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 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 $160 copayment for each Medicare-covered radiological diagnostic 
service, not including X-rays; a $30 copayment for Medicare-covered non-radiological diagnostic services; and 
20% coinsurance for each Medicare-covered Part B drug and each Medicare-covered medical supply. You can 
find this information on pages 4-33 to 4-35 and 4-37 to 4-42 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 $90 copayment for emergency services. You can find this information 
on pages 67-68 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 that the following indications are covered nationally unless otherwise indicated: 
1. Computer analysis of EKGs when furnished in a setting and under the circumstances required for 
coverage of other EKG services. 
2. EKG services rendered by an IDTF, including physician review and interpretation. Separate physician 
services are not covered unless he/she is the patient's attending or consulting physician. 
3. Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed 
as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance 
at the time the service is performed or immediately thereafter. 
4. Home EKG services with documentation of medical necessity. 
5. Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications 
described below, when performed with equipment meeting the standards described below, subject to the 
limitations and conditions specified below. Coverage is further limited to the amounts payable with 
respect to the physician's service in interpreting the results of such transmissions, including charges for 
rental of the equipment. The device used by the beneficiary is part of a total diagnostic system and is 
not considered DME separately. Covered uses are to: 
a. Detect, characterize, and document symptomatic transient arrhythmias; 
b. Initiate, revise, or discontinue arrhythmic drug therapy; or, 
c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); 
(only if 24-hour coverage is provided, see C.5. below).  
Certain uses other than those specified above may be covered if, in the judgment of the local Medicare 
Administrative Contractor (MAC), such use is medically necessary. 
Additionally, the transmitting devices must meet at least the following criteria: 
a. They must be capable of transmitting EKG Leads, I, II, or III; and, 
b. The tracing must be sufficiently comparable to a conventional EKG. 
You can find this rule in the National Coverage Determination Manual Chapter 1, Section 20.15. 
 
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 only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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 says that the only covered chiropractic service is manual manipulation of the spine to correct 
a subluxation. You can find this information on page 55 of the Plans 2019 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 payment may not be made for a subsequent annual wellness visit that is performed for a 
beneficiary who has had either an initial preventive physical examination or annual wellness visit performed 
within the past 12 months. You can find this rule in 42 Code of Federal Regulations, Section 410.15. 
 
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 an annual wellness visit is covered once every 12 months. You can find this information in 
Chapter 4 on page 4-7 of the Plan's 2019 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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.
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 Group 2 Multiple Power Option PWC (K0841-K0843) is covered if all of the coverage 
criteria for a standard power wheelchair are met and if: 
 
1. The beneficiary meets coverage criteria for a power tilt and recline seating system (see Wheelchair Options 
and Accessories policy) and the system is being used on the wheelchair. 
2. The beneficiary uses a ventilator which is mounted on the wheelchair. 
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical 
professional, such as a PT or OT, or practitioner who has specific training and experience in rehabilitation 
wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features (see 
Documentation Requirements section). The PT, OT, or practitioner may have no financial relationship with the 
supplier. 
4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional 
(ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection 
for the beneficiary. 
 
These rules can be found in Local Coverage Determination (LCD):Power Mobility Devices (L33789), and 
Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). 
 
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 does not include 
coverage for endodontic therapy (D3330) according to the list of covered benefits chart. You can find this 
information on pages 4-68 to 4-76 of the Plans 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 providers may ask you for more than one cost share payment if you get more than one service 
at an appointment. For example, your doctor will ask for a copayment for the office visit and additional 
copayments for each x-ray that is performed while you are there. You can find this information on page 4-6 of 
the Plan's 2020 EOC. 
 
The Plan contract also says that enrollees must pay a $30 copayment for Medicare-covered non-radiological 
diagnostic services. You can find this information on page 4-40 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 state that medical supplies directly associated with delivering insulin to the body, including syringes, 
needles, alcohol swabs, gauze, and insulin injection delivery devices not otherwise covered under Medicare 
Part B, such as insulin pens, pen supplies, and needle-free syringes, can satisfy the definition of a Part D drug.  
However, test strips, lancets and needle disposal systems are not considered medical supplies directly 
associated with the delivery of insulin for purposes of coverage under Part D. You can find this information in 
the Medicare Benefit Policy Manual, Chapter 6, 10.5. 
 
