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 417.414. 
 
The rules also say that when a physician/practitioner furnishes services to a registered inpatient, payment is 
made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a 
patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital place of service (POS) 
code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. You can find 
this in the Medicare Claims Processing Manual, Chapter 26, 10.5 under heading, "Special Considerations for 
Services Furnished to Registered Inpatients". 
 
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 payment may be made for a one-time ultrasound screening for AAA for beneficiaries who 
meet specific criteria. You can find this rule in the Medicare Claims Processing Manual, Chapter 18, Section 
110.2. 
 
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). 
 
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 $275 copayment for advanced imaging services and a $110 copayment 
for basic radiological services with an in-network provider at an outpatient hospital setting. You can find this 
information on pages 77-78 of the Plan's 2020 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 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 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. You can find this information on pages 34-42 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 at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that effective January 1, 2002, sacral nerve stimulation is covered for the treatment of urinary 
urge incontinence, urgency-frequency syndrome, and urinary retention. Sacral nerve stimulation involves both 
a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent 
implantation in appropriate candidates. Both the test and the permanent implantation are covered. 
 
The following limitations for coverage apply to all three indications: 
Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical 
corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can 
occur. 
Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with 
peripheral nerve involvement) which are associated with secondary manifestations of the above three 
indications are excluded. 
Patient must have had a successful test stimulation in order to support subsequent implantation. Before a 
patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement 
through test stimulation. Improvement is measured through voiding diaries. 
Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of 
the implant procedure can be properly evaluated. 
 
You can find these rules in the Medicare National Coverage Determination (NCD) for Sacral Nerve 
Stimulation For Urinary Incontinence, Section 230.18. 
 
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 30% coinsurance for durable medical equipment and supplies received 
from out-of-network providers. You can find this information on page 68 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 pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You 
can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
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 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 also includes a 
list of the covered supplemental dental benefits. The afterhours office visit is not on this list and is not a 
covered supplemental benefit. You can find this information on page 63 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 items and services furnished outside the United States are excluded from coverage except 
for the following services, and certain services rendered on board a ship:  
Emergency inpatient hospital services where the emergency occurred:  
o While the beneficiary was physically present in the United States; or  
o In Canada while the beneficiary was traveling without reasonable delay and by the most direct 
route between Alaska and another State. 
 Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the 
United States, if the hospital was closer to, or substantially more accessible from, the beneficiary's 
United States residence than the nearest participating United States hospital which was adequately 
equipped to deal with and available to provide treatment of the illness or injury;  
 Physician and ambulance services furnished in connection with a covered foreign hospitalization. 
Program payment may not be made for any other Part B medical and other health services, including 
outpatient services furnished outside the United States;  
Services rendered on board a ship in a United States port, or within 6 hours of when the ship arrived at, 
or departed from, a United States port, are considered to have been furnished in United States territorial 
waters. Services not furnished in a United States port, or within 6 hours of when the ship arrived at, or 
departed from, a United States port, are considered to have been furnished outside United States 
territorial waters, even if the ship is of United States registry; and  
 
The term "United States" means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the 
Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of services rendered 
on a ship, includes the territorial waters adjoining the land areas of the United States. You can find these rules 
in Medicare Benefit Policy Manual Chapter 16, Section 60. 
 
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 the Plan covers emergency care and urgently needed services outside of the United States and 
its territories. You can find this information in Chapter 3 on page 46 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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract says 1 periapical 
x-ray per calendar year is covered. You can find this information on page 87 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 all enrollees without full Medicaid must pay a $50 copayment each day, for days 1-7 per 
admission, for Medicare-covered inpatient hospital care visits. Enrollees pay a $0 copayment each day, for 
days 8-90 per admission, for Medicare-covered inpatient hospital care visits. The inpatient hospital copayment 
starts the day you are admitted to the hospital per admission. You will not be charged a copayment for the day 
of discharge. You can find this information on pages 71-72 of the Plan's 2020 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 Guardant360 panel must be billed with procedure code 81479. You can find this rule at 
Local Coverage Determination (LCD): MolDX: Guardant360 Plasma-Based Comprehensive Genomic 
Profiling in Non-Small Cell Lung Cancer (NSCLC) (L37649) (eff. 10/20/18). 
 
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 $25 copayment for physician/practitioner services/out-of-network/office 
visits and a $35 copayment for physician/practitioner services/in-network/specialist. You can find this 
information on ages 87-89 of the Plans 2020 Evidence of Coverage. The Plan contract says that enrollees must 
also pay a 35% coinsurance for outpatient diagnostic tests/out-of-network/x-rays and a $20 copayment for 
outpatient diagnostic tests/lab. You can find this information on pages 79-81 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 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 $250 copayment for diagnostic procedures or tests at a network 
outpatient facility. You can find this information on page 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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(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 contract 
says that the Plan offers a supplemental benefit for non-cataract related routine eyewear. The benefit provides 
up to $300 toward eyewear every 12 months. The contract also clearly states that the benefit allowance must be 
used on the same date of service and that there is no remaining balance for future use within the 12-month 
period. Frequency of coverage is noted to be limited to one pair of lenses/frames every 12 months.  You can 
find this on page 125 of your plan's 2020 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 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-OASIS matching key output by the Grouper 
software. This is known as the Treatment Authorization Code or TAC 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 these elements may be returned as un-processable. You can find this rule in the Medicare 
Claims Processing Manual, Chapter 1, Section 80.3.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 1 
comprehensive oral evaluation is covered every 3 plan years. You can find this information on page of the 
Plan's 2020 Evidence of Coverage (EOC).