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 an expandable controller is capable of accommodating one or more of the following
additional functions:
1. Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin
control, head control, etc.)
2. Non-proportional input devices (e.g., sip and puff, head array, etc.)
3. Operate 3 or more powered seating actuators through the drive control.
An expandable controller may also be able to operate one or more of the following:
4. A separate display (i.e., for alternate control devices)
5. Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's
drive control)
6. An attendant control
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting
hardware.
Codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more
of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional
interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation,
power seat elevation, power standing. It includes a function selection switch which allows the beneficiary to
select the motor that is being controlled and an indicator feature to visually show which function has been
selected. When the wheelchair drive function has been selected, the indicator feature may also show the
direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate
display box or may be integrated into the wheelchair interface.
You can find this information in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article
(A52504).
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

You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare may cover medically accepted off-label uses for Food and Drug Administration (FDA) approved drugs used in an anti-cancer chemotherapeutic regimen. Medicare maintains a list of compendia which define if a use is medically accepted. The off-label use must be supported in one or more of these compendia or in published, peer-reviewed medical literature. An off-label use must be supported in one or more of the compendia and the use must not be listed as unsupported, not indicated, not recommended, or equivalent terms, in any of the compendia. An off-label use may also be determined by the carrier in the state to be reasonable and necessary. You can find these rules and the list of the Medicare-recognized compendia in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.5.
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 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. You can find this information
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare
Program Integrity Manual, Chapter 15, Section 15.1.
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. The Plan
contract also says that while you can get your care from an out-of-network provider, the provider must be
eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to
participate in 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. Check with your provider before receiving services to
confirm that they are eligible to participate in Medicare. You can find this information on page 42 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 that surgical dressings are covered when a qualifying wound is present. A qualifying wound is defined as either of the following: -A wound caused by, or treated by, a surgical procedure; or, -After debridement of the wound, regardless of the debridement technique. You can find this rule in the Local Coverage Article (LCA) - Surgical Dressings - Policy Article (A54563) - Effective May 1, 2021. The rules say that self-adherent bandages (A6454) and conforming bandages (A6446) are covered when they are used to hold wound cover dressings in place over any wound type i.e., as a secondary dressing over a qualified wound. You can find this rule in the Local Coverage Article (LCA) - Surgical Dressings - Policy Article (A54563) - Effective May 1, 2021. The rules say that impregnated gauze dressings (A6456) are woven or non-woven materials into which substances such as iodinated agents, petrolatum, zinc paste, crystalline sodium chloride, chlorhexidine gluconate (CHG), bismuth tribromo (BTP), water, aqueous saline, hydrogel, or other agents have been incorporated into the dressing material by the manufacturer. These codes are not to be used for gauze dressings containing substances that are not recognized as effective dressing materials such as silver, honey, copper, cadexomer iodine, charcoal, or other similar materials (not all-inclusive). You can find this rule in the Local Coverage Article (LCA) - Surgical Dressings - Policy Article (A54563) - Effective May 1, 2021.
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, Publication 100-16, 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 under certain circumstances, members may obtain services from out-of-network providers. Newly eligible members who are undergoing an existing course of treatment under the care of an out-of-network provider at the time of eligibility may continue to obtain services from that provider for up to forty-five (45) days or until treatment can be transitioned to an in-network provider. Out-of-network providers with members under a current treatment plan have up to forty-five (45) days to notify the health plan and request authorization of services, as appropriate according to the plan benefits. Once the health plan is notified that the member is under the care of an out-of-network provider, the provider must submit a request for authorization. All supporting clinical information must be provided to substantiate the continuation of the requested service(s). You can find this information on page 56 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 that a status indicator of I represents a code that is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. You can find this rule in Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30.2.2.
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 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 pays only for ambulance transport. Ambulance vehicles must be designed and
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens,
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other lifesaving
equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You
can find this rule at 42 CFR Section 410.41(a).
The rules say that plans may offer a supplemental benefit to provide transport not covered by original
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the
doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3.
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 contract
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit
covers up to 48 one-way trips are covered per calendar year (limited to ground transportation only). Each oneway
trip must not exceed 50 miles of driving distance. You can find this information on page 4-56 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, Publication 100-16, 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 43 of the Plan's 2021.
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, Publication 100-02, 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 does not include an intraoral complete series of radiographic images. You can find this information on pages 72-73 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 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, Publication 100-02, 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. 2-surface resin based composite on a posterior tooth is not listed as a covered dental service. You can find this information on pages 122 to 133 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 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, Publication 100-02, 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 an intraoral periapical radiographic image once per calendar year. You can find this information on pages 93-94 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 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, Publication 100-02, 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 does not list custom fabricated abutments, abutment supported crowns, or pontic as covered services. If a service is not listed, it is not covered. You can find this information on pages 4-76 to 4-80 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 a Medicare plan may restrict members to a network of providers if 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 page 8 and 9 of the 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 that providers must report services correctly. Procedures should be reported with the Current
Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the
Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for
Medicare Services, Chapter I(A).
The rules say that all line items for the same beneficiary, same NPI, and same date of service shall be subject to
NCCI Procedure-to-Procedure (PTP) edits. If the correct coding modifier indicator (CCMI) of a PTP edit is
"0," the Column Two code is not eligible for payment even if an NCCI PTP-associated modifier is
appropriately appended to one of the codes. If the CCMI of a PTP edit is "1," the edit may be bypassed, and the
Column Two code of the edit may be eligible for payment if an NCCI PTP-associated modifier is appropriately
appended to one of the codes. You can find this rule in the Centers for Medicare and Medicaid Services,
Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9.1.1
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 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 $90 copayment for Medicare-covered ambulance services per day for Ambulance Services. You can find this information on page 67 of the Plan's 2020 Evidence of Coverage (EOC).