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 enteral nutrition is considered reasonable and necessary for a patient with a functioning
gastrointestinal tract who, due to pathology to, or non-function of, the structures that normally permit food to
reach the digestive tract, cannot maintain weight and strength commensurate with his or her general condition.
Enteral therapy may be given by nasogastric, jejunostomy, or gastrostomy tubes and can be provided safely and
effectively in the home by nonprofessional persons who have undergone special training. However, such
persons cannot be paid for their services, nor is payment available for any services furnished by non-physician
professionals except as services furnished incident to a physician's service.

Typical examples of conditions that qualify for coverage are head and neck cancer with reconstructive surgery
and central nervous system disease leading to interference with the neuromuscular mechanisms of ingestion of
such severity that the beneficiary cannot be maintained with oral feeding. However, claims for Part B coverage
of enteral nutrition therapy for these and any other conditions must be approved on an individual, case-by-case
basis. Each claim must contain a physician's written order or prescription and sufficient medical documentation
(e.g., hospital records, clinical findings from the attending physician) to permit an independent conclusion that
the patient's condition meets the requirements of the prosthetic device benefit and that enteral nutrition therapy
is medically necessary. Allowed claims are to be reviewed at periodic intervals of no more than 3 months by
the A/B MAC (B) medical consultant or specially trained staff, and additional medical documentation
considered necessary is to be obtained as part of this review.

Medicare pays for no more than one month's supply of enteral nutrients at any one time. If the claim involves a
pump, it must be supported by sufficient medical documentation to establish that the pump is medically
necessary, i.e., gravity feeding is not satisfactory due to aspiration, diarrhea, dumping syndrome.

Program payment for the pump is based on the reasonable charge for the simplest model that meets the medical needs of the patient as established by medical documentation. You can find this information in the National Coverage Determination (NCD) for Enteral and Parenteral Nutritional Therapy (180.2). 

The rules state that procedure code S9343 - home therapy - has a Status Code of "I", indicating that this code is not valid for Medicare purposes and is not payable. Medicare uses another code (or codes) for the reporting of, any payment for, these services. You can find this information in the 2020 National Physician Fee Schedule Relative Value File.

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 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 effective for services performed on or after April 4, 2005, cochlear implantation may be
covered for treatment of bilateral pre- or-post-linguistic, sensorineural, moderate-to-profound hearing loss in
individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined
by test scores of less than or equal to 40% correct in the best-aided listening condition on tape-recorded tests of
open-set sentence cognition. Medicare coverage is provided only for those patients who meet all of the
following selection guidelines.

-Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from
appropriate hearing (or vibrotactile) aids;
-Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation;
-Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation,
and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system;
-No contraindications to surgery; and
-The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling.

You can find this rule in National Coverage Determination (NCD) for Cochlear Implantation (50.3) - Effective
April 4, 2005.

The rules say that effective for services performed on or after April 4, 2005, cochlear implantation may be
covered for individuals meeting the selection guidelines above and with hearing test scores of greater than 40%
and less than or equal to 60% only when the provider is participating in, and patients are enrolled in, either an
FDA-approved category B investigational device exemption clinical trial as defined at 42 CFR 405.201, a trial
under the Centers for Medicare & Medicaid (CMS) Clinical Trial Policy as defined at section 310.1 of the
National Coverage Determinations Manual, or a prospective, controlled comparative trial approved by CMS as
consistent with the evidentiary requirements for National Coverage Analyses and meeting specific quality
standards. You can find this rule in National Coverage Determination (NCD) for Cochlear Implantation (50.3) -
Effective April 4, 2005.

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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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 in Chapter 3 of the Plan's 2021
Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary when ALL of the following conditions are met: 

- The patient is symptomatic. Such symptoms may include pain which interferes with the activities of daily living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness 
- The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts 
- If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, laboratory and imaging studies (i.e. the pain and functional disability is not considered likely to be due to a diagnosis other than osteoarthritis of the knee.) 
- The patient has failed at least three months of conservative therapy. Conservative therapy is defined as: 
- Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss, physical therapy if indicated); and - If not contraindicated, simple analgesics and NSAIDS. 
- The patient has failed to respond to aspiration of the knee and intra-articular corticosteroid injection therapy when inflammation is a significant component of the patient's symptoms and intra-articular corticosteroids are not contraindicated. You can find this information in the Local Coverage Determination (LCD): Viscosupplementation Therapy For Knee (L33767).

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 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 Part B generally does not pay for drugs that are usually self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are:

1. blood-clotting factors; 
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients; 
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs; 
6. oral anti-emetics used in certain situations; 
7. drugs treated as supplies during an outpatient hospital procedure; and 
8. drugs required for the effective use of durable medical equipment.

Medicare Part B coverage is extended to include oral anti-cancer drugs that are prescribed as anti-cancer chemotherapeutic agents providing they have the same active ingredients and are used for the same indications as anti-cancer chemotherapeutic agents which would be covered if they were not self-administered and they were furnished incident to a physician's service as drugs and biologicals. 

You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.

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.
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 auricular percutaneous electrical nerve stimulators are listed as electro-acupuncture devices used for stimulation of auricular acupuncture points, and as such are non-covered. Acupuncture for stimulation of auricular points it not a covered Medicare benefit. A percutaneous nerve field stimulator system placed behind the patient's ear is described as nearly identical to an electrical auricular device for a different intended use. This device is non-covered by Medicare when used for any indication. You can find this rule in Local Coverage Article (LCA) Billing and Coding: Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device) (A55240).

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 20% coinsurance for each Medicare-covered item. You can find this
information on pages 78 to 79 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 Part B prescription drugs. The Plan
contract also says that enrollees must pay a $35 copayment for physician/practitioner services, including
doctor's office and specialist visits. You can find this information on pages 76-77 and 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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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 page 42 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 $375 copayment for Medicare-covered outpatient hospital surgery services. You can find this information on page 95 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 $50 copayment for physician/practitioner services, including doctor's office visits and specialist visits. The Plan contract also says that enrollees must pay a $20 copayment for chiropractic services including acupuncture. The Plan contract also says that enrollees must pay a $40 copayment for outpatient rehabilitation services. You can find this information on pages 4-10, 4-36, 4-39 to 4-40, of the Plan's 2020 and 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 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, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by the Centers for Medicare and Medicaid Service. 

You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that screening mammograms every 12 months for women age 40 and older is covered by the Plan. You can find this information on page 4-9 of the Plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say 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 $35 copayment for each outpatient rehabilitation service. You can find
this information on pages 94-95 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 code 80050 (general health panel) is considered a non-covered code. You can find this rule
in the Medicare Program Memorandum, Transmittal No. A-03-050, June 6, 2003.

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 only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
The Plan contract says that the only covered chiropractic service is manual manipulation of the spine to correct a subluxation. You can find this information on page 4-12 of the Plan's 2021 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services,
Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes root
canal therapy, and you are responsible for a 50% coinsurance of the covered plan allowance after the $100
deductible is met. The Plan contract says that services are covered when medically necessary and based on the
benefit limitations and clinical criteria described in the Plan's Office Manager Reference Manual (ORM). The
contract also says that you can get care from an out-of-network dental provider, but you may pay more. You
can find this information on pages 62 and 94 of the Plan's 2020 Evidence of Coverage (EOC).

The ORM includes a list of covered supplemental dental services. Cone beam CT capture and interpretation
(D0364) is not included on this list and is not a covered supplemental benefit. You can find this information on
pages 107 to 151 of the Plan's 2020 ORM.