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 Original Medicare pays physicians, providers and suppliers for Medicare-covered services 
furnished to enrollees who have elected hospice. The Plan is responsible for non-hospice services that are not 
Medicare-covered, but that are offered as supplemental benefits under the Plan. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 
8, Section 70.3.1. 
 
The rules also say that the Medicare hospice pays claims for services related to the terminal illness. Original 
Medicare pays claims for Medicare-covered non-hospice services provided by physicians, providers or 
suppliers. Original Medicare continues to pay for services furnished after the revocation or expiration of the 
enrollee's hospice election until the first day of the month after the hospice election has been revoked or 
terminated. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Medicare Claims Processing Manual, Chapter 11, Section 30.4. 
 
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.
Appeal type: unknown
Decision: unknown

The rules say that the PACE benefit package must include the following: 

(a) All Medicare-covered services; 
(b) All Medicaid-covered services, as specified in the State's approved Medicaid plan; and
(c) Other services determined necessary by the interdisciplinary team to improve and maintain the enrollee's overall health status.

You can find this rule at 42 Code of Federal Regulations (CFR) Section 460.92.

The rules say that an inpatient admission is generally appropriate when the admitting physician expects the patient to need hospital care that crosses at least two midnights. The expectation should be based on such complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and medical risk. The factors must be documented in the medical record. 

If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as "inpatient only" is generally appropriate, regardless of the length of stay. An inpatient admission may be appropriate if the admitting physician expects a patient to require hospital care for only a limited period of time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be supported by the medical record. You can find this rule at 42 CFR Section 412.3.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
Medicare rules say that the provider must notify the enrollee in writing before it ends coverage of home health services. A Notice of Medicare Non-Coverage (NOMNC) must be issued no later than two days before the last
covered day. If the span of time between services exceeds two days, the notice should be given no later than the next to last time services are furnished. The notice must include: 1. The date that coverage of service ends; 2. The date the enrollee becomes responsible to pay for the service; and 3. A description of the enrollee's right to a fast-track appeal and other appeal procedures. You can find this rule at 42 CFR Section 422.624(b). A Health Plan is financially liable for continued services until two days after the enrollee receives valid notice. You can find this rule at 42 CFR Section 422.624(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 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. The rules say that section 1128 of the Social Security Act provides the authority to Medicare to exclude various health care providers from receiving payment under Medicare. When an exclusion is imposed, no payment is made to anyone for any items or services in any capacity furnished, ordered, or prescribed by an excluded party under the Medicare, Medicaid, and all federal health care programs. In addition, no payment is made to any business or facility, e.g., a hospital, that submits claims for payment of items or services provided, ordered, prescribed, or referred by an excluded party. You can find this information in the Medicare Program Integrity Manual, Chapter 4, Section 4.19.2.
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 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). Medicare guidance says "For Medicare to consider coverage and payment for an item or service, the information submitted by the supplier or provider must corroborate the services so we can confirm Medicare coverage has been met. "According to the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1: "Physicians must report services correctly. This manual discusses general coding principles in Chapter I and principles more relevant to other specific groups of HCPCS/CPT codes in the other chapters. There are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed." You can find this guidance in the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1, page I-7 and I-8; National Correct Coding Initiative Policy Manual for Medicare Services, 2021, Chapter 4, page IV-2 and Medicare Program.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 one (1) comprehensive oral exam per year. The benefit also includes one (1) periodical exam every six months. You can find this information on page 76 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 state that the following are covered indications of Next Generation Sequencing: 1. Somatic (Acquired) Cancer
Effective for services performed on or after March 16, 2018, the Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements are met:
a. Patient has:
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy).
b. The diagnostic laboratory test using NGS must have:
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and,
ii. an FDA-approved or -cleared indication for use in that patient's cancer; and,
iii. results provided to the treating physician for management of the patient using a report template to specify treatment options.
2. Germline (Inherited) Cancer
Effective for services performed on or after January 27, 2020, CMS has determined that NGS as a diagnostic laboratory test is reasonable and necessary and covered nationally for patients with germline (inherited) cancer, when performed in a CLIA-certified laboratory, when ordered by a treating physician and when all of the following requirements are met:
a. Patient has:
i. ovarian or breast cancer; and,
ii. a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer; and,
iii. a risk factor for germline (inherited) breast or ovarian cancer; and
iv. not been previously tested with the same germline test using NGS for the same germline genetic content.
b. The diagnostic laboratory test using NGS must have all of the following:
i. FDA-approval or clearance; and,
ii. results provided to the treating physician for management of the patient using a report template to specify treatment options.
You can find these rules in the Medicare National Coverage Determination (NCD) for Next Generation Sequencing (NGS), Section 90.2.
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 contract says that covered, non-routine dental care is limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. You can find this information on page 79 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, 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 endodontics is not covered. You can find this information on page 44 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 state that when completing the 1500 claim form, providers must enter the correct Place of Service (POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. You can find this rule at Medicare Claims Processing Manual Chapter 26 Section 10.6. 

The rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I. 

The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You can find this rule at 42 CFR Section 424.5.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 Medicare plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 45-46 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 Part B generally does not pay for drugs that are usually self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are: 1. blood-clotting factors; 2. drugs used in immunosuppressive therapy; 3. erythropoietin for dialysis patients; 4. osteoporosis drugs for certain homebound patients; 5. certain oral cancer drugs; 6. oral anti-emetics used in certain situations; 7. drugs treated as supplies during an outpatient hospital procedure; and 8. drugs required for the effective use of durable medical equipment. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.
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 Plan contract says that covered drugs include those that usually aren't self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. You can find this information on page 96 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, 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 under certain circumstances, members may obtain services from out-of-network providers. Newly eligible members who are undergoing an existing course of treatment under the care of an out-of-network provider at the time of eligibility may continue to obtain services from that provider for up to forty-five (45) days or until treatment can be transitioned to an in-network provider. Out-of-network providers with members under a current treatment plan have up to forty-five (45) days to notify the health plan and request authorization of services, as appropriate according to the plan benefits. Once the health plan is notified that the member is under the care of an out-of-network provider, the provider must submit a request for authorization. You can find this information on pages 56-57 of the Plan's 2021.
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 Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. This rule can be found in Medicare Local Coverage Article: Billing and Coding: MolDX: Testing of Multiple Genes (A57880).
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. The Plan contract also
includes a list of covered supplemental dental benefits. The alveoloplasty (D7321) is not on this list and is not a
covered supplemental benefit. You can find this information on pages 4-80 to 4-84 of the Plan's 2021 Evidence
of Coverage.