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 Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Sections 422.2 and 422.136.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You can find this information on page 80 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 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). A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. You can find this information in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787). L5968 describes a product that is used as an addition to L-code foot systems for lower limb prosthesis construction. The product provides multiaxial motion in the coronal and sagittal plane from articulating components. At transition of stance phase to swing phase, the product will increase the ankle's dorsiflexion angle and maintain it throughout swing phase. The product provides an accommodation of changing heel heights without the user's input. The predicate product is the Rincoe R-Hab Ankle. You can find this information in Local Coverage Article: Lower Limb Prostheses - Policy Article (A52496).
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 $110 copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). You can find this information on pages 4-38 to 4-43 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services,
Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers certain dental services as a supplemental (extra) benefit. The Plan contract says that
dental splints, dental prostheses, dentures, dental implants or any dental treatment for teeth, gums, or jaw,
periodontal cleanings, and dental treatment related to Temporomandibular Disorders (TMD) are not covered by
the Plan. You can find this information on page 129 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, 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 Plan contract says to always make sure your provider is in the network before you receive care. You can find this information on page 75 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).
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 there are no cost-sharing charges for colorectal cancer screenings. You can find this
information in Chapter 4 on page 76 of the Plan's 2020 Evidence of Coverage (EOC).
The Plan contract also says that there is a $750 deductible. You can find this information in Chapter 4 on pages
67 - 68 of the Plan's 2020 EOC.
The Plan contract also says that after the $750 deductible has been met, enrollees must pay a $125 copayment
for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers. You can find this information in Chapter 4 on page 97 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 Medicare covers a lung cancer screening counseling and shared decision-making visit, and for appropriate beneficiaries, annual screening for lung cancer with LDCT, as an additional preventive service benefit under the Medicare program when certain criteria are met. This will be covered as an annual service. For purposes of Medicare coverage of lung cancer screening with LDCT, beneficiaries must meet all of the following eligibility criteria: 1. Age of 55-77 years, 2. Absence of signs/symptoms of lung cancer, 3. Tobacco smoking history of at least 30 pack-years (one pack-year equates to smoking one pack/day for one year, 4. Current smoker or former smoker who quit within the last 15 years. All these criteria must be clearly documented in the medical record, including the actual pack-year smoking history as a number. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National Coverage Determination (NCD) for Lung Cancer Screening with Low Dose Computed Tomography (LDCT) (210.14).
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 LDCT is covered every 12 months. You can find this information on page 92 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 providers must report services correctly. Procedures should be reported with the Current
Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the
Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for
Medicare Services, Chapter I(A).
The rules say that for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. You can find this rule in the
Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Program Integrity Manual,
Chapter 3, Section 3.3.2.1.
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 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, 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 11 of the Plan's 2021 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, 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 says that services are covered when medically necessary and based on the benefit limitations and clinical criteria described in the Plan's Office Manager Reference Manual (ORM). You can find this information on page 69 of the Plan's 2021 Evidence of Coverage (EOC). The ORM includes a list of covered supplemental dental services. Biologic materials to aid in tissue regeneration (D3431) is not included on this list and is not a covered supplemental benefit. You can find this information in Exhibit E on pages 306 to 345 of the Plan's 2021 ORM.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract includes a list of covered supplemental dental services. Core buildup, including any pins when required (D2950) is not included on this list and is not a covered supplemental benefit. This benefit includes crown (D2750) and is limited to 2 of either codes D2750, D2751, D2752, or D2753 per calendar year. You can find this information on pages 90 to 110 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 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).
The rules say that radiofrequency ablation used for sacroiliac joint pain is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. You can find this rule in the Local Coverage Determination for Pain Management, L33622 (eff 06/24/20).
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 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, 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 1-6 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 pays only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41(a). 

The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 4, Section 30.3.

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 contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers up to 12 one-way trips to a Plan network approved location. There is a 30-mile limit per trip. You can find this information on pages 115-116 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 an expandable controller is capable of accommodating one or more of the following
additional functions:

-Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin
control, head control, etc.)
-Non-proportional input devices (e.g., sip and puff, head array, etc.)
-Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)

An expandable controller may also be able to operate one or more of the following:

-A separate display (i.e., for alternate control devices)
-Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive
control)
-An attendant control

You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective
January 1, 2020.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes specific preventative and comprehensive services that are listed in the contract. Services not listed are not covered. Some services may require prior authorization or be subject to limitations in frequency. You can find this information on pages 90-110 of the Plan's 2021 Evidence of Coverage (EOC).