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 for the routine costs of qualifying clinical trials. Medicare also pays 
for reasonable and necessary items and services used to diagnose and treat complications arising from 
participation in all clinical trials. The rules also say that Medicare plans must cover these services even if they 
are not available through in-network providers. Medicare plans may require reporting when enrollees 
participate in clinical trials but cannot require prior authorization or approval. You can find these rules in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National 
Coverage Determinations Manual, Chapter 1, Section 310.1. 
 
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 a clinical research study or clinical trial is a way that doctors and scientists test new 
types of medical care. They test new medical care procedures or drugs by asking for volunteers to help with the 
study. This kind of study is one of the final stages of a research process that helps doctors and scientists see if a 
new approach works and if it is safe. 
 
An enrollee who is in a clinical research study may stay enrolled in the Plan and continue to get the care that is 
not related to the study through the Plan. Enrollees must tell the plan before they start participating in a clinical 
research study. 
 
If an enrollee participates in a Medicare-approved study, Original Medicare pays most of the costs for the 
covered services received as part of the study. After Medicare has paid its share of the cost for these services, 
the Plan will also pay for part of the costs. The Plan will pay the difference between the cost-sharing in 
Original Medicare and the cost-sharing as a member of the Plan. This means the enrollee will pay the same 
amount for the services received as part of the study as he or she would if these services were received from the Plan.  
 
The Plan contract also says that enrollees must pay 20% coinsurance for Medicare-covered therapeutic 
radiology. You can find this information on pages on pages 61 to 62 and pages 104 to 106 of the Plan's 2021 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes oral 
exams, cleanings, bitewing x-rays, and full mouth x-rays. Removal of residual tooth roots (D7250) is not 
included on this list and is not a covered benefit. You can find this information on page 65 of the Plan?s 2021 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
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 there is a a $1500 deductible which applies to certain items and services. The Plan 
deductible applies to the out-of-network breast prosthesis and mastectomy bra. You can find this information 
on pages 61 and 114 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 invasive procedures for the treatment of varicose veins are considered medically reasonable 
and necessary when a duplex scan of the deep and superficial venous systems supports the examination 
findings and a duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers 
in the saphenous, or perforator veins is 500 milliseconds or greater3 and absence of deep venous obstruction. 
You can find this information in Local Coverage Determination (LCD): Treatment of Chronic Venous 
Insufficiency of the Lower Extremities (L34924). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 1, Section 20.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that 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. All supporting clinical information must be provided to substantiate the continuation of the requested services. You can find this information on page 56 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 plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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 immunizations are not covered unless they are directly related to the treatment of an injury or 
direct exposure to a disease or condition. In the absence of injury or direct exposure, vaccination or inoculation 
is not covered. However, pneumococcal, hepatitis B, influenza virus vaccines, and any FDA-approved COVID-
19 vaccines are exceptions to this rule. You can find this rule at 42 CFR Section 411.15(e) and Section 3713 of 
the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). 
 
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 says that in terms of immunizations, covered Medicare Part B services include: 
 
-Pneumonia vaccine 
-Flu shots, once each flu season in the fall and winter, with additional flu shots if medically necessary. 
-Hepatitis B vaccine if you are at high or intermediate risk of getting Hepatitis B 
-Other vaccines if you are at risk and they meet Medicare Part B coverage rules 
 
There are also some vaccines that are covered under the Part D prescription drug benefit. 
 
You can find this information on page 67 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 Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes periodic 
oral exams, comprehensive oral exams, and prophylaxis. You can find this information on pages 59 to 60 of the 
Plan?s 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). 

The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $360 copay per day for days 1 to 5 and a $0 copay per day for days 6 to 90 in a network hospital for Inpatient hospital care. 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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 42 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 screening tests are excluded from coverage. The only exceptions are for the following services:
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64.

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 $290 each Medicare covered day for days 1-6 for each inpatient 
hospitalization. You can find this information on page 71 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 pays for ambulance services that meet certain origin and destination requirements. 
In order to meet this requirement, the ambulance supplier must transport the patient for whom the emergency 
call was placed. If an ambulance responds to a call but does not transport the person for whom the call was 
placed, Medicare does not pay for the service. You can find this rule at 42 CFR Section 410.40(f) and in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 10, Section 10. 
 
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, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers certain dental services as a supplemental (extra) benefit. You can find this information
on pages 4-88 to 4-102 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 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, Publication 100-16, 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, 
Publication 100-04, 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 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 National Correct Coding Initiative (NCCI) was developed to prevent inappropriate 
payment of services that should not be reported together. NCCI edits are organized in a Column I/Column 2 
table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of an edit 
pair, only the Column 1 code is payable. For edits with a modifier indicator of 1, the Column 2 code is payable 
only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. If the 
modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a modifier is used. You can 
find this in the NCCI Manual, Chapter I. 
 
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.

A pneumatic compression device (PCD) coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when all of the following are met:

1. The beneficiary has lymphedema of an extremity. 

2. The coverage criteria for an E0650 or E0651 PCD are met. 

3. The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial.

A four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651 is required. The four-week trial of conservative therapy must include all of the following:

1. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 PCD after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided 
2. Compliant use of an appropriate compression bandage system or compression garment to provide adequate graduated compression 
3. Regular exercise 
4. Elevation where appropriate 
5. Manual lymphatic drainage (where available) and self-manual lymphatic drainage (MLD) for at least 30 minutes per day 
6. Evaluation of diet and implementation of any necessary change 
7. Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.) 
8. Correction (where possible) of anemia and/or hypoproteinemia

You can find this information at Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).

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.