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 at42 Code of Federal  Regulations  (CFR) Section 422.101.The  rules  say that  physical  therapy  (PT), occupational  therapy  (OT), and speech  therapy  (ST) services  are covered  only  when  they  are medically  reasonable  and  necessary.  Therapy  services  are considered  reasonable and necessary  when:1. The  services  are specific  and effective  treatment  for  the  patient's  condition,2. The  services  require  the skills  or direct  supervision  of a therapist, 3. The  amount,  frequency,  and duration  of  the services  is  reasonable  under  accepted standards  of practice,  and  4. The  services  are needed to address recovery  of or improvement  in  function  OR to establish,  design,  deliver, or carry  out  a maintenance  program. Medicare  coverage  is  based not  on a patient's  potential  for improvement,  but rather  on the  patient's  need for skilled  care. You  can find  these  rules  in  the  Medicare  Benefit  Policy  Manual,  Chapter  15, Section  220.2.If  you  want  to read these  Medicare  rules,  you  can go to this  website www.medicareappeal.com.ThePlan  contract  says that the  Plancovers  items  and services  in  accordance  with  Medicare  rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that a contract plan provider is an agent of the plan. Services and referrals obtained from a plan provider are viewed as plan-approved unless notice is given that the services will not be covered. Whena plan provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service. If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or item is never covered, the plan does not have to hold the enrollee harmless. For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 160.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract lists the dental
services that are covered by the Plan. This benefit includes a 50% coinsurance for preventive dental services
that you receive out of network. Unspecified preventive dental service is not listed and therefore is not a
covered service. The contract also says that benefits received out of network are subject to any in network
benefit maximums, limitations, and/or exclusions. You may be billed by the out of network provider for any
amount greater than the payment made by the Plan to the provider. You can find this information on pages 90
to 92 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 Medicare plan may not pay for services given by a physician or other practitioner who has opted out of Medicare. This rule does not apply to emergency or urgently needed services. This rule applies to all other services, as well as to supplemental benefits. A Medicare plan must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a private contract withthe enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the Medicare Managed Care Manual, Chapter 6, Section 60.2.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.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item ifregular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2

.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on pages 44-45 and 47-48 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 Code of Federal Regulations (CFR) Section 422.101.

The rules say that a long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).  

The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need medical care. You can find this rule in the Medicare Program Integrity Manual, Chapter 6, Section 6.5.2

.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
Appeal type: unknown
Decision: unknown

he 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 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 non medical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners;

2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that a Medicare plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the 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 38-45 of the plan's 2020 Evidence of Coverage
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the 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. There are limitation on the
number of covered services within a service category. Frequency limits vary depending on the time on covered
service. Some exclusions may apply. See the Plan's Dental Care Plan Information guide for details on covered
services. You can find this information on page 42 of the Plan's 2020 Evidence of Coverage (EOC).
The plan contact also states, for cost sharing information, refer to the Plan's Dental Plan Information Guide.
You can find this on page 62 of the Plan's 2020 EOC.
The patient charge for upper partial denture - cast metal framework with resin denture bases (including
retentive/clasping materials, rests, and teeth) (D5213) is $715. You can find this on page 12 of the Plan's 2020
Dental Plan Information Guide.
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 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 also say that for tele health distant site services furnished between January 27, 2020, and June 30, 2020 that are also FQHC qualifying visits, you must report 3 HCPCS/CPT codes: 

The FQHC Prospective Payment System (PPS) specific payment code (G0466, G0467,G0468, G0469, or G0470)

The HCPCS/CPT code that describes the services furnished via tele health with modifier95G2025 with modifier 95

You can find this information in the MLN Matters Number: SE20016.



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 rule
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 institutional providers, including home health agencies, use one of two institutional claim formats to bill Original Medicare. In the great majority of cases, these providers are required to use the electronic HIPAA standard institutional claim transaction, the 837I. The minority of providers that are eligible for an exception to electronic claim submission use the paper Form CMS-1450, also known as the UB-04. Effective for all services provided on or after October 1, 2000, all services under the home health plan of care are included in the home health PPS payment amount, aside from osteoporosis drugs and durable medical equipment. Other services not under an HH plan of care provided by an HHA are billed using type of bill 034X. You can find this information in the Medicare Claims Processing Manual, Chapter 10, Section 10.
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 medicalservice  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  for  any  DMEPOS item  to be covered  by Medicare,  the  patient's  medical  record must  containsufficient  documentation  of the patient's  medical  condition  to substantiate  the  necessity  for the  type and quantity  of  items  ordered and for  the  frequency  of use or replacement  (if  applicable).  The  information  should include  the  patient's  diagnosis  and other  pertinent  information  including,  but not  limited  to, duration  of the patient's  condition,  clinical  course  (worsening  or improvement),  prognosis,  nature  and extent  of functional limitations,  other  therapeutic  interventions  and results,  past experience  with  related  items,  etc. You  can find  this rule  in  the  Medicare  Program  Integrity  Manual,  Chapter  5, Section  5.7.The  rules  say that  as a condition  for  payment,  42 CFR 410.38 and Final  Rule  1713 (84 Fed. Reg  Vol  217) require  that  a treating  practitioner  have  a face-to-face  encounter  with  a beneficiary  within  the  six  (6) months prior  to prescribing  items  that  appear on the Required  List.  The  face-to-face  encounter  must  support  payment for  the item(s)  ordered/prescribed,  and be documented  in  the  pertinent  portion  of  the medical  record (for example,  history,  physical  examination,  diagnostic  tests, summary  of findings,  progress  notes,  treatment  plans or other  sources  of  information  that  may  be appropriate).  The  supporting  documentation  must  include subjective  and objective  beneficiary  specific  information  used for  diagnosing,  treating,  or managing  a clinical condition  for  which  the  DMEPOS is ordered. You  can find  this  rule  in  the  Local  Coverage  Article  for Standard Documentation  Requirements  for All  Claims  Submitted  to DME  MACs, A55426 (eff  04/06/20).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 ifregular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that you receive your care from a provider who is eligibleto provide services under Original Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. You can find this information on pages 40-41 of the plan's 2020 Evidence of Coverage
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that LCD L36523 denies coverage for all CV risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. You can find this rule in the Local Coverage Determination (LCD) for MolDX: Biomarkers in Cardiovascular Risk Assessment (L36523).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers itemsand services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. In general, preventive and routine dental services are not covered under Original Medicare. Your Plan's Supplemental Dental Benefit provides coverage for the dental services described in detail below. Any services not listed below are not covered. You can find this information on pages 4-55 to 4-59 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at42 Code of Federal Regulations (CFR) Section 422.101.The rules 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 orneurogenic 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 (L34995) -Effective December 1, 2019.The rules say that dual MBBs (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably high false positive rate of single MBB injections.  A second confirmatory MBB is allowed if documentation indicates the first MBB produced= 80% relief of primary (index) pain and duration of relief is consistent with the agent employed. You can find this rule in Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L34995) -Effective December 1, 2019.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical careand 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 46 and 49 of the Plan's 2020 Evidence of Coverage
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the 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 is limited to
services obtained from a provider in the Plan's dental vendor network. The contract says that services obtained
from vendors outside of this network are not covered. You can find this information on page 44 of the Plan's
2020 Evidence of Coverage (EOC).