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. The contract lists the specific 
dental services that are covered. Prefabricated post and core in addition to a crown is not listed and therefore is 
not a covered service. The contract also says that if a dental item or service is not listed or listed with NC, then 
it is not covered. You can find this information on pages 22 to 29 of the Dental Plan's 2020 Customer Handbook.
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 only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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 says that covered chiropractic services only include manual manipulation of the spine to correct 
subluxation. Enrollee's must pay a $20 copay per Medicare-covered visit, and a $20 copay per routine visit. 
Routine coverage only covers manual manipulation of the spine to correct subluxation to correct subluxation. 
You can find this information on page 63 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 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 providers may ask you for more than one cost share payment if you get more than one service 
at an appointment. You can find this information on page 4-6 of the Plan's 2020 EOC.  
 
The Plan contract says that enrollees must pay a $30 copayment for Medicare-covered non-radiological 
diagnostic services, 20% coinsurance for each Medicare-covered medical supply and a $125 copayment for 
each Medicare-covered radiological diagnostic service. You can find this information on pages 4-29 to 4-31 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 as a member of the Plan, the most you will have to pay out-of-pocket for in-network covered 
Part A and Part B services in 2020 is $6,700. The amounts you pay for copayments and coinsurance for in-
network covered services count toward this maximum out-of-pocket amount. You can find this information on 
page 58 of the Plan's 2020 EOC.  
 
The Plan contract also says that enrollees must pay a $0 copayment per day, days 1 to 20 and a $178 
copayment per day, days 21 to 100 at an in-network skilled nursing facility. You can find this information on 
page 84 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 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). Ultrasound diagnostic procedures utilizing low energy sound waves are being widely employed to determine the composition and contours of nearly all body tissues except bone and air-filled spaces. This technique permits noninvasive visualization of even the deepest structures in the body. The use of the ultrasound technique is sufficiently developed that it can be considered essential to good patient care in diagnosing a wide variety of conditions. You can find this information in National Coverage Determination (NCD) for Ultrasound Diagnostic Procedures (220.5).
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 a pneumatic compression device (PCD) coded as E0650 or E0651 is covered for the 
treatment of chronic venous insufficiency (CVI) of the lower extremities only if the patient has all of the 
following: 
&#61623; Edema in the affected lower extremity 
&#61623; One or more venous stasis ulcer(s) 
&#61623; The ulcer(s) have failed to heal after a six-month trial of conservative therapy directed by the treating 
practitioner. 
 
A PCD coded as E0650 or E0651 used to treat CVI that does not meet all of the requirements above is not 
eligible for reimbursement. Claims will be denied as not reasonable and necessary. A PCD coded as E0650 or 
E0651 used to treat ulcers in locations other than the lower extremity or ulcers and wounds from other causes is 
not eligible for reimbursement. Claims will be denied as not reasonable and necessary. A six-month trial of 
conservative therapy demonstrating failed response to treatment is required. The six-month trial of conservative 
therapy must include all of the following: 
&#61623; Compliant use of an appropriate compression bandage system or compression garment to provide 
adequate graduated compression 
&#61623; Adequate compression is defined as (1) sufficient pressure at the lowest pressure point to cause fluid 
movement and (2) sufficient pressure across the gradient (from highest to lowest pressure point) to 
move fluid from distal to proximal. The compression used must not create a tourniquet effect at any 
point. 
&#61623; The garment may be prefabricated or custom-fabricated but must provide adequate graduated 
compression starting with a minimum of 30 mmHg distally. 
&#61623; Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.) 
&#61623; Regular exercise 
&#61623; Elevation of the limb 
&#61623; Appropriate wound care for the ulcer (including sharp debridement where appropriate) 
 
At the end of the six-month trial, if there has been improvement, then reimbursement for a PCD is not 
reasonable and necessary. Where improvement has occurred, the trial of conservative therapy must be 
continued with subsequent reassessments. When no significant improvement has occurred for a continuous 
period of six months and the coverage criteria above are still met, then the use of a PCD to treat CVI is eligible 
for reimbursement. You can find these rules in 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.