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 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. Although the Plan has a Point-of-Service (POS) option to cover 
certain out-of-network services, this benefit only applies to covered routine dental services. You can find this 
information on page 43 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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 in Chapter on page 4 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 Under the home health prospective payment system as refined by the Patient-Driven 
Groupings Model (PDGM), a case-mix adjusted payment for a 30-day period of care is made using one of 432 
HHRGs. On Medicare claims, these HHRGs are represented as Health Insurance Prospective Payment System 
(HIPPS) codes. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.1.8. 
 
The rules say that a case-mix methodology adjusts the 30-day payment rate based on characteristics of the 
patient and his/her corresponding resource needs (e.g., diagnoses, functional impairment level, and other 
factors). The 30-day period payment rate is adjusted by a case-mix methodology based on information from 
home health claims, other Medicare claims, and data elements from the Outcome and Assessment Information 
Set (OASIS).  The following case-mix variables are obtained from home health or other Medicare claims: 
 Admission Source-Institutional (i.e., acute hospital, inpatient rehabilitation facility, skilled nursing 
facility, long-term care hospital, inpatient psychiatric facility) or Community; 
 Timing-Early (the first 30-day period of care) or Late (all subsequent 30-day periods of care, unless 
there is a gap of more than 60-days between the end of one period of care and the start of another), 
 Clinical Group-As determined by the principal diagnosis reported on home health claims; 30-day 
periods are assigned to one of 12 clinical groups describing the primary reason for the home health 
encounter. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 7, Section 10.2.  
 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.
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 inpatient hospital stay. You can find this information on page 53 of the Plan's 2023 
Evidence of Coverage (EOC).   
 
The Plan contract also says that enrollees must pay a $795 copayment per hospital stay, after the deductible. 
You can find this information on page 88 of the Plan's 2023 EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility 
limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The rules also say that if the power wheelchair (PWC) base is not covered, then related accessories will be 
denied. 
 
You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices L33789 (eff 1/1/17). 
 
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 $45 copayment for in-network outpatient diagnostic tests, including 
ultrasounds. You can find this information on page(s) 76-78 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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. The Plan has a Point-of-Service (POS) option to cover certain 
out-of-network services. You can find this information on page 43 of the Plan's 2022 Evidence of Coverage 
(EOC). 
 
The Plan contract also says that out-of-network physician/practitioner services are not covered. You can find 
this information on page 121-125 of the Plans 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 state that coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this information in the Local Coverage Determination (LCD) 
Lower Limb Prostheses L33787. 
 
Replacement of a prosthesis or prosthetic component is covered if the treating practitioner orders a replacement 
device or part because of any of the following: 
1. A change in the physiological condition of the beneficiary; or 
2.  Irreparable wear of the device or a part of the device; or 
3.The condition of the device, or part of the device, requires repairs and the cost of such repairs would be more 
than 60% of the cost of a replacement device, or of the part being replaced. 
You can find this information in the Local Policy Article A52496. 
 
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 effective for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement 
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following 
requirements are met: 
 
1. Patient has: 
-either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and, 
-either not been previously tested using the same NGS test for the same primary diagnosis of cancer, or repeat 
testing using the same NGS test only when a new primary cancer diagnosis is made by the treating physician; 
and, 
-decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
2. The diagnostic laboratory test using NGS must have: 
- Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
- an FDA-approved or -cleared indication for use in that patients cancer; and, 
- results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
You can find this rule in National Coverage Determination (NCD) for Next Generation Sequencing (NGS) 
(90.2) - Effective March 16, 2018. 
 
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 20 one-way trips to plan-approved locations every year. You can find this information on page 52 
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 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 Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and 
necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments 
(CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements 
are met: 
   a. Patient has: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, 
and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
   b. The diagnostic laboratory test using NGS must have:  
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; 
and, 
ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
iii. results provided to the treating physician for management of the patient using a report template 
to specify treatment options. 
National Coverage Determination (NCD) Next Generation Sequencing (NGS) 90.2. 
 
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.
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 Original Medicare pays physicians, providers and suppliers for Medicare-covered services 
furnished to enrollees who have elected hospice. The Plan is responsible for non-hospice services that are not 
Medicare-covered, but that are offered as supplemental benefits under the Plan. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 8, Section 70.3.1. 
 
The rules also say that the Medicare hospice pays claims for services related to the terminal illness. Original 
Medicare pays claims for Medicare-covered non-hospice services provided by physicians, providers or 
suppliers. Original Medicare continues to pay for services furnished after the revocation or expiration of the 
enrollee's hospice election until the first day of the month after the hospice election has been revoked or 
terminated. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.4.  
 
The rules say that hospices must bill for their Medicare beneficiaries on a monthly basis. Monthly billing must 
conform to a calendar month (i.e., limit services to those in the same calendar month if services began mid-
month) rather than a 30-day period which could span two calendar months. For example, if a patient is 
admitted to hospice on August 8th and revokes the benefit on September 1st, the hospice must submit two 
claims. A claim is submitted for dates of service August 8 to August 31and a separate claim is submitted with 
dates of service September 1 to September 1. Hospice claims should not span multiple months. Any hospice 
claim spanning multiple months will be returned to the provider for correction. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 11, Section 90. 
 
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 health plans, physicians, hospitals, and other health care providers must comply with the 
Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding 
Guidelines. You can find this rule in the Medicare Claims Processing Manual, Chapter 23, Section 10. 
 
The rules say that the ICD-10-CM has two types of excludes notes. Each type of note has a different definition 
for use, but they are all similar in that they indicate that codes excluded from each other are independent of 
each other. 
a. Excludes1 
A type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. An 
Excludes1 is 
used when two conditions cannot occur together, such as a congenital form versus an acquired form of the 
same condition. 
 
An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each 
other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the 
provider. For example, code F45.8, Other somatoform disorders, has an Excludes1 note for "sleep related teeth 
grinding (G47.63)," because "teeth grinding" is an inclusion term under F45.8. Only one of these two codes 
should be assigned for teeth grinding. However psychogenic dysmenorrhea is also an inclusion term under 
F45.8, and a patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 
together. 
b. Excludes2 
A type 2 Excludes note represents Not included here. An excludes2 note indicates that the condition 
excluded is not part of the condition represented by the code, but a patient may have both conditions at the 
same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the 
excluded code together, when appropriate. You can find this in the International Classification of Diseases 
(ICD)-10-CM Official Guidelines for Coding and Reporting FY 2023 -- UPDATED April 1, 2023. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.