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 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 only certain codes/services are covered under the Plan. The EOC lists specific services which are a covered benefit and any service not listed in this section is not a covered benefit. You can find this information in Chapter 4 on pages 55 and 80 of the plan's 2019 Evidence of Coverage. The health plan contract says that non-routine dental care (covered services are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician). You can find this information in Chapter 4 on page 71 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 procedures with the status indicator of "I" is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. You can find this rule in the Medicare Claims Processing Manual, Chapter 23, Section 30.2.2.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).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 state that the coverage indications for all facet joint injections, medial branch blocks, and facet joint radiofrequency neurotomy procedures are:&#61623;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).&#61623;The pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with radiculopathy or neurogenic claudication.&#61623;There is no non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor, infection or significant deformity.&#61623;Clinical assessment implicates the facet joint as the putative source of pain.For each covered spinal region, no more than 2 thermal radiofrequency sessions will be covered in any rolling 12 month period. You can find these rules in Local Coverage Determination (LCD) 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 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 CFR422.101.The rules state that the Decipher GC assay is covered only when the following clinical conditions are met:&#61623;Patient with prostate cancer who has undergone a RP within the previous 60 months and is being considered for postoperative secondary therapy due to one or more cancer-recurrence risk factors, and&#61623;Patient must have achieved initial PSA nadir (defined as PSA at or below 0.2ng/ml) within 120 days of RP surgery, and&#61623;Patient must not have any evidence of distant metastasis, and&#61623;Patient must not have received any neo-adjuvant treatment prior to surgery, and&#61623;Decipher GC is performed on a patient's RP specimen, and&#61623;Patient's surgical pathology report or medical records must have documented presence of adverse pathology:oPathological stage T2 disease with a positive surgical margin, oroPathological stage T3 disease (e.g., extraprostatic extension, seminal vesicle invasion, bladder neck invasion), oroRising PSA after initial PSA nadir, and&#61623;Testing has been ordered by a physician who is certified in the Decipher Biosciences Decipher Certification and Training Registry (CTR)You can find these rules in Local Coverage Determination (LCD) MolDX: Decipher Prostate Cancer Classifier Assay (L36343).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 Medicare will pay for an IRF admission when the services are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week. The patient does not need to be expected to achieve complete independence in self-care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. You can find these rules in the Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR ?412.622.
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 pays for air ambulance services only if the enrollee's medical condition is such that transportation by either basic or advanced life support ground ambulance is not appropriate. Air ambulance services may be covered only if: 1. certain vehicle and crew requirements are met; 2. the enrollee's medical condition needed immediate and rapid ambulance transport that could not have been provided by ground ambulance; and 3. either the point of pickup is not accessible by ground vehicle or great distances or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities. You can find this rule in the Medicare Benefit Policy Manual, Chapter 10, Section 10.4 and 10.4.1. Where inpatient services in a foreign hospital are covered, payment may also be made for ambulance services, where necessary, for the trip to the hospital in conjunction with the beneficiary's admission as an inpatient. Return trips from a foreign hospital are not covered. You can find this rule in the Medicare Claims Processing Manual, Chapter 1, Section 10.1.4.1.
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. The Plan contract also says that transportation back to the United States from another country is not a covered benefit. You can find this information on page 4-23 of the Plan's 2018 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 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 modifier -59 is used to indicate a distinct procedural service. This may represent a different session or patient encounter, different procedure or surgery, different site, or organ system, separate incision/excision, or separate injury. You can find this rule in the Medicare Claims Processing Manual, Chapter 23, Section 20.9.1.1B.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 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 includes a list of covered supplemental dental services. The contract specifically says that any procedure not listed is not covered. Surgical placement of implant body: endosteal implant is not included on this list and is not a covered supplemental benefit. You can find this information on pages 4-65 to 4-71 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 health plan contract says that enrollees must pay a $250 copayment per day, days 1-7 for each in-network Medicare-covered hospital admission/stay. You can find this information in Chapter 4 on page 87 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 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 not pay 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. Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 280.1 provides a list of items that are non-covered with the reason for denial. Wig, any type, (A9282), will be denied as non-covered when submitted to the DME MAC. Does not meet the definition of DME.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 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).
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, 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 41 and 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 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).
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 one of thefollowing secondary diagnosis codes must accompany a primary diagnosis code. The use of these diagnosis codes implies that the medical necessity of the 3-D rendering and interpretation is documented in the medical record with a written request for the study from the referring physician and is available upon request.Medicare expects that there will be a primary diagnosis code(s) that is representative of the patient's medical condition, which supports the need for the base imaging procedure. Use the secondary diagnosis that most closely represents the body area that is to be 3-D imaged (implies medical necessity for 3-D rendering and interpretation).The CPT/HCPCS codes included in this Local Coverage Determination (LCD) will be subjected to "procedure todiagnosis" editing. The following lists include only those secondary diagnoses for which the identified CPT/HCPCS procedures are covered. Note: If a covered secondary diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.Covered secondary diagnoses:R90.82White matter disease, unspecifiedR91.1Solitary pulmonary noduleR91.8Other nonspecific abnormal finding of lung fieldR93.0Abnormal findings on diagnostic imaging of skull and head, not elsewhereclassifiedR93.1Abnormal findings on diagnostic imaging of heart and coronary circulationR93.2Abnormal findings on diagnostic imaging of liver and biliary tractR93.3Abnormal findings on diagnostic imaging of other parts of digestive tractR93.41Abnormal radiologic findings on diagnostic imaging of renal pelvis, ureter, or bladderR93.421Abnormal radiologic findings on diagnostic imaging of right kidneyR93.422Abnormal radiologic findings on diagnostic imaging of left kidneyR93.429Abnormal radiologic findings on diagnostic imaging of unspecified kidneyR93.49Abnormal radiologic findings on diagnostic imaging of other urinary organsR93.5Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneumR93.6Abnormal findings on diagnostic imaging of limbsR93.7Abnormal findings on diagnostic imaging of other parts of musculoskeletal systemR93.89Abnormal findings on diagnostic imaging of other specified body structuresYou can find these rules in Local Coverage Determination (LCD): 3D Interpretation and Reporting of Imaging Studies (L33416).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 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 Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for a person who meets the following criteria: 1.The person must have a personal mobility deficit; 2.The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, grooming and bathing in customary locations within the home; 3.The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and4.The person must be capable of safely operating the PMD. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.3(B).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.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 supplemental dental contract covers beyond that of Medicare. The plan will only pay for dental services you receive from an in-network provider. If you receive services from an out of network provider,you will be responsible for all costs related to those services.You can find this information on page 6 in the 2019  customer handbook.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 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).
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, 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 9-10 of the 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 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).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 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).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).If you want to read these Medicare rules, you can go tothis web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.