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 for ambulance service claims, institutional-based providers and suppliers must report an 
origin and destination modifier for each ambulance trip provided in HCPCS/Rates. However, in the case where 
the beneficiary was pronounced dead after the ambulance is called/dispatched but before the ambulance arrives 
at the scene: Payment may be made for a BLS service if a ground vehicle is dispatched. 
 
Providers or suppliers report the A0428 (BLS) non-emergency or A0429 (BLS) emergency transport HCPCS 
code if an emergency response and modifier QL (Patient pronounced dead after ambulance called) in 
"HCPCS/Rates" instead of the origin and destination modifier for ground vehicles. In addition to the QL 
modifier, institutional-based providers report modifier QM or QN. If the time of death pronouncement is after 
takeoff to point of pickup but before the beneficiary is loaded on-board the air ambulance, air ambulance 
providers or suppliers bill the A0430 or A0431 depending on the type of aircraft and modifier QL. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 15, Section 30.2(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 state that 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 rule in the ICD-10-CM Guidelines, Section I.B.10. 
 
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 acupuncture. You can find this information on page 
67 of the Plan's 2022 and 2023 Evidence of Coverage (EOC) and 58 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 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 modifier XE is a valid modifier. This modifier gives greater reporting specificity in situations 
where you used modifier 59 previously. Modifier XS is defined as - "Separate Encounter, a service that is 
distinct because it occurred during a separate encounter." This modifier should only be used to describe 
separate encounters on the same date of service. You can find this rule in the in the Medicare Learning 
Network (MLN) Fact Sheet - Proper Use of Modifiers 59, XE, XP, XS, XU. 
 
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 wireless capsule endoscopy of the small bowel is payable only once per episode of illness 
for patients who have previously undergone an upper gastrointestinal (GI) endoscopy, and lower GI 
colonoscopy, but have failed to reveal a source of bleeding. An episode of illness is defined as the time frame 
from the onset of signs and symptoms until the GI bleeding is resolved. You can find this information in Local 
Coverage Determination (LCD): Wireless Capsule Endoscopy (L33774). 
 
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 BRCA1/BRCA2 genetic testing for susceptibility to breast or ovarian cancer is not covered 
for any other indication including any of the following because it is considered not medically reasonable and 
necessary for these indications: 
- Genetic screening in the general population. Such testing is considered screening and is excluded by 
Medicare statute. 
- Testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, 
pancreatic, or prostate cancer. Such testing is considered screening and is excluded by Medicare statute. 
- Testing of individuals under 18 years of age. 
 
You can find these rules in Local Coverage Determination (LCD) BRCA1 and BRCA2 Genetic Testing 
(L36499). 
 
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 in the case of a clinical laboratory test provided under an arrangement (as defined in 
SS1861(w)(1)) made by a hospital, CAH or SNF, payment is made to the hospital or SNF. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 16, 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 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 $5 copayment for diagnostic lab services and diagnostic procedures and 
tests. You can find this information on page 100 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $20 copayment for each basic imaging service. You can 
find this information on page 100 of the Plan's 2022 EOC. 
 
The Plan contract also says that enrollees must pay a $35 copayment for each in-person specialist visit. You 
can find this information on page 106 of the Plan's 2022 EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that Medicare 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 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 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. 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 that a safety belt/pelvic strap (E0978) is covered if the beneficiary has weak upper body muscles, 
upper body instability or muscle spasticity which requires use of this item for proper positioning. You can find 
this information in the Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Healthcare Common Procedure Coding System (HCPCS) or 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). 
 
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 Physician Fee Schedule Status Indicator P means that these are bundled/excluded codes. 
There are no RVUs and no payment amounts for these services. No separate payment is made for them under 
the fee schedule. 
 
If the item or service is covered as incident to a physician service and is provided on the same day as a 
physician service, payment for it is bundled into the payment for the physician service to which it is incident 
(an example is an elastic bandage furnished by a physician incident to a physician service). 
 
If the item or service is covered as other than incident to a physician service, it is excluded from the fee 
schedule (for example, colostomy supplies) and is paid under the other payment provision of the Act. 
 You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
The rules say that there should be no billing and there will be no separate allowance for replacement electrodes 
(A4556), conductive paste or gel (A4558), replacement batteries (A4630), or a battery charger used with a 
TENS unit. You can find this rule in the Local Coverage Article for Transcutaneous Electrical Nerve 
Stimulators (TENS) - Policy Article, A52520. 
 
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 $150 copayment for outpatient diagnostic tests/all other duagnostic 
procedures and test. You can find this information on page(s) 54 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that for coverage eligibility the test must have satisfactorily completed a Technical Assessment 
(TA) by Molecular Diagnostic Services Program (MolDX) for the stated indications of the test. You can find 
this information in Local Coverage Determination (LCD): MolDX: Lab-Developed Tests for Inherited Cancer 
Syndromes in Patients with Cancer (L38974). 
 
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 21 to 22 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 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, combined in and out-of-network, are covered each year. You can find this 
information on pages 108-109 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 a heavy duty extra wide hospital bed (E0301, E0303) is covered only if your weight is more 
than 350 pounds but does not exceed 600 pounds. You can find this rule at Centers for Medicare and Medicaid 
Services, Local Coverage Determination L33820 entitled "Hospital Beds and Accessories." 
 
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.