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 CFR 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 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 422.2.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that enrollees must pay a $40 copayment for services obtained from an in-network specialist or
under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician
health care professionals in a specialist's office. Covered services include consultation, diagnosis, and treatment
by a specialist. You can find this information on pages 4-39 to 4-42 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 CFR 422.101.
The rules state that when completing the 1500 claim form, providers must enter the correct Place of Service (POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. You can find this rule at Medicare Claims Processing Manual Ch. 26 10.6.
The rules say that for definitive drug testing, limitations apply when denials are likely, whether based on medical necessity or other coverage reasons. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. For codes G0480, G0481, G0482, G0483, G0659, 80305, 80306, and 80307, diagnosis codes and physician documentation must be coded to the highest level of specificity. You can find this in the Local Coverage Article: Billing and Coding: Drug Testing (A56645). The rules say that Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare policies. You can find this in the Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, Section 3.3.2.4 entitled Signature Requirements.
If you want to read these Medicare rules, you can go to this web site 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 CFR 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 411.15 and 411.15(o).The rules state that contract suppliers are not required to furnisha specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical outcome. A physician or treating practitioner (that is a physician assistant, clinical nurse specialist, or nurse practitioner) may prescribe, in writing, a particular brand of a competitively bid item or mode of delivery for an item if he or she determines that the particular brand or mode of delivery is necessary to avoid an adverse medical outcome for the beneficiary. The physician or treating practitioner must document in the beneficiary's medical record the reason why the specific brand or mode of delivery is necessary to avoid an adverse medical outcome. You can find this information in Medicare Manual Chapter 36 of the Claims Processing Manual Section 30.4.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health plan contract says the only covered brands of test strips are Accu-Chek or Trividia products. You can find this information on page 62 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 CFR 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 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 422.2.
If you want to read these Medicare rules, you can go to this web site 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 most you will have to pay out-of-pocket for in-network covered Part A and Part B services in 2019 is $3,800. You can find this information on page 52 of the Plan's 2019 Evidence of Coverage.
The Plan contract also says that enrollees must pay 20% of the cost for Part B covered chemotherapy drugs and
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 CFR 422.101.Medicare rules say that Tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. Tier Exceptions are only available for Part D drugs. This information can be found in 42 CFR 423.4
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 CFR 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 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 422.2.
If you want to read these Medicare rules, you can go to this web site 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 each emergency room visit. You can find this information on page 4-16 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 CFR 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 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 422.2.
If you want to read these Medicare rules, you can go to this web site 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 20% coinsurance for chemotherapy drugs at an in-network outpatient hospital. Covered drugs include drugs that usually aren't self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. You can find this information on page 73 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 CFR 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 web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract lists the specific dental services that are covered by the Plan. Post and core in addition to crown, indirectly fabricated, is not listed and therefore is not a covered service. You can find this information on pages 90 to 101 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 CFR 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 web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says implant services are limited replacing a single missing natural anterior (front) tooth. You can find this information on page 110 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 CFR 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 web site 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 dental coverage includes 2 oral exams a year, 2 bitewing x-rays a year, 2 fluoride treatments a year, 2 cleanings every year and 1 deep cleaning every 2 years. There is also an annual maximum of $2,000. You can find this information on pages 4-54 to 4-68.
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 CFR 422.101.
The rules state that continuous passive motion devices are devices Covered for patients who have received a total knee replacement. To qualify for coverage, use of the device must commence within 2 days following surgery. In addition, coverage is limited to that portion of the 3-week period following surgery during which the device is used in the patient's home. There is insufficient evidence to justify coverage of these devices for longer periods of time or for other applications. You can find this information in the National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules saythat 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 CFR 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 422.112(a)(3).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service oritem if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that incontinence supplies are not covered because they are hygienic items that are non-reusable. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.1.If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. This rule does not apply to: 1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed; 2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL; and 3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with an IOL. You can find this rule at 42 CFR 411.15(b).Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR 411.15(c).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health plan contract says vision coverage includes 1 routine eye exam a year and 1 pair of eyeglasses or contact lenses after each cataract surgery. You can find this information on pages 4-46 to 4-47 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 CFR 422.101.The rules state that coverage and payment for Medicare telehealth services includes consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system. Eligible geographic areas include rural health professional shortage areas (HPSA) and counties not classifiedas a metropolitan statistical area (MSA). The originating site for telehealth services (location to which the enrollee presents) must be a practitioner's office, hospital, rural health clinic (RHC), federally qualified health center (FQHC), skilled nursing facility or community mental health center. You can find this rule in the Medicare Claims Processing Manual, Chapter 12, Sections 190.1 and 190.2.The rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. You can find this in the CMS MLN document entitled "Telehealth Services."
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 CFR 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, and9. screening electrocardiograms10. certain other testing recommended by the United States Preventive Services Task Force and approved by CMSYou can find this rule at 42 CFR 411.15(a)(1) and 42 CFR 410.64.The rules say that testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer is not a covered benefit. Such testing is considered screening and is excluded by Medicare statute. An ABN must be obtained for BRCA 1 and BRCA 2 testing for individuals without signs and symptoms of breast, ovarian or other hereditary cancer syndromes as indicated in this policy. You can find this rule in Local Coverage Determination (LCD): MolDX: BRCA1 and BRCA2 Genetic Testing (L36082) -Effective December 4, 2019.If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.
Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise reasonable and necessary for the patient. FDA approved drugs used for indications other than what is indicated on the official label may be covered if the use is determined to be medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50.4.1 and 50.4.2.
The rules say that for postmenopausal osteoporosis at high risk for fracture, documentation should include but is not limited to:
1. Menopausal status (for female beneficiaries only)
2. Patients age and sex.
3. Documentation supporting the diagnosis of osteoporosis.
4. Previous treatment of osteoporosis, agents used, outcomes and adverse reactions if any.
5. History of previous fractures, including type of fracture, cause and time since occurrence.
6. Risk factors for future fracture including preventive measures.
You can find this rule in the Local Coverage Article for Billing and Coding: Denosumab (Prolia, Xgeva), A52399 (eff 11/07/19).
If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.
The rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A). The rules say that for definitive drug testing, limitations apply when denials are likely, whether based on medical necessity or other coverage reasons. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. For codes G0480, G0481, G0482, G0483, G0659, 80305, 80306, and 80307, diagnosis codes and physician documentation must be coded to the highest level of specificity. You can find this in the Local Coverage Article: Billing and Coding: Drug Testing (A56645). The rules say that Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare policies. You can find this in the Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, Section 3.3.2.4 entitled Signature Requirements.
If you want to read these Medicare rules, you can go to this web site 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 CFR 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 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 422.2.
If you want to read these Medicare rules, you can go to this web site 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 $35 copayment per specialist visit. You can find this information on page 97 of the Plan's 2019 Evidence of Coverage.