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 at42 Code of Federal  Regulations  (CFR) Section 422.101.The  rules  say that  Medicare  will  pay for durable  medical  equipment  that  is mainly  used to serve a medical purpose.  Items  such  as hospital  beds, respirators,  wheelchairs  and crutches  are examples  of  equipment  that  are clearly  used for  medical  purposes.  Medicare  will  not  pay for:1. Equipment  that  is  primarily  and customarily  used  for nonmedical  purposes.  Examples  include  air conditioners,  humidifiers,  dehumidifiers  and electric  air  cleaners;2. Equipment  used for a patient's  comfort  or for the convenience  of a person caring  for the patient.  Examples include  elevators,  stairway  elevators,  physical  fitness  equipment  and self-help  devices  such  a grab  bars. You can find  these  rules  in  the  Medicare  Benefit  Policy  Manual,  Chapter  15, Section  110.1.The  rules  say that  the  power seat elevation  feature  (E2300) and power standing feature  (E2301)  are non-covered  because they  are not  primarily  medical  in  nature.  If a wheelchair  has an electrical  connection  device described  by code E2310 or E2311 and  if  the  sole  function  of the  connection  is  for  a power seat elevation  or power standing  feature,  it  will  be denied  as non-covered.  You can find  this  rule  in  Local  Coverage  Article: Wheelchair  Options/Accessories -Policy  Article  (A52504) -Effective  January  1, 2018.If  you  want  to read these  Medicare  rules,  you  can go to this  website www.medicareappeal.com.The Plan  contract  says that the  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 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. The contract says if you 
receive services from an dentist that does not participate with the dental plan, you will be responsible for the 
full cost of those services and no payment will be made. You can find this information on page 58 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 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 $325 copayment for surgical service at an outpatient hospital facility.  
The Plan contract also says that if a doctor thinks it is necessary to perform a colonoscopy for medical reasons 
(e.g. due to the presence of symptoms), this is not considered a screening colonoscopy and outpatient surgery 
copayments will apply. You can find this information on pages 70-71 and page 96 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 specifically listed dental services are covered by the Plan as a supplemental (extra) benefit. This 
benefit does not include coverage for dental implants. You can find this information 60-61, and pages 240-243 
of the Plan?s 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The Appeal Number is: 
1-9549163666 
 
 
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 CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(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

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 $300 copayment per day for days 1-5. There is a $0 copayment for 
additional days for inpatient hospital care. You can find this information on pages 48-49 of the Plan's 2019 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Medicare Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 28-29 of the Plan's 2020 
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 $40 copayment for each urgently needed visit in a non-contracted 
Urgent Care Center or walk-in clinic in the United States. The Plan contract also says that enrollees must pay a 
$14 copayment for each Medicare-covered standard X-ray service and that enrollees must pay 20% 
coinsurance for each Medicare-covered Part B drug. You can find this information on pages 4-33 to 4-41 and 
page 4-68 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 Plan 
contract includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. Resin-based composite of one surface (D2391) and resin-based composite 
of two surfaces (D2392) are not included on this list and are not covered supplemental benefits. You can find 
this information on pages 4-52 to 4-55 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 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 as a member of the plan, you can choose to receive care from out-of-network providers. Our 
plan will cover services from either in-network or out-of-network providers, as long as the services are covered 
benefits and medically necessary. However, if you use an out-of-network provider, your share of the costs for 
your covered services may be higher. You can find this information on page 10 of the 2020 Evidence of 
Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules state that in order for a Continuous Glucose Monitor to be covered, the enrollee must be insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. This rule can be found in Local Coverage Determination (LCD): Glucose Monitors (L33822).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that either intraarticular injections or medial branch blocks may provide temporary or long-
lasting or permanent relief of facet-mediated pain. Injections may be repeated if the first injection results in 
significant pain relief (at least 50%) for at least 3 months. You can find this rule and full criteria for coverage in 
Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint 
Radiofrequency Neurotomy (L35936). 
 
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 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). 
  
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). 
 
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 Health 
Plan contract also says that you have an allowance of up to $100 every two years for a combination of routine 
prescription contacts, routine prescription lenses, routine vision frames, and/or upgrades, such as tinting. This 
means we will pay up to $100 every two years for routine vision hardware. You can find this information on 
page 107 of the Plan's 2020 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 Appeal Number is: 
1-9605477536 
 
 
 
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). 
 
The rules say that for purposes of Medicare coverage of lung cancer screening with low dose computed 
tomography (LDCT), beneficiaries must meet all of the following eligibility criteria: 
  
1. Age 55 - 77 years; 
2. Asymptomatic (no signs or symptoms of lung cancer); 
3. Tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 
1 pack = 20 cigarettes); 
4. Current smoker or one who has quit smoking within the last 15 years; and 
5. Receive a written order for lung cancer screening with LDCT. Written orders for lung cancer LDCT 
screenings must be appropriately documented in the beneficiary's medical records, and must contain the 
following information: 
  
-Beneficiary date of birth; 
-Actual pack - year smoking history (number); 
-Current smoking status, and for former smokers, the number of years since quitting smoking; 
-Statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer); and 
-National Provider Identifier (NPI) of the ordering practitioner. 
  
You can find this rule in National Coverage Determination (NCD) for Lung Cancer Screening with Low Dose 
Computed Tomography (LDCT) (210.14) - Effective February 5, 2015. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a Group 1 mattress overlay or mattress (E0181, E0182, E0184, E0185, E0186, E0187, 
E0188, E0189, E0196, E0197, E0198, E0199 and A4640) is covered if one of the following three criteria are 
met: 
 
   1. The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without 
assistance, or 
   2. The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body 
position significant enough to alleviate pressure and at least one of conditions A-D below, or 
    3. The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D 
below. 
 
Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition 
sufficiently to demonstrate the medical necessity for a pressure reducing support surface): 
 
    A. Impaired nutritional status 
    B. Fecal or urinary incontinence 
    C. Altered sensory perception 
    D. Compromised circulatory status 
 
When the coverage criteria for a Group 1 mattress overlay or mattress are not met, the claim will be denied as 
not reasonable and necessary.  
 
You can find this information in Medicare's Local Coverage Determination (LCD): Pressure Reducing Support 
Surfaces - Group 1 (L33830). 
 
The rules say that a fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or 
more of the following criteria (1-4) are met: 
 
    1. The beneficiary has a medical condition which requires positioning of the body in ways not feasible with 
an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a 
hospital bed, or 
   2. The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to 
alleviate pain, or 
    3. The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration, or 
    4. The beneficiary requires traction equipment, which can only be attached to a hospital bed. 
 
A semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if the beneficiary meets one 
 
 
of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate 
need for a change in body position. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Hospital Beds And 
Accessories (L33820). 
 
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 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 also includes a 
list of the covered supplemental dental benefits. The treatment of root canal obstruction (D3331) is not on this 
list and is not a covered supplemental benefit. You can find this information on pages 4-50 to 4-63 of the Plan's 
2020 Evidence of Coverage (EOC).