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 state that a portable oxygen system is covered if the beneficiary is mobile within the home and the qualifying blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood gas study was performed during sleep, portable oxygen will be denied as not reasonable and necessary.If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary system. See exception in the related Policy Article Non-Medical Necessity Coverage and Payment Rules, OXYGEN EQUIPMENT, Initial 36-Months section.If a portable oxygen system is covered, the supplier must provide whatever quantity of oxygen the beneficiary uses; Medicare's reimbursement is the same, regardless of the quantity of oxygen dispensed.You can find this rule in Local Coverage Determination (LCD): Oxygen and Oxygen Equipment (L33797).Code E1392 describes an oxygen concentrator which is designed to be portable, is capable of delivering 85% or greater oxygen concentration, and is capable of operating on either AC or DC (e.g., auto accessory outlet) power. Code E1392 includes the device itself, an integrated battery or beneficiary-replaceable batteries that are capable of providing at least 2 hours of remote portability at a minimum of 2 LPM equivalency, a battery charger, an AC power adapter, a DC power adapter, and a carry bag and/or cart. The combined weight of the concentrator and the battery/batteries capable of 2 hours of portability must be 20 pounds or less. If a concentrator meets all of these criteria and is also capable of functioning as a stationary concentrator, operating 24 hours per day, 7 days per week, the stationary concentrator code (E1390) is billed in addition to code E1392.You can find these rules in Local Coverage Article: Oxygen and Oxygen Equipment -Policy Article (A52514).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 $250 copayment for each separate one-way ambulance service. You can find this information on page 60 of the Plan's2020 EOC.
Appeal type: unknown
Decision: unknown

The  rules  say that  plans  must  pay for  a medical  service  or item  ifregular  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,  cementumof the  teeth,  and alveolar  process. You  can find  this rule  in  the  SSA, Section  1862(a)(12)  and Medicare  Benefit  Policy  Manual,  Chapter  15, Section  150.If  you  want  to read these  Medicare  rules,  you  can go to this  website www.medicareappeal.com.The  Plan  contract  says that  the  Plan  covers  items  and services  in  accordance  with  Medicare  rules. The  contract says  that  the Plan  covers certain  dental  services  as a supplemental  (extra)  benefit.  The  contract  lists  the dental services  that  are covered.  Root canal  is not  listed  and  therefore  is  not  a covered service.  You can find  this information  on pages 93 and 94 of the Plan's 2020 Evidence  of Coverage (EOC)
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes
cleanings and are limited to one every 6 months. The Plan contract also includes fluoride treatment and is
limited to 1 every year. You can find this information on pages 82 and 83 of the Plan's 2020 Evidence of
Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare will 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, whichincludes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes:- Preventive oral exam(s) (Two total per calendar year) either as comprehensive oral exam (One procedure every three years) or periodic oral exam (Two procedures per calendar year)- Prophylaxis (cleanings) (Two procedures per calendar year)- Scaling and root planing (deep cleaning) (One procedure per calendar year, per quadrant)- Bitewing x-rays (Two sets per calendar year)- Panoramic x-ray film(s) (One procedure per calendar year)- Amalgam (silver) or resin-based composite (white) fillings (Four procedures per calendar year)- Non-surgical or surgical extractions (pulling teeth) (Six procedures per calendar year)- Crown(s) (Two procedures per calendar year)- Root canal (One procedure per calendar year)- Complete dentures (upper and lower) (One upper complete and one lower complete denture every five years, including routine post-delivery care) or Partial dentures (upper and lower) (One upper and/or one lower partial denture every five years, including routine post-delivery care)- Denture reline (One procedure per calendar year)- Necessary anesthesia with covered serviceYou can find this information on pages 80-81 of the Plan's 2020 Evidence of Coverage (EOC).The plan contract says that the plan covers up to 2 crowns per calendar year identified with codes D2740 or D2750. You can find this information in the 2020 Dental Benefit Schedule
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the following dental services:Preventive dental care:- Oral exams 2 every year- Cleanings (prophylaxis) 2 every year- Fluoride treatments 2 every year- Bitewing dental x-rays 1 series 2 every year- Full-mouth x-rays 1 complete series every three yearsComprehensive dental care:- Resin filling on anterior teeth- Amalgam filling- Simple Extraction performed by General Dentist- Full mouth debridement- Total superior prosthesis- Total inferior prosthesis- Partial DenturesYou can find this information on page 49 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules state that effective January 1, 2006, items and services which include but are not limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately for ambulance services. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 10.4.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  plans  must  pay for  a medical  service  or item  if  regular  Medicare  would  pay for it  in  this  case. You  can find  this  rule  at 42 Code of Federal  Regulations  (CFR) Section  422.101.The  rules  say that  Medicare  pays for  care in  a skilled  nursing  facility  (SNF) when all  of the  following  four factors  are met:1. The  patient  requires  skilled  nursing  or skilled  rehabilitation  services;2. The  patient  requires  these  services  on a daily  basis;3. As a practical  matter,  the daily  skilled  services  can be provided  only  on aninpatient  basis  in  a SNF; and4. The services are reasonable and necessary for the treatment  of the patient's  illness  or injury  or the services must  be needed  to establish  a safe  and effective  maintenance  program  or to prevent  the patient's  condition  fromgetting  worse. You  can find  these rules  at 42 CFR Section  409.31 and  in  the  Medicare  Benefit  Policy  Manual,  Chapter  8, Section  30.  The  rules  say that  custodial  care is not  covered.  Custodial  care is personal  care for  a person  who does not need ongoing  care from  trained  medical  or paramedical  staff.  Custodial  care serves  to help  with  the activities  of daily  living.  This  means  the care includes  help  in  walking,  getting  in  and out of  bed, bathing,  dressing,  feeding, and using  the toilet.  Fixing  meals  andtaking  charge  of  medicine  that  usually  can  be self-administered  are also custodial  care services.  You  can find  this  rule  in  the  Medicare  Benefit  Policy  Manual,  Chapter  16, Section  110.If  you  want  to read these  Medicare  rules,  you  can go to this  website www.medicareappeal.com.The  Plan  contract  says that  the  Plan  covers  items  and services  in  accordance  with  Medicare  rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes a limited exam to evaluate a problem once per plan year. You can find this information on pages 4-72 to 4-85 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 Correct Coding Initiative was developed to promote correct coding and to control improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on code is not eligible for payment ifit is the only procedure reported by a practitioner. The only exception is as follows: 

