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 a separate allowance will be made for replacement supplies when they are reasonable and necessary and are used with a covered TENS. Usual maximum utilization is: 2 TENS leads - a maximum of one unit of A4595 per month. 4 TENS leads - a maximum of two units of A4595 per month. You can find this in the Local Coverage Determination (LCD): Transcutaneous Electrical Nerve Stimulators (TENS) (L33802).
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 dndoscopy procedures can only be allowed if abnormal signs or symptoms or known disease are present.
1.	Indications which support esophagogastroduodenoscopies (EGD[s]) for diagnostic purpose(s) are as follows: 
o	Upper abdominal distress which persists despite an appropriate trial of therapy;
o	Upper abdominal distress associated with symptoms and/or signs suggesting serious organic disease (e.g., prolonged anorexia and weight loss);
o	Dysphagia or odynophagia;
o	Esophageal reflux symptoms which are persistent or recurrent despite appropriate therapy;
o	Persistent vomiting of unknown cause;
o	Other systemic diseases in which the presence of upper GI pathology might modify other planned management. Examples include patients with a history of GI bleeding who are scheduled for organ transplantation; long term anticoagulation; and chronic non-steroidal therapy for arthritis;
o	X-ray findings of:
&#61607;	A suspected neoplastic lesion, for confirmation and specific histologic diagnosis;
&#61607;	Gastric or esophageal ulcer; or
&#61607;	Evidence of upper gastrointestinal tract stricture or obstruction.
o	The presence of gastrointestinal bleeding:
&#61607;	In most actively bleeding patients or those recently stopped;
&#61607;	When surgical therapy is contemplated;
&#61607;	When re-bleeding occurs after acute self-limited blood loss or after endoscopic therapy;
&#61607;	When portal hypertension or aortoenteric fistula is suspected; or
&#61607;	For presumed chronic blood loss and for iron deficiency anemia when colonoscopy is negative.
o	When sampling of duodenal or jejunal tissue or fluid is indicated;
o	To assess acute injury after caustic agent ingestion; or
o	Intraoperative EGD when necessary to clarify location or pathology of a lesion.
You can find this rule at Local Coverage Determination (LCD): Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (L35350) (eff. 10/17/19).

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 supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) must have an order from the treating physician before giving any DMEPOS item to an enrollee. The supplier must keep the order and proof of delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. You can find this rule in the Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1 and 5.8. If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say 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 porcelain fused to high noble metal crown is a covered service. The Plan also says that some dental codes require prior authorization. In order for these codes to be approved, they must meet our clinical and business criteria. You can find this information on page 93 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.
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 290(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 health plan contract says that orthopedic shoes are not covered by Medicare and they are only covered under specific conditions: some limited coverage provided according to Medicare guidelines, e.g., if you have diabetes. Supportive devices for the feet are not covered by Medicare and only covered under specific conditions: orthopedic or therapeutic shoes for people with diabetic foot disease. You can find this information in Chapter 4 on page 104 of the plan's 2019 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 at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that facet joint blocks will be considered reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. Facet joint block is one of the methods used to document/confirm suspicions of posterior element biomechanical pain of the spine. Hallmarks of posterior element biomechanical pain are:-The pain does not have a strong radicular component.-There is no associated neurological deficit and the pain is aggravated by hyperextension, rotation or lateral bending of the spine, depending on the orientation of the facet joint at that level.You can find this rule in Local Coverage Determination (LCD): Paravertebral Facet Joint Blocks (L33930) -Effective January 8, 2019.
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 for home health care services under a prospective payment system (HH PPS). Home health services under a plan of care are paid based on a 60-day episode of care. Payment for home health care episodes is usually made in two parts. To receive the first part of the HH PPS split payment, the home health agency must submit a Request for Anticipated Payment (RAP). Specific data elements are required to submit a RAP. The home health agency must enter the claim -Outcome and Assessment Information Set (OASIS) matching key output by the Grouper software. This is known as the Treatment Authorization Code. You can find this rule, a list of the data elements, and instructions for the Treatment Authorization Code in the Medicare Claims Processing Manual, Chapter 10, Section 40.1.The rules say that after a RAP has been paid and a 60-day episode has been completed or the enrollee has been discharged, the home health agency must submit a claim to receive the rest of payment due for the episode. You can find this rule and detailed instructions for the claim in the Medicare Claims Processing Manual, Chapter 10, Section 40.2.The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid information for all of these elements may be returned as unprocessable. You can find this rule in the Medicare Claims Processing Manual, Chapter 1, Section 80.3.1.HH claims must be submitted with TOB 0329. The HH PPS claim will include elements submitted on the RAP, and all other line item detail for the episode/period.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 all services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code. Many of these generic activities are common to virtually all procedures and, on other occasions, some are integral to only a certain group of procedures butare still essential to accomplish these particular procedures. Accordingly, it is inappropriate to separately report these services based on standard medical and surgical principles. You can find this information in the Medicare Claims Processing Manual, Chapter 12, Section 30(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 Medicare pays for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins upon admission to a hospital or SNF and ends after 60 days in a row without the patient receiving hospital or skilled SNF services. You can find this rule in the Social Security Act, Section 1862(a)(18), at 42 CFR Sections 409.60(a) and (b) and Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, Section 10.4.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 rules also state that you are covered for up to 100 days each benefit period for inpatient services in a SNF, in accordance with Medicare guidelines. A benefit period begins on the first day you go toa Medicare-covered inpatient hospital or a skilled nursing facility. The benefit period ends when you haven't been an inpatient at any hospital or SNF for 60 days in a row. You can find this on page 4-61 and 4-62 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 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 also includes a list of covered supplemental (extra) dental benefits. The custom fabricated abutmentand abutment supported crown are not on this list and arenot a covered supplemental benefits.You can find this information on pages 4-50 to 4-63 of the Plan's 2020Evidence 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 $225 copayment for each one-way Medicare-covered ambulance trip. You can find this information on page 41 of the Plan's 2019 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 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 lists the specific dental services that are covered by the Plan. Comprehensive oral exam is not listed and therefore is not a covered service. Panoramic x-ray is not listed and therefore is not a covered service. Bitewing x-ray is not listed and therefore is not a covered service. Periapical x-ray is not listed and therefore is not a covered service. The Plan contract also says that any services not listed are not covered. You can find this information on pages 4-49 to 4-54 of the Plan's 2019 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 all of the following basic criteria (A-C) must be met for a power mobility device or a push-rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are listed below.
A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:
o Prevents the beneficiary from accomplishing an MRADL entirely, or
o Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
o Prevents the beneficiary from completing an MRADL within a reasonable time frame.
B. The beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.
C. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day.
o Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
o An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.
You can find this rule at Local Coverage Determination (LCD): Power Mobility Devices (L33789) (eff. 1/1/20).
The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your home may be a dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, an institution may not be considered your home if it is an acute hospital or a skilled nursing facility (SNF). You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that medically necessary services are those that are reasonable and necessary for thediagnosis 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).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.
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 "structuresdirectly 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 Plan contract says if you use an out of network dentist, your share of the cost may be higher. The contract says you pay 50% for a periodic oral evaluation when you receive this service out of network. The contract says you pay 50% for bitewing x-rays when you receive this service out of network. The Plan contract also says you pay 75% for periodontal maintenance when you receive this service out of network. You can find this information on pages 96 and 97 of the Plan's 2019 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 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 coverage for partial dentures once every 5 plan years. You can find this information on pages 4-61 and 4-62 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 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 The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes coverage for bitewing x-rays is limited to once every 12 months. You can find this information on page 63 of the Plan's 2019 Evidence of Coverage (EOC).