or E0467 when used to provide continuous positive airway pressure (CPAP) or BiPAP (with or 
without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS 
payment category and will be denied as not reasonable and necessary. You can find this rule in the Local 
Coverage Determination (LCD): Respiratory Assist Devices (L33800). 
 
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 there is a wide range of services and programs that a hospital may provide to its outpatients 
who need psychiatric care, ranging from a few individual services to comprehensive, full-day programs; from 
intensive treatment programs to those that provide primarily supportive care. The comprehensive outpatient 
psychiatric treatment covered by Medicare is called a partial hospitalization program (PHP). PHPs are 
structured to provide intensive psychiatric care through active treatment that utilizes a combination of the 
clinically recognized items and services described in Section 1861(ff) of the Social Security Act (the Act). The 
treatment program of a PHP closely resembles that of a highly structured, short-term hospital inpatient 
program. It is treatment at a level more intense than outpatient day treatment or psychosocial rehabilitation. 
You can find this information in the Centers for Medicare and Medicaid Service (CMS), Internet-Only Manual, 
Publication Number 100-02, Medicare Benefit Policy Manual, Chapter 6, Sections 70.1 and 70.3. 
 
The rules also state that, for the first time, due to Congressional action, Medicare is proposing to pay for an 
intermediate level of care, called Intensive Outpatient Program (IOP), which can be performed by hospital 
outpatient departments, community mental health clinics, Federally Qualified Health Centers, or Rural Health 
Clinics. This new benefit category would significantly expand access to behavioral health services. This policy 
has not yet been finalized. You can find this information at the CMS website blog at 
https://www.cms.gov/blog/important-new-changes-improve-access-behavioral-health-medicare. 
 
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 or supplies needed for use in the home.
Your home may be a dwelling, an apartment, a relative's home, a home for the aged, or some other type of
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled
nursing facility (SNF). 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(D).
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 page 37 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 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 certain dental services as a supplemental (extra) benefit. Limitations
and exclusions apply. You can review your dental benefits starting on page 9 of the Plans 2023 Evidence of
Coverage. Benefits Insert.
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 criteria for hyperbaric oxygen therapy includes Diabetic wounds of the lower extremities in 
patients who meet the following three criteria: 
1. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; 
2. Patient has a wound classified as Wagner grade III or higher; and 
3. Patient has failed an adequate course of standard wound therapy. 
 
You can find these rules in National Coverage Determination (NCD) Hyperbaric Oxygen Therapy (20.29) 
 
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 $1,000 deductible which applies to certain items and services. The Plan 
deductible applies to an office visit. You can find this information on pages 58 to 59 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 the -79 modifier is used for subsequent surgical procedures during a global surgical period.  
You can find this rule in the Center for Medicare and Medicaid Services (CMS) Internet-Only Manual 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.8. 
 
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 $20 copayment for outpatient non-radiological diagnostic tests. The
Plan contract also says that enrollees must pay 20% coinsurance for diagnostic testing medical supplies and/or
Medicare Part B physician administered drugs. You can find this information on pages 4-31 to 4-34 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 the submission of certain skin-substitute application procedures require the reporting of a 
skin-substitute product for the same day. Certain skin-substitute application procedures and skin-substitute 
products will be divided into two lists based on high or low cost. Claims containing a high-cost skin-substitute 
application procedure without any of the high-cost skin-substitute product codes, and conversely any low-cost 
skin-substitute application procedure without a low-cost skin-substitute product code for the same day, will be 
returned to the provider (edit 87). You can find this rule in the Integrated Outpatient Code Editor (IOCE) CMS 
Specifications, V15.0  Effective January 1, 2014. 
 
The rules say that 15271 and 15272 are considered high-cost skin-substitute procedures. You can find this rule 
in the Centers for Medicare and Medicaid Services, OCE, I/OCE Quarterly Release Files. 
 
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 following data elements are required to submit a claim under home health Prospective 
Payment System (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.  
 
Home health agencies (HHAs) submit a Notice of Admission (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. 
 
Type of Bill 
Required - This 4-digit alphanumeric code gives two pieces of information. The first three digits indicate the 
base type of bill. The fourth digit indicates the sequence of this bill in this particular episode of care. 
The types of bills accepted for HH PPS claims are: 
 
032x - Home Health Services under a Plan of Treatment 
4th Digit  Definition 
 
7 - Replacement of Prior Claim - HHAs use to correct a previously submitted bill. Apply this code for the 
corrected or new bill. These adjustment claims must be accepted at any point within the timely filing period 
after the payment of the original claim. 8 - Void/Cancel of a Prior Claim - HHAs use this code to indicate this bill is an exact duplicate of an incorrect 
bill previously submitted. A replacement claim must be submitted for the period of care to be paid. 
 
9 - Final Claim for an HH PPS Period  This code indicates an HH original bill to be processed following the 
submission of an HH PPS Notice of Admission (Type of Bill (TOB) 032A) HHAs must submit HH PPS claims 
with the 4th digit of 9. These claims may be adjusted with code 7 or cancelled with code 8. A/B MACs 
(HHH) do not accept late charge bills, submitted with code 5, on HH PPS claims. To add services within the 
period of a paid HH claim, the HHA must submit an adjustment. 
 
You can find this information in the Medicare Claims Processing Manual Chapter 10 - Home Health Agency  
Billing, 40.2 - HH PPS Claims 
 
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 precautionary equipment or precautionary items as they did not
serve a direct medical purpose. 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. The Plan
contract says that as a member of our plan, however, you usually will not acquire ownership of rented DME
items no matter how many copayments you make for the item while a member of our plan. Under certain
limited circumstances we will transfer ownership of the DME item to you. Call Customer Service (phone
numbers are printed on the back cover of this booklet) to find out about the requirements you must meet and
the documentation you need to provide. You can see this on page 37 of the Plans 2022 Evidence of Coverage.