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 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).

You can find this rule at Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504) (eff. 1/1/20).

The rules say that Medicare will pay for durable medical equipment (DME) that is reasonable and necessary for treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment already available to an enrollee. 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(C).

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 contract does not list bone replacement grafts, osseous surgery, biological materials to help healing, or other drugs and/or medicine as a covered benefit. You can find this information on pages 53-54, and 92-111 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 a supplemental benefit is an item or service not covered by original Medicare, that is primarily health related and for which the MA plan must incur a non-zero direct medical cost. Supplemental benefits need not be provided through Medicare providers nor at Medicare certified facilities. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 30.1.
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. The Plan contract also says that the Plan covers Special Supplemental Benefits for the Chronically Ill. To be eligible for these additional benefits, you must meet the following requirements: You must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning -see the list of applicable conditions. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. You can find this information on page 67-68 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 pay for durable medical equipment (DME) that is reasonable and necessary for
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment
already available to an enrollee. 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(C).

The rules say that replacement refers to the provision of an identical or nearly identical item. Equipment which
the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage.
Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood). A physician's order
and/or new Certificate of Medical Necessity (CMN), when required, is needed to reaffirm the medical necessity
of the item. Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific
event cannot be identified. Replacement of equipment due to irreparable wear takes into consideration the
reasonable useful lifetime of the equipment. You can find this rule in the Medicare Benefit Policy Manual,
Chapter 15, Section 100.2.

The rules say that the reasonable useful lifetime of durable medical equipment is determined through program
instructions. In the absence of program instructions, A/B MACs may determine the reasonable useful lifetime
of equipment, but in no case can it be less than five years. You can find this rule in the Medicare Benefit Policy
Manual, Chapter 15, Section 100.2.

The rules say that socket replacements are considered reasonable and necessary if there is adequate
documentation of functional and/or physiological need. It is recognized that there are situations where the
explanation includes but is not limited to: changes in the residual limb; functional need changes; or irreparable
damage or wear/tear due to excessive beneficiary weight or prosthetic demands of very active amputees. 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 may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 

Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee.

Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Sections 422.2 and 422.136.

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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You can find this information on pages 70 and 102 in 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 co-payments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).

The rules say that a co-payment 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 $450 co-payment for surgery services at an outpatient hospital. You can find this information on pages 77 to 78 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 psoriasis is a chronic skin disease, for which several conventional methods of treatment have been recognized as covered. These include topical application of steroids or other drugs; ultraviolet light (actinotherapy); and coal tar alone or in combination with ultraviolet B light (Goeckerman treatment). A newer treatment for psoriasis uses a psoralen derivative drug in combination with ultraviolet A light, known as PUVA. PUVA therapy is covered for treatment of intractable, disabling psoriasis, but only after the psoriasis has not responded to more conventional treatment. The Medicare Administrative Contractor should document this before paying for PUVA therapy. In addition, reimbursement for PUVA therapy should be limited to amounts paid for other types of photochemotherapy; ordinarily, payment should not be allowed for more than 30 days of treatment, unless improvement is documented.

You can find this information in Medicare's National Coverage Determination (NCD) for Treatment of Psoriasis (250.1). 

The rules say Ultraviolet Cabinets: Covered for selected patients with generalized intractable psoriasis. Using appropriate consultation, the Medicare Administrative Contractor's (MAC) should determine whether medical and other factors justify treatment at home rather than at alternative sites, e.g., outpatient department of a hospital. You can find this information in Medicare's National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1).

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 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.

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 $40 copayment for outpatient diagnostic tests and therapeutic services and supplies. You can find this information on pages 76-81 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.

The rules say that elastic stockings are not covered because they are non-reusable supply items. Elastic stockings are not durable medical equipment. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.1.

The rules say that gradient pressure garments may be covered when used as dressings following burn injuries. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Chapter 1, Section 270.5.

The rules also say that compression bandages, multi-layer systems, and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. A qualifying wound is either a wound caused or treated by surgery or a wound that must be debrided. A gradient compression stocking or wrap described by codes A6531, A6532, or A6545 is only covered when it is used in the treatment of an open venous stasis ulcer. Gradient compression stockings and wraps identified with codes A6531, A6532, and A6545 are not covered when they are used to treat the following conditions:
1. Venous insufficiency without stasis ulcers; 
2. Prevention of stasis ulcers; 
3. Prevention of the reoccurrence of stasis ulcers that have healed; 
4. Treatment of lymphedema in the absence of ulcers.
You can find these rules in Local Coverage Determination (LCD): Surgical Dressings L33831 and Local Coverage Article: Surgical Dressings-Policy Article A54563, effective for services performed on or after July 24, 2017.

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 if medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG)
Positron Emission Tomography (PET) scan to determine the initial level of cancer treatment needed for an
enrollee. After the completion of the initial anti-cancer therapy, additional FDG PET scans may be covered at
the discretion of Medicare. You can find this rule in the Centers for Medicare and Medicaid Services, Internet
Only Manual, National Coverage Determinations Manual, Section 220.6.17.

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 20% coinsurance for medical supplies. You can find this information on
page 75 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 a standard walker and related accessories are covered if all of the following criteria (1-3) are met:
1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home; and 
2. The beneficiary is able to safely use the walker; and 
3. The functional mobility deficit can be sufficiently resolved with use of a walker. 
You can find this information in the Local Coverage Determination (LCD): Walkers (L33791).

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, 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 10 of the 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.

The rules say that the plan must pay for emergency and urgently needed services. This rule applies whether the
services are obtained in or out of the plan's network. This rule applies whether or not there is prior
authorization for the services. The rules say that an emergency is defined as when a prudent layperson would
believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules
say that urgently needed services are those needed because of an unforeseen illness or condition and it is not
reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside
of the service area. You can find this rule at 42 CFR Section 422.113.

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 if the enrollee is outside of the Plan's service area and cannot get care from a network
provider, the Plan will cover urgently needed services obtained from any provider. You can find this
information in Chapter 3 on pages 71 to 72 of the Plan's 2020 Evidence of Coverage.