For the same date of service only one physician of the same specialty in the group practice may report code 99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care services with CPT code 99292.

The Coding Policy Manual also explains what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code pairs that should not be reported together. You can find this rule in the Medicare Claims Processing Manual, Chapter 23, Section 20.9.

MACs subject all line items for the same beneficiary, same NPI, and same date of service to NCCI edits. You can find this information in Medicare Claims Processing Manual Chapter 23, Section 20.9.1.1.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The  rules  say that  plans  must  pay for  a medical  service  or item  if  regular  Medicare would  pay for it  in  this  case. You  can find  this  rule at42 Code of Federal  Regulations  (CFR) Section 422.101.

The  rules  say that  medically  necessary  services  are those  that  are reasonable  and necessary  for  the diagnosis  or treatment  of  an illness  or injury.  Medically  necessary  services  include  services  to improve  the functioning  of a malformed  body member.You can find  this  rule  in  the Social  Security  Act, Section  1862(a)(1)(A). 

The rules  say that  services  that  are not  medically  necessary  are not covered.  The  rules  also  say that experimental  and investigational  devices  are not  covered.  You can find  this  rule  at 42 CFR Sections  411.15 and 411.15(o).

If  you  want  to read these  Medicare  rules,  you  can go to this  website www.medicareappeal.com.

The Plan  contract  says that the  Plan covers  items  and services  in  accordance  with  Medicare  rules.
Appeal type: unknown
Decision: unknown

The  rules  say that  plans  must  pay for  a medical  service  or item  if  regular  Medicare  would  pay for it  in  this  case. You  can find  this  rule  at 42 Code of Federal  Regulations  (CFR) Section  422.101.The  rules  say that  Medicare  will  not pay for  dental  services.  Dental  services  are items  and services  involving the  care, treatment,  filling,  removal  or replacement  of teeth  or structures  directly  supporting  the  teeth.  Medicare defines  "structures  directly  supporting  the teeth"  as the periodontium,  which  includes  the  gingivae, dentogingival  junction,  periodontal  membrane,  cementum  of the  teeth,  and alveolar  process. You  can find  this rule  in  the  SSA, Section  1862(a)(12)  and Medicare  Benefit  Policy  Manual,  Chapter  15, Section  150.If  you  want  to read these  Medicare  rules,  you  can go to this  website www.medicareappeal.com.The  Plan  contract  says that  the  Plan  covers  items  and services  in  accordance  with  Medicare  rules. The  contract says  that  the Plan  covers certain  dentalservices  as a supplemental  (extra)  benefit.  The  Plan  contract  says  that  to be covered  in-network,  you  need to use a provider  that  is  contracted  with  the  Plan's  dental  vendor  to provide supplemental  dental  services.  Care rendered  by a provider  that  is not part of the  Plan's  supplemental  dental network is not covered. You can find  this information  on page 56 of the Plan's 2020 Evidence  of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The  rules  say that  plans  must  pay for  a medical  service  or item  if  regular  Medicare  would  pay for it  in  this  case. You  can find  this  rule  at 42 Code of Federal  Regulations  (CFR) Section  422.101.The  rules  say that  Medicare  does not  pay for eye  exams  for  the  purpose of  prescribing,  fitting,  or changing eyeglasses  or contact  lenses  for  refractive  error only.  Medicare  does not pay for  procedures  performed  in  the course  of any  eye exam  to determine  the refractive  state  of the  eyes. Refractive  procedures  are not covered even  when  done in  connection  with  otherwise  covered  diagnosisor treatment  of  illness  or injury.  You  can find these  rules  at 42 CFR Section  411.15(c).If  you  want  to read these  Medicare  rules,  you  can go to this  website www.medicareappeal.com.The  Plan  contract  says that  the  Plancovers  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 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's records. If the enrollee was directly admitted to home healthfrom 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 must document that he or she or an allowed non-physician practitioner (NPP) had 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 Medicare Benefit Policy Manual, 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.The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance withMedicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes a list of claims that are covered with any services not listed not covered. You can find this information on pages 4-72to 4-79 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

he 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 at42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that CT scans are covered if there is literature to support its use for the patient's condition and the scan is reasonable and necessary for the patient. You can find this rule in the Medicare National Coverage Determinations Manual, Section 220.1(A).

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

he 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 eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR Section 411.15(c).The following ancillary tests are not routinely indicated in the preoperative workup for cataract surgery, and if performed, will not be considered a covered benefit unless medical necessity is defended by a statement in the patient's record:Potential vision testingCorneal TopographyAnterior or Posterior Segment Ocular Coherence TomographyFormal visual fieldsFluorescein angiographyExternal photographyCorneal pachymetry/Specular microscopySpecialized color vision testingElectrophysiologic testingFundus photographyExtended ophthalmoscopy , andOphthalmic ultrasound B scan.You can find this information in the Local Coverage Determination (LCD): Cataract Surgery (L34413).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.