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 state that no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. Further, it is essential that each 
provider and supplier enroll with the appropriate Medicare fee-for-service contractor. Chapter 15 - Medicare 
Enrollment 
 
A provider is defined and generally means a hospital, critical access hospital, skilled nursing facility, 
comprehensive outpatient rehabilitation facility, home health agency or hospice, that has in effect an agreement 
to participate in Medicare; or a clinic, rehabilitation agency, or public health agency that has in effect a similar 
agreement but only to furnish outpatient physical therapy or speech pathology services; or a community mental 
health center that has in effect a similar agreement but only to furnish partial hospitalization services. You can 
find this rule at 42 CFR ?400.202. 
 
A supplier means a physician or other practitioner, or an entity other than a provider that furnishes health care 
services under Medicare. You can find this rule at 42 CFR ?400.202. 
 
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 Medicarerules, 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 says that you have $250 every year for non-Medicare-covered preventive dental services and non-Medicare-covered comprehensive dental services combined. You are responsible for any amount above the dental coverage limit. You can find this information on pages 60 and 61 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. 
 
In this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous 
positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) 
when it is used in the treatment of obstructive sleep apnea. 
 
An E0470 device is covered for those beneficiaries with obstructive sleep apnea (OSA) who meet criteria A-C, 
in addition to criterion D: If E0470 is billed for a beneficiary with OSA and criteria A-D are not met, it will be 
denied as not reasonable and necessary. 
 
A bi-level positive airway pressure device with back-up rate (E0471) is not reasonable and necessary if the 
primary diagnosis is OSA. If an E0471 is billed with a diagnosis of OSA, it will be denied as not reasonable 
and necessary. 
 
You can find this information in Local Coverage Determination (LCD): Positive Airway Pressure (PAP) 
Devices for the Treatment of Obstructive Sleep Apnea (L33718). 
 
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 indications for facet joint injections are: 
  
-At least 3 months of moderate to severe pain with functional impairment inadequately responsive to 
conservative care such as NSAIDs, acetaminophen, physical therapy (if tolerated). 
-Predominant axial pain that is not associated with radiculopathy or neurogenic claudication. 
-Absence of non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor, 
infection, or significant deformity. 
-Clinical assessment that implicates the facet joint as the putative source of pain. 
  
You can find this rule in Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, 
and Facet Joint Radiofrequency Neurotomy (L35996) - Effective December 26, 2019. 
 
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 $325 copayment per day for days 1-5. There is no charge for additional days for inpatient hospital care. You can find this information on pages 74-76 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).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 copayment for laboratory tests. You can find this information on page 4-39 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 all of the following basic criteria (A-C) must be met for a power mobility device or a pushrim
activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are
listed below.
A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing,
grooming, and bathing in customary locations in the home. A mobility limitation is one that:
o Prevents the beneficiary from accomplishing an MRADL entirely, or
o Places the beneficiary at reasonably determined heightened risk of morbidity or mortality
secondary to the attempts to perform an MRADL; or
o Prevents the beneficiary from completing an MRADL within a reasonable time frame.
B. The beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an
appropriately fitted cane or walker.
C. The beneficiary does not have sufficient upper extremity function to self-propel an optimallyconfigured
manual wheelchair in the home to perform MRADLs during a typical day.
o Limitations of strength, endurance, range of motion, or coordination, presence of pain, or
deformity or absence of one or both upper extremities are relevant to the assessment of upper
extremity function.
o An optimally-configured manual wheelchair is one with an appropriate wheelbase, device
weight, seating options, and other appropriate nonpowered accessories.
You can find this rule at Local Coverage Determination (LCD): Power Mobility Devices (L33789) (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 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 group 2 power wheelchair (K0824) is covered if all the coverage criteria are met, and the 
wheelchair is appropriate for the beneficiary's weight. You can find this rule in Local Coverage Determination 
(LCD): Power Mobility Devices (L33789) - 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 state that facet injections are covered for the following indications: 
 
   - Patient must have a history of at least 3 months of moderate to severe pain with functional impairment and 
the pain is inadequately responsive to conservative care such as non-steroidal anti-inflammatory drugs 
(NSAIDs), acetaminophen and/or physical therapy (as tolerated). 
 
