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 a contract plan provider is an agent of the plan. Services and referrals obtained from a plan
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan,
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or
item is never covered, the plan does not have to hold the enrollee harmless.
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless.
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication
100-16, Medicare Managed Care Manual, Chapter 4, Section 160.
The rules say to qualify for home health services, the patient must be:
1. Confined to the home;
2. Under the care of a physician or allowed practitioner;
3. Receiving services under a plan of care established and reviewed by a physician;
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d)
continuing occupational therapy.
You can find this rule at 42 CFR Section 409.42.
The rules say that eligibility for the home health benefit will be determined based on the certifying physician or
allowed practitioner's records. If the enrollee was directly admitted to home health from an acute or post-acute
care facility, the facility records may be used instead. The medical records for the enrollee must contain
information that justifies the referral for home health services.
The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the
enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face
encounter visit. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only
Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and
30.5.1.2.
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.
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 A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and with complete replacement of the expandable controller. Code K0108 must not be used for any component or feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. However, if individual components of the harness are replaced, code K0108 should be used. You can find these rules in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).
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 $200 copayment per trip for ambulance services. You can find this information on page 75 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 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 $35 copayment per visit for physical therapy services. You can find this information on page 91 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 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, Publication 100-02, 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 says that you are covered for one comprehensive oral evaluation exam once every three plan years. You can find this information on pages 4-64 to 4-77 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 molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage when ALL of the following criteria are met: 

1. Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are unavailable or results are clearly equivocal; AND 
2. Availability of a clinically valid test, based on published peer reviewed medical literature; AND 
3. Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed test) or LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) of analytical validity and clinical utility; AND 
4. Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND 
5. For testing panels, including but not limited to, multiple genes or multiple conditions, and in cases where a tiered approach/method is clinically available, testing would be covered ONLY for the number of genes or test that are reasonable and necessary to obtain necessary information for therapeutic decision making; AND 
6. Individual has not previously received genetic testing for the disease/condition. (In general, diagnostic genetic testing for a disease should be performed once in a lifetime.) Exceptions include clinical scenarios whereby repeat testing of somatically-acquired mutations (for example, pre- and post- therapy) may be required to inform appropriate therapeutic decision-making. 

You can find this rule in the Local Coverage Determination (LCD) - Molecular Pathology Procedures (L35000) - Effective July 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, Publication 100-02, 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 1 complete series x-ray every 3 plan years. You can find this information on page 4-64 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 tests evaluated through the application process and/or technical assessment will be reviewed to answer the following questions: 1. Is the test performed in the absence of clinical signs and symptoms of disease? 2. Will the test results provide the clinician with information that will improve patient outcomes and/or change physician care and treatment of the patient? 3. Will the test results confirm a diagnosis or known information? 4. Is the test performed to determine risk for developing a disease or condition? 5. Will risk assessment change management of the patient? 6. Is there a diagnosis specific indication to perform the test? 7. Is the test performed to measure the quality of a process or for Quality Control/Quality Assurance (QC/QA), i.e., a test to ensure a tissue specimen matches the patient? You can find this rule in the Local Coverage Determination (LCD) - MolDX: Molecular Diagnostic Tests (MDT) (L36807) - 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, Publication 100-02, 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 dental
services are only covered from network providers. You can find this information on page 87 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 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, Publication 100-02, 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 also
includes a list of covered supplemental dental benefits. The adjunctive pre-diagnostic test and fluoride varnish
application are not on this list and are not covered supplemental benefits. You can find this information on
pages 83 and 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 that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 38 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 $45 copayment for a specialist's office visit. You can find this
information on pages 83-84 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 providers must report services correctly. Procedures should be reported with the Current
Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the
Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for
Medicare Services, Chapter I(A).
The rules say that Medicare does not allow payment for routine or related dialysis treatments, which are
covered and paid under the ESRD PPS, when furnished to ESRD patients in the outpatient department of a
hospital. However, in certain medical situations in which the ESRD outpatient cannot obtain her or his
regularly scheduled dialysis treatment at a certified ESRD facility, the OPPS rule for 2003 allows payment for
non-routine dialysis treatments (which are not covered under the ESRD benefit) furnished to ESRD outpatients
in the outpatient department of a hospital. Payment for unscheduled dialysis furnished to ESRD outpatients and
paid under the OPPS is limited to specific circumstances. In these situations, non-ESRD certified hospital
outpatient facilities are to bill Medicare using the Healthcare Common Procedure Coding System (HCPCS)
code G0257 (Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient
department that is not certified as an ESRD facility). You can find this information in the Centers for Medicare
and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual,
Chapter 4, 200.2.
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 plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 1, Section 20.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 41 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 $200 copayment for outpatient surgery at an ambulatory surgery center. You can find this information on page 81 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 Plan contract also says that the Plan covers a supplemental vision benefit with a frames and lens package. You have a choice of a $100 (combined in and out-of-network) benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year) You can find this information on pages 91 and 92 of the Plan's 2021 Evidence of Coverage.