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.

Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. This rule does not apply to:

1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed; 

2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL; and 

3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with an IOL. 
You can find this rule at 42 CFR Section 411.15(b).

Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR Section 411.15(c).

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 LASIK surgeries or other laser procedures are not covered by the Plan. You can find this information on page 4-83 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 supplier of a covered item of durable medical equipment (DME) may not contact an 
individual by telephone regarding the furnishing of a covered item to the individual unless: the individual has 
given written permission to the supplier to make contact by telephone regarding the furnishing of a covered 
item; or, the supplier has furnished a covered item to the individual and the supplier is contacting the individual 
only regarding the furnishing of such covered item, or another covered item to this same individual within 15 
months. If a supplier knowingly contacts an individual in violation of this prohibition, no payment may be 
made for any item subsequently furnished to the individual by the supplier. You can find this information in the 
Social Security Act, Section 1834(a)(17). 
 
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 on pages 51-53 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 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. The rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for patients with suspected or documented cardiovascular disease. You can find this Medicare guidance in the Medicare Local Coverage Article: Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57559), Local Coverage Determination (LCD): MolDX: Biomarkers in Cardiovascular Risk Assessment (L36523), Code of Federal Regulation 42 CFR 410, Subpart B - Medical and Other Health Services (screening tests).
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 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.

The rules say that CPT Code 81445 Targeted genomic sequence analysis panel, solid organ neoplasm, DNA
analysis, and RNA analysis when performed, 5-50 genes (EG, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT,
KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants
and copy number variants or rearrangements, if performed is considered not medically necessary except when
used to guide treatment decision making in individuals with non-small cell lung cancer (please refer to LCD
L37810). You can find this information in Medicare's Local Coverage Article: Billing and Coding: Molecular
Pathology Procedures (A56199).

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 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. The rules say that to receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. You can find this rule in 42 Code of Federal Regulations (CFR) Section 424.505 Basic Enrollment Requirements.
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 health plan contract says that you can see any provider (network or out-of-network) at the same cost share, as long as they accept the plan and have not opted out of or been excluded or precluded from the Medicare Program. You can find this information in Chapter 3 on page 3-3 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 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 health plan contract says that enrollees must pay a $15 copayment for each covered visit or consultation in an outpatient location with a specialist. Covered services include: Virtual check-ins (for example, by phone or video chat) with your doctor for 5-10 minutes if: You're not a new patient and; The check-in isn't related to an office visit in the past 7 days and; The check-in doesn't lead to an office visit within 24 hours or the soonest available appointment. Evaluation of video and/or images you send to your doctor, and interpretation and follow-up by your doctor within 24 hours if: You're not a new patient and; The evaluation isn't related to an office visit in the past 7 days and; The evaluation doesn't lead to an office visit within 24 hours or the soonest available appointment. You can find this information in Chapter 4 on page 100 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 CGS considers one iStent, iStent inject, or Hydrus device per eye medically reasonable and necessary for the treatment of adults with mild or moderate open-angle glaucoma and a cataract when the individual is currently being treated with an ocular hypotensive medication and the procedure is being performed in conjunction with cataract surgery. In that setting these procedures offer a reduction in IOP, decreased dependence on glaucoma medications, and an excellent safety profile. However, their role within the glaucoma treatment algorithm continues to be clarified and differs from the role of more invasive, external filtration glaucoma surgeries such as trabeculectomy or external aqueous drainage implants. Therefore, all other indications are considered not reasonable and necessary at this time. There is no additional payment for multiple stents (so-called "dosing"), regardless of method, since a statistical benefit has not been demonstrated (27), especially in conjunction with cataract surgery. You can find this information in the Local Coverage Determination (LCD): Micro-Invasive Glaucoma Surgery (MIGS) (L37578).
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 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 life-saving 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, 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 24 one-way transportation trips per calendar year. You can find this information on page 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 the following list of individuals and entities frequently attempt to enroll in Medicare but are
not eligible to do so. If the contractor receives an enrollment application from any of these individuals or
entities, the contractor shall deny the application, with the exception of entities eligible to enroll using the Form
CMS-20134, which is specific to the furnishing of MDPP services. An assisted living facility, for example, that
also provides the DPP and is eligible to enroll as an MDPP supplier may enroll through the CMS-20134,
however, this enrollment only pertains to the rendering of MDPP services. These providers are Acupuncturist,
Assisted Living Facility, Birthing Center, Certified Alcohol and Drug Counselor, Certified Social Worker,
Drug and Alcohol Rehabilitation Counselor, Hearing Aid Center/Dealer, Licensed Alcoholic and Drug
Counselor, Licensed Massage Therapist , Licensed Practical Nurse, Licensed Professional Counselor,
Marriage Family Therapist , Master of Social Work, Mental Health Counselor, National Certified Counselor,
Occupational Therapist Assistant, Physical Therapist Assistant, Registered Nurse, and Speech and Hearing
Center. You can find this in the Medicare Program Integrity Manual Chapter 15 - Medicare Enrollment
Suppliers Not Eligible to Participate (Rev. 765; Issued: 01-08-18; Effective: 01-01-18; Implementation: 01-19-
18) section 15.4.8.

The rules say that Medicare has created a crosswalk of taxonomy codes that links the types of providers and
suppliers who are eligible to apply for enrollment in the Medicare program with the appropriate Healthcare
Provider Taxonomy Codes. Claim eligibility will be based on the submission of the appropriate codes. You can
find this in the Data.CMS.Gov Crosswalk Medicare Provider/Supplier to Healthcare Provider Taxonomy.

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.
A Pneumatic Compression Device (PCD) that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a preventative service or function are excluded from coverage under the Medicare DME benefit. You can find this information at Local Coverage Article: Pneumatic Compression Devices - Policy Article (A52488) related to Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).
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 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 health
plan contract says that enrollees must pay a $200 copayment for a ambulatory surgery visit. You can find this
information in Chapter 4 on page 90 of the plan's 2020 Evidence of Coverage.
The health plan contract says that enrollees must pay 20% of the cost for Part-B covered chemotherapy drugs
and other Part-B covered drugs. You can find this information in Chapter 4 on page 86 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 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 Plan
contract includes a list of covered supplemental dental services. Panoramic x-ray (D0330) is not included on
this list and is not a covered supplemental benefit. You can find this information on pages 86 and 87 of the
Plan's 2020 Evidence of Coverage.

The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit
includes resin-based composite (D2331), and you must pay a 50% coinsurance when the service is provided innetwork.
You can find this information on page 85 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 may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Sections 422.2 and 422.136.
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. The health plan contract says that Rituxan is subject to step therapy. There must be a trial and failure of the plan's preferred step therapy drug - Ruxience. You can find this rule in the plan's step therapy policy.
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 for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare
Program Integrity Manual Chapter 3  3.3.2.1.

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.