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 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 SSA, Section 1862(a)(12) and 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 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 3-4 of the Plan's 2020 
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 enrollee is not receiving care at a more distant location - further away than normal 
community patterns of care. Additionally, per page 29 of her 2020 Schedule of Cost sharing: Transplant 
providers may be local or outside of the service area. If the Plan's in-network transplant services are at a distant 
location, you may choose to go locally or distant as long as the local transplant providers are willing to accept 
the Original Medicare rate. If our plan provides transplant services at a distant location (outside of the service 
area) and you chose to obtain transplants at this distant location, we will arrange or pay for appropriate lodging 
and transportation costs for you and a companion. Standard policy is a distance greater than 100 miles from 
home. You can find this information in the Medicare Managed Care Manual, Chapter 4 Benefits and 
Beneficiary Protections 10.11 Transplant Services (Rev. 121, Issued: 04-22-16). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The health plan contract says that under certain conditions, the following types of transplants are covered: 
corneal, kidney, kidney-pancreatic, heart, liver, lung, heart/lung, bone marrow, stem cell, and 
intestinal/multivisceral. If you need a transplant, the Plan will arrange to have your case reviewed by a 
Medicare-approved transplant center that will decide whether you are a candidate for a transplant. Transplant 
providers may be local or outside of the service area. If the Plan's in-network transplant services are outside the 
community pattern of care, you may choose to go locally as long as the local transplant providers are willing to 
accept the Original Medicare rate. If the Plan provides transplant services at a location outside the pattern of 
care for transplants in your community and you choose to obtain transplants at this distant location, the Plan 
will arrange or pay for appropriate lodging and transportation costs for you and a companion. You can find this 
information in Chapter 4 on pages 4-73 to 4-74 of the plan's 2020 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 payment for items and services is included in the fee schedule payment. Such items and 
services include but are not limited to oxygen, drugs, extra attendants, and EKG testing - but only when such 
items and services are both medically necessary and covered by Medicare under the ambulance benefit. You 
can find this information in the Medicare Claims Processing Manual, Chapter 15, 30.1.1. 
 
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 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 $50 copayment for physician/practitioner services/specialist. You can 
find this information on pages 4-33 to 4-36 of the Plan's 2020 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 at42 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 authorizationbefore receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the 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 Plancovers 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 11 of the 2020 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 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 effective for services performed on or after April 4, 2005, cochlear implantation may be 
covered for treatment of bilateral pre- or-post-linguistic, sensorineural, moderate-to-profound hearing loss in 
individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined 
by test scores of less than or equal to 40% correct in the best-aided listening condition on tape-recorded tests of 
open-set sentence cognition. Medicare coverage is provided only for those patients who meet all of the 
following selection guidelines. 
 
Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from 
appropriate hearing (or vibrotactile) aids; 
Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation; 
Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and 
freedom from lesions in the auditory nerve and acoustic areas of the central nervous system; 
No contraindications to surgery; and 
The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling. 
 
You can find this information in the National Coverage Determination (NCD) for Cochlear Implantation 
(50.3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $90 copayment for emergency care. The copayment is waived if you are 
admitted to the hospital within 24 hours for the same condition. You can find this information in Chapter 4 on 
pages 55 - 56 of the Plan's 2020 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 intravenous immune globulin (IVIG) is covered if all of the following criteria are met: 
 
It is an approved pooled plasma derivative for the treatment of primary immune deficiency disease; and 
The patient has a diagnosis of primary immune deficiency disease (See Diagnosis Codes that Support 
Medical Necessity section); and 
The IVIG is administered in the home; and 
The treating practitioner has determined that administration of the IVIG in the patient's home is medically 
appropriate. 
 
If all of the criteria are not met and the IVIG is not administered with an infusion pump, the IVIG will be 
denied as noncovered - no benefit category. 
 
If the criteria are not met and the IVIG is administered with an infusion pump, refer to the Intravenous Immune 
Globulin LCD. 
 
You can find these rules in Local Coverage Article: Intravenous Immune Globulin - Policy Article (A52509). 
 
