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 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 44-45 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 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 networkis 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 3-4 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 patient's medical records must establish medical necessity for a hospital bed due to one of the following reasons:1. The patient's condition requirespositioning of the body,e.g., to alleviate pain, promote good body alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or 2. The patient's condition requires special attachments that cannot be fixed and used on an ordinary bed. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.7(A).In order to qualify for a semi-electric hospital bed, the patient's condition must require frequent change in body position and/or there may be an immediate need for a change in body position (i.e., no delay can be tolerated) and the patient can operate the controls and cause the adjustments. Exceptions may be made to this last requirement in cases of spinal cord injury and brain damaged patients. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.7(D).The rules say that aGroup 1 mattress overlay or mattress (E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0196, E0197, E0198, E0199and 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, or2.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, or3.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 statusB.Fecal or urinary incontinenceC.Altered sensoryperceptionD.Compromised circulatory statusWhen 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 rule at Local Coverage Determination (LCD): Pressure Reducing Support Surfaces -Group 1 (L33830)(eff. 1/1/20).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 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 10% coinsurance for outpatient diagnostic tests/laboratory tests. You can find this information on page 75 of the Plan's 2020 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item ifregular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementumof the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. You can find this information on pages 4-73 to 4-82 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 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 Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Grievance Manual, Section 50.12.1.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 says complete/partial dentures are limited to coverage once per arch, per 60 months. You can find this information on page 67 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 Medicare has determined for which surgical services an assistant surgeon is medically necessary. This information can be found in the Medicare Fee Schedule Database. If the database contains an assistant at surgery indicator of 1 for the surgical procedure in question, Medicare has determined that an assistant is not medically necessary. Assistant surgeons will not be paid for these procedures. You can find this rule in the Medicare Claims Processing Manual, Chapter 12, Section 40.8. The rules say that if the Medicare Fee Schedule Database contains an assistant at surgery indicator of 0 for a surgical procedure, assistant at surgery services are generally not medically necessary. Assistant at surgery services will not be paid unless supporting documentation is submitted to establish medical necessity. You can find this rule in the Medicare Claims Processing Manual, Chapter 12, Section 40.8(D). 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 Section 411.15(o).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that a Medicare plan may restrictmembers 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 39 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 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 Plancovers 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 does not list dentures as a covered benefit. You can find this information on page 11 of the 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 1 complete or partial denture every 5 years. You can find this information on page 79 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 at42 Code of Federal Regulations (CFR) Section 422.101.The rules state that a harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also includes all thenecessary fasteners, connectors, and mounting hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and with complete replacement of the expandable controller. Code K0108 must not be used for any component or feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313.The rules say that a 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.The rules say that an expandable controller is capable of accommodating one or more of the following additional functions:&#61623;Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.)&#61623;Non-proportional input devices (e.g., sip and puff, head array, etc.)&#61623;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.)You can find these rules in the Local Coverage Article for Wheelchair Options/Accessories -Policy Article, A52504. This LocalCoverage Article is effectivefor services provided on or after 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 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 itemsand services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. Coverage is limited to services provided by plan-contracted providers. Services obtained out-of-network are not covered. You can find this information on page 82 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 20% coinsurance for Medicare-covered Part B drugs. You can find this information on page 71 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 a seat lift mechanism is covered if all of the following are met:1. The enrollee must have severe arthritis of the hip or knee or havea severe neuromuscular disease. 2. The seat lift mechanism must be a part of the treating practitioner's course of treatment and be prescribed to improve, or stop deterioration of, the enrollee's condition.3. The enrollee must be completely unable to stand up from a regular armchair or any chair in the home. 4. Once standing, the enrollee must have the ability to walk.You can find this rule in the Medicare Local Coverage Determination (LCD) L33801, Seat Lift Mechanisms (eff. 1/1/20).The rules saythat 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 notpay 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.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 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).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 Plan contract does not list abutment crowns as a covered benefit. You can find this information on page 61 of the 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 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 Plan contract does not list second stage implant surgery as a covered benefit. You can find this information on page 51 of the 2021 Evidence of Coverage (EOC).