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). 
 
Effective January 1, 2002, new modifiers were developed to allow practitioners and suppliers to bill Medicare 
for items and services that are statutorily non-covered or do not meet the definition of a Medicare benefit and 
items and services not considered reasonable and necessary by Medicare. 
 
1. Definitions of the GA, GY, and GZ Modifiers. The modifiers are defined below: 
 
GA - Waiver of liability statement on file. 
GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit. 
GZ - Item or service expected to be denied as not reasonable and necessary. 
 
The GZ modifier must be used when physicians, practitioners, or suppliers want to indicate that they expect 
that Medicare will deny an item or service as not reasonable and necessary, and they have not had an Advance 
Beneficiary Notification (ABN) signed by the beneficiary. You can find this information in CMS Manual 
system, Pub 100-04 Medicare Claims Processing, Transmittal 2148, Change Request 7228. 
 
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 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 specific 
preventative and comprehensive services which are listed in the Plan's contract. Services not listed are not 
covered. You can find this information on pages 94-100 of the Plans 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that genetic tests are covered when the test results provide the clinician with information that 
will improve patient outcomes and/or change physician care and treatment of the patient. Tests in the absence 
of clinical signs and symptoms of disease are non-covered. These rules can be found in Local Coverage 
Determination (LCD): Molecular Diagnostic Tests (L36021).??????? 
 
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 MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the 
following conditions are met (42 CFR 422.100(l)): 
1. The MA plan provides all categories of DME covered under original Medicare Part B; 
2. The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) 
DME products or brands; 
3. The MA plans contracted suppliers provide access to all preferred DME brands; 
4. During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will 
provide a 90-day transition period (commencing with the initial time of enrollment) during which the plan 
provides (and repairs, as applicable) non-preferred DME brands furnished in the previous year; 
5. Although the MA plan may add brands to its preferred formulary during the year, it may not remove 
any brands mid-year; 
6. The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
7. The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-
preferred DME product or brand with the EOC and ANOC and on its website; and 
8. The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories 
or subcategories annually determined by CMS to require full coverage. 
 
You can find this rule in the Center for Medicare Services (CMS) Internet-Only Manual, Publication 100-16, 
Medicare Managed Care Manual, Chapter 4, Section 10.12.2. 
 
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 we cover Abbott and Lifescan glucometers, diabetic test strips, lancets, control solutions and 
a  continuous glucose monitoring device are available for dispense via a retail or mail order pharmacy. You can 
find this information on page 68 of the 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 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 Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
  Modifiers XE, XS, XP, XU were effective January 1, 2015. These modifiers were developed to provide greater 
reporting specificity in situations where modifier 59 was previously reported and may be used in lieu of 
modifier 59 whenever possible. You can find this information in the National Correct Coding Initiative Policy 
Manual for Medicare Services. 
 
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 provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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). 
 
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 Medicare plan may not pay for services given by a physician or other practitioner who has 
opted out of Medicare. This rule does not apply to emergency or urgently needed services. A Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 6, Section 60.2. 
 
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 health 
plan contract says that you can get your care from an out-of-network provider, however, in most cases that 
provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who 
has opted out of or been excluded or precluded from the Medicare Program. If you receive care from a provider 
who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you 
receive. Check with your provider before receiving services to confirm that they are eligible to participate in 
Medicare. You can find this information in Chapter 4 on page 3-6 of the plan's 2021 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. 
 
Medicare guidance says to receive payment for covered Medicare items or services from either Medicare (in 
the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or 
supplier must be enrolled in the Medicare program. You can find this guidance in Medicare Code of Federal 
Regulations CFR Section 424.505. 
 
Medicare guidance says certain doctors and other health care providers who dont want to work with the 
Medicare program may opt out of Medicare. Medicare doesnt pay for any covered items or services you get 
from an opt-out doctor or other provider, except in the case of an emergency or urgent need. If you still want to 
see an opt-out provider, you and your provider can set up payment terms that you both agree to through a 
private contract. A doctor or other provider who chooses to opt-out must do so for two years, which 
automatically renews every two years unless the provider requests not to renew their optout status. You can 
find this guidance in the 2021 Medicare & You booklet on page 56. 
 
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 health 
plan contract says that a medical emergency is when you, or any other prudent layperson with an average 
knowledge of health and medicine, believe that you have medical symptoms that require immediate medical 
attention to prevent loss of life, loss of limb, or loss of function of a limb. The medical symptoms may be an 
illness, injury, severe pain, or a medical condition that is quickly getting worse. What you must pay when you 
get these services In-Network and Out-of-Network is a $65 copayment for each emergency room visit.  You 
can find this information in Chapter 4 on page 4-21 of the plan's 2021 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 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 status code B: Payment for covered services are always bundled into payment for other services 
not specified. There will be no RVUs, or payment amounts for these codes and no separate payment is ever 
made. When these services are covered, payment for them is subsumed by the payment for the services to 
which they are incident (an example is a telephone call from a hospital nurse regarding care of a patient). You 
can find this information in the CMS Manual System; Pub 100-04 Medicare Claims Processing; Transmittal 
1005. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a review of the available evidence found five combinatorial pharmacogenomics (PGx) tests 
for which outcome data has been published. These studies focus on testing for drug selection for psychiatric 
and neurological use and include the Genesight Psychotropic assay. A review of the published clinical studies 
performed demonstrated that, despite showing some promising findings, these studies had several shortcomings 
in that they failed to meet their primary endpoints, were not representative of the Medicare population, or had 
other significant shortcomings such as a possible biased sample population. While there are some large PGx 
studies, the Medicare contractor is not aware of large high-quality studies that used a clear evidence-based 
prescribing approach in the control arm. As a number of prominent psychiatrists with expertise in the biological 
underpinnings of mental health have pointed out, it is not clear that PGx testing is a better tool for drug 
selection than using a standardized evidence-based protocol which does not rely on genetics, or a consultation 
from a knowledgeable provider. In summary, the present evidence does not clearly demonstrate that routine 
PGx testing for the purpose of medication selection offers a benefit over selection of medications based on 
contemporary evidence-based medication selection protocols. You can find this information in the Local 
Coverage Determination (LCD): MolDX: Pharmacogenomics Testing (L38394). 
 
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. 
 
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 $45 copayment for Medicare-covered services to diagnose and/or treat a 
disease or condition of the eye. You can find this information on pages 111-114 of the Plan's 2021 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 items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract lists the dental 
services that are covered. This benefit includes a problem focused oral evaluation once every 12 months. Pulp 
vitality test is not listed and therefore is not a covered service. You can find this information on pages 122 to 
125 of the Plans 2021 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 only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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 says that for chiropractic care, covered services only include manual manipulation of the spine to 
correct subluxation. Prior authorization may be required and is the responsibility of your provider. You can see 
this on page 65 of the Plans 2021 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. 
 
Medicare guidance says to receive payment for covered Medicare items or services from either Medicare (in 
the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or 
supplier must be enrolled in the Medicare program. You can find this guidance in Medicare CFR Section 
424.505. 
 
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 health 
plan contract says that while you can get your care from an out-of-network provider, the provider must be 
eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to 
participate in Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be 
responsible for the full cost of the services you receive. Check with your provider before receiving services to 
confirm that they are eligible to participate in Medicare. You can find this information in Chapter 4 on page 54 
of the plan's 2021 Evidence of Coverage.