The rules also say if the coverage criteria for IVIG specified in the related Policy Article (PA) are not met and 
the IVIG is administered with an infusion pump, the IVIG will be denied as not reasonable and necessary 
(because the pump is denied as not reasonable and necessary). You can find this rule in Local Coverage 
Determination (LCD): Intravenous Immune Globulin (L33610). 
 
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 $15 copayment for each specialist office visit. You can find this 
information on pages 81-84 of the Plan's 2020 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 an inpatient admission is generally appropriate when the admitting physician expects the 
patient to need hospital care that crosses at least two midnights. The expectation should be based on such 
complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and 
medical risk. The factors must be documented in the medical record. The order for inpatient admission must be 
present in the medical record.  
 
If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be 
considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as 
"inpatient only" is generally appropriate, regardless of the length of stay. An inpatient admission may be 
appropriate if the admitting physician expects a patient to require hospital care for only a limited period of 
time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be 
supported by the medical record. You can find this rule at 42 CFR Section 412.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 SSA, Section 1862(a)(12) and 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 says that a 
prophylaxis is covered two procedures per plan year and a comprehensive exam is covered one procedure 
every three plan years. Providers are paid based on Maximum Allowable Charge (MAC). For services covered 
under the plan, you may still be billed by an out-of-network provider for any amount greater than the MAC 
payment made by the plan to the provider. You can find this information on pages 4-73 to 4-75 of the Plan's 
2020 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 an external infusion pump is covered for the following indications (I-V): 
 
I. Administration of deferoxamine for the treatment of chronic iron overload 
 
II. Administration of chemotherapy for the treatment of primary hepatocellular carcinoma or colorectal cancer 
where this disease is unresectable or where the beneficiary refuses surgical excision of the tumor.  
 
III. Administration of morphine when used in the treatment of intractable pain caused by cancer. 
 
IV. Administration of continuous subcutaneous insulin for the treatment of diabetes mellitus. 
 
V. Administration of other drugs if either of the following sets of criteria (1) or (2) are met: 
Criteria set 1: 
 
Parenteral administration of the drug in the home is reasonable and necessary 
An infusion pump is necessary to safely administer the drug 
The drug is administered by a prolonged infusion of at least 8 hours because of proven improved  clinical 
efficacy 
The therapeutic regimen is proven or generally accepted to have significant advantages over intermittent bolus 
administration regimens or infusions lasting less than 8 hours 
 
Criteria set 2:  
 
Parenteral administration of the drug in the home is reasonable and necessary 
An infusion pump is necessary to safely administer the drug 
The drug is administered by intermittent infusion (each episode of infusion lasting less than 8 hours) which 
does not require the beneficiary to return to the practitioner's office prior to the beginning of each infusion 
Systemic toxicity or adverse effects of the drug are unavoidable without infusing it at a strictly controlled rate 
as indicated in the Physicians Desk Reference, or the U.S. Pharmacopeia Drug Information 
 
You can find this information in the Local Coverage Determination (LCD):  External Infusion Pumps 
(L33794). 

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 SSA, Section 1862(a)(12) and 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 
preventive dental, fillings, crowns, periodontal care, bridges, extractions, and emergency pain treatment. The 
chart provides a list of covered services and the dental codes. Services not listed are noted to be noncovered. 
Extractions are covered with 50% coinsurance You can find this information on pages 4-71 to 4-80 of the 
Plan's 2020 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 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 $0 copayment for days 1-20 and a $128 copayment per day for days 21-
100 for skilled nursing facility services. In addition, a new benefit period will begin when you have been 
discharged from a skilled care in a skilled nursing facility for 60 consecutive days. You can find this 
information on page 83 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that if an independent lab bills for services, the place where the sample was taken is reported as 
the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of 
service. You can find this information in the Medicare Claims Processing Manual, Chapter 26, Section 10.6.  
 
The rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other 
supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two 
exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or 
outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You 
can find this information in the MLN Matters article number MM7631, "Revised and Clarified Place of Service 
(POS) Coding Instructions". 
 
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.