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 the 4Kscore test will be considered medically reasonable and necessary when all the
following are met:
1. When all of the components of the algorithm are present
2. Testing of men 45 years of age and older, prior to an initial biopsy or following a negative biopsy, who have
a confirmed moderately elevated PSA (greater than 3 and less than 10 ng/mL; greater than or equal to 4 and
less than 10 ng/mL in men greater than 75 years of age) when BOTH of the following are present:
A. No other relative indication for prostate biopsy including ANY of the following:
-DRE suspicious for cancer should be encouraged to undergo biopsy
-Persistent and significant increase in PSA should be encouraged to undergo biopsy
-Positive multiparametric magnetic resonance imaging (MRI) (if done)
-Other major risk factor for prostate cancer including: (this may not be an all-inclusive list)
i. Ethnicity at higher risk for prostate cancer
ii. First-degree relative with prostate cancer
ii. High-penetrance prostate cancer risk gene(s) per the National Comprehensive Cancer Network (NCCN) (if
known)
B. No other relative contraindication** for prostate biopsy including ANY of the following:
-Less than a 10-year life expectancy
-Benign disease not ruled out
You can find this rule in Local Coverage Determination (LCD): 4Kscore Test Algorithm (L37798) - Effective
January 6, 2020.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that a determination of the medical necessity for certain components/additions to the prosthesis is
based on the beneficiary's potential functional abilities. Potential functional ability is based on the reasonable
expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to:

1. The beneficiary's past history (including prior prosthetic use if applicable); and
2. The beneficiary's current condition including the status of the residual limb and the nature of other medical
problems; and
3. The beneficiary's desire to ambulate.
You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective
January 1, 2020.

The rules say that a level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical
of the community ambulator who has the ability to traverse most environmental barriers and may have
vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. You
can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective
January 1, 2020.

The rules say that a fluid, pneumatic or electronic/microprocessor knee (L5828, L5848, L5856) is covered for
beneficiaries who functional level is 3 or above. You can find this rule in Local Coverage Determination
(LCD): Lower Limb Prostheses (L33787) - Effective January 1, 2020.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 dentures once every 5 calendar years, per patient, per arch. You can find this information on pages 95 to 96 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will 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 as grab bars. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 110.1.

The rules say that an expandable controller is capable of accommodating one or more of the following additional functions:

-Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) 
-Non-proportional input devices (e.g., sip and puff, head array, etc.) 
-Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)

An expandable controller may also be able to operate one or more of the following:

-A separate display (i.e., for alternate control devices) 
-Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control) 
-An attendant control

You can find this rule in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504) - Effective January 1, 2020.

The rules say that the power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. You can find this rule in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504) - Effective January 1, 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 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 as grab bars. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. The rules also say that cervical traction devices (E0840, E0849, E0850, E0855 and E0860) are covered only if both of the following criteria are met: 1. The beneficiary has a musculoskeletal or neurologic impairment requiring traction equipment; and 2. The appropriate use of a home cervical traction device has been demonstrated to the beneficiary and the beneficiary tolerated the selected device. If criteria 1 and 2 are not met, cervical traction will be denied as not reasonable and necessary. You can find these rules in Local Coverage Determination (LCD): Cervical Traction Devices (L33823).
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 therapeutic continuous glucose monitors (CGMs) and related supplies are covered by Medicare when all of the following coverage criteria (1-6) are met:
1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses); and 
2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and 
3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and 
4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and 
6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.

You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822).

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 $750 deductible that applies to certain items and services. Out-of-network office visits are not excluded from the deductible. You can find this information on pages 55 to 56 of the Plan's 2021 Evidence of Coverage.

The Plan contract also says enrollees must pay 50% coinsurance for provider and professional services at an out-of-network PCP's office and out-of-network specialist's office. You can find this information on pages 83 to 84 of the Plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say 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 20% coinsurance for durable medical equipment. You can find this information on page 4-14 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 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, 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 42 to 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 state that a spinal orthosis (L0450 - L0651) is covered when it is ordered for one of the following
indications:

1. To reduce pain by restricting mobility of the trunk; or
2. To facilitate healing following an injury to the spine or related soft tissues; or
3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or
4. To otherwise support weak spinal muscles and/or a deformed spine.
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically
necessary.

You can find this rule at Local Coverage Determination (LCD): Spinal Orthoses: TLSO and LSO (L33790).

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 20% coinsurance for durable medical equipment. You can find this information on pages 4-13 to 4-14 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 following list of individuals and entities frequently attempt to enroll in Medicare but are
not eligible to do so. If the contractor receives an enrollment application from any of these individuals or
entities, the contractor shall deny the application, with the exception of entities eligible to enroll using the Form
CMS-20134, which is specific to the furnishing of MDPP services. An assisted living facility, for example, that
also provides the DPP and is eligible to enroll as an MDPP supplier may enroll through the CMS-20134,
however, this enrollment only pertains to the rendering of MDPP services. These providers are Acupuncturist,
Assisted Living Facility, Birthing Center, Certified Alcohol and Drug Counselor, Certified Social Worker,
Drug and Alcohol Rehabilitation Counselor, Hearing Aid Center/Dealer, Licensed Alcoholic and Drug
Counselor, Licensed Massage Therapist , Licensed Practical Nurse, Licensed Professional Counselor,
Marriage Family Therapist , Master of Social Work, Mental Health Counselor, National Certified Counselor,
Occupational Therapist Assistant, Physical Therapist Assistant, Registered Nurse, and Speech and Hearing
Center. You can find this in the Medicare Program Integrity Manual Chapter 15 - Medicare Enrollment
Suppliers Not Eligible to Participate (Rev. 765; Issued: 01-08-18; Effective: 01-01-18; Implementation: 01-19-
18) section 15.4.8.

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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services,
Internet Only Manual, 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 a
comprehensive oral evaluation once every three plan years. It also includes bitewing x-rays once per plan year
but not in the same year as a full mouth set of x-rays. You can find this information on pages 4-62 to 4-63 of
the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are covered only when they are medically reasonable and necessary. Therapy services are considered reasonable and necessary when:

1. The services are specific and effective treatment for the patient's condition, 
2. The services require the skills or direct supervision of a therapist, 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, or carry out a maintenance program. Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 220.2.

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 Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 includes a list of covered supplemental dental services. This benefit includes crown (D2740) and core buildup, including any pins when required (D2950), and you are responsible for a 50% coinsurance. You can find this information on page 115 of the Plan's 2020 Evidence of Coverage (EOC).