   - The pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with 
radiculopathy or neurogenic claudication. 
 
   - There is no non-facet pathology that could explain the source of the patient?s pain, such as fracture, tumor, 
infection or significant deformity. 
 
   - Clinical assessment implicates the facet joint as the putative source of pain. 
 
You can find this rule in the Local Coverage Determination (LCD) for Facet Joint Injections, Medial Branch 
Blocks, and Facet Joint Radiofrequency Neurotomy (L36471). 
 
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 $195 copayment per day for skilled nursing facility services at an out-
of-network facility for days 1-35. You can find this information 4-55 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 SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
The rules say that health 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 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 45 to 51 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). 
 
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 $225 per day copayment for days 1-5 of inpatient hospital services. You 
can find this information on pages 4-20 to 4-22 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 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 says that oral 
evaluations are covered two procedures per calendar year, one intraoral x-ray is covered per calendar year and 
one bitewing x-ray is covered per calendar year. The prefabricated post and core are not listed as a covered 
benefit. You can find this information on pages 94 and 95 of the Plan's 2019 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 contract lists the specific 
dental services that are covered. Bone graft is not listed and therefore is not a covered service. Bone 
replacement graft is not listed and therefore is not a covered service. Guided tissue regeneration is not listed 
and therefore is not a covered service either. The contract also says any services not listed are not covered. You 
can find this information on pages 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 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 have a 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. 
This LCD is effective for services provided on or after July 1, 2016.  
 
The rules say that a seat lift mechanism is covered if all of the following criteria are met: 
 
    1. The beneficiary must have severe arthritis of the hip or knee or have a severe neuromuscular disease. 
    2. The seat lift mechanism must be a part of the treating practitioner's course of treatment and be prescribed 
to effect improvement, or arrest or retard deterioration in the beneficiary's condition. 
    3. The beneficiary must be completely incapable of standing up from a regular armchair or any chair in their 
home. (The fact that a beneficiary has difficulty or is even incapable of getting up from a chair, particularly a 
low chair, is not sufficient justification for a seat lift mechanism. Almost all beneficiaries who are capable of 
ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.) 
    4. Once standing, the beneficiary must have the ability to ambulate. 
 
Coverage of seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the 
beneficiary, and effectively assist a beneficiary in standing up and sitting down without other assistance. 
Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden, catapult-
like motion and jolts the beneficiary from a seated to a standing position. 
 
The practitioner ordering the seat lift mechanism must be the treating practitioner or a consulting practitioner 
for the disease or condition resulting in the need for a seat lift. The practitioner's record must document that all 
appropriate therapeutic modalities (e.g., medication, physical therapy) have been tried and failed to enable the 
beneficiary to transfer from a chair to a standing position. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Seat Lift Mechanisms 
(L33801). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that the PACE benefit package must include the following:  
(a) All Medicare-covered items and services;  
(b) All Medicaid-covered items and services, as specified in the State's approved Medicaid plan; and  
(c) Other services determined necessary by the interdisciplinary team to improve and maintain the enrollee's 
overall health status.  
You can find this rule at 42 Code of Federal Regulations (CFR) Section 460.92. 
 
The rules say that Home Health Aide (HHA) services may be covered only if the enrollee needs one or more of 
the following qualified skilled services:  
 
1. Skilled nursing care;  
2. Physical therapy;  
3. Occupational therapy; or  
4. Speech pathology services.  
 
HHA services are no longer covered for enrollees once the qualifying skilled service has ended. To be covered, 
home health aide services must be reasonable and necessary. You can find this rule at 42 CFR Sections 409.44 
and 409.45. 
 
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.