Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that Medicare Advantage Plans may not make payment directly or indirectly for Medicare covered services furnished to a Medicare beneficiary by a physician or practitioner who has opted out of Medicare except in cases involving emergency or urgent care services furnished to a beneficiary who has not previously entered into a private contract with the physician or practitioner. You can find this rule at 42 CFR 422.220 and in the Medicare Benefit Policy Manual, Chapter 15, Section 40.37.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Health Plan contract also says that if you receive care from 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 page 49 of the Plan's 2019 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 417.414.
The rules say that except for emergency and urgently needed services, Cost plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. You can find this rule at 42 CFR 417.448(a).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that you generally must receive care from an in-network provider for the Plan to cover services. If the Plan does not cover services received from an out-of-network provider, the services will be covered by Original Medicare if they are Medicare-covered services. Except for emergency or urgently needed services, if you get services covered by Original Medicare from an out-of-network provider then you must pay Original Medicare's cost-sharing amounts. You can find this information in Chapter 3 on pages 27 to 28 of the Plan's 2019 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that 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, and9. screening electrocardiograms10. certain other testing recommended by the United States Preventive Services Task Force and approved by CMSYou can find this rule at 42 CFR 411.15(a)(1) and 42 CFR ?410.64.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that sacroiliac (SI) joint injections would be considered medically reasonable and necessary for the diagnosis and/or treatment of chronic low back pain that is considered to be secondary to suspected sacroiliac joint dysfunction. Diagnostic and therapeutic injections of the SI joint would not likely be performed unless conservative therapy and noninvasive treatments (i.e., rest, physical therapy, NSAIDs, etc.) have failed. You can find this rule at Local Coverage Determination (LCD): Pain Management (L33622) (eff. 10/1/19).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical serviceor item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that a Medicare plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR 422.112(a)(3).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 8 of the Plans 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 at42 CFR 422.101.The patient's medical records must establish medical necessity for a hospital bed due to one of the following reasons:1. The patient's condition requires positioning of the body; e.g., to alleviate pain, promote good body alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or 2. The patient's condition requires special attachments that cannot be fixed and used on an ordinary bed. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.7(A).In order to qualify for a semi-electric hospital bed, the patient's condition must require frequent change in body position and/or there may be an immediate need for a change in body position (i.e., no delay can be tolerated) and the patient can operate the controls and cause the adjustments. Exceptions may be made to this last requirement in cases of spinal cord injury and brain damaged patients. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.7(D).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 417.414.The rules statethat payment may not be made for items and services furnished by a provider of service or agency of the Federal government. Federal providers are excluded from participation in the Medicare program. You can find this information in the Medicare Benefit Policy Manual, Chapter 16, Section 50.2.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR 422.111(a) and (b).The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR 422.2.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contractsays that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs. You can find this information in Chapter 4 on page 77 of the Plan's 2019Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that 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, and9. screening electrocardiograms10. certain other testing recommended by the United States Preventive Services Task Force and approved by CMSYou can find this rule at 42 CFR 411.15(a)(1) and 42 CFR 410.64.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that Medicare pays for home health careservices under a prospective payment system (HH PPS). Home health services under a plan of care are paid based on a 60-day episode of care. Payment for home health care episodes is usually made in two parts. To receive the first part of the HH PPS split payment, the home health agency must submit a Request for Anticipated Payment (RAP). Specific data elements are required to submit a RAP. The home health agency must enter the claim -Outcome and Assessment Information Set (OASIS) matching key output by theGrouper software. This is known as the Treatment Authorization Code. You can find this rule, a list of the data elements, and instructions for the Treatment Authorization Code in the Medicare Claims Processing Manual, Chapter 10, Section 40.1.The rules say that after a RAP has been paid and a 60-day episode has been completed or the enrollee has been discharged, the home health agency must submit a claim to receive the rest of payment due for the episode. You can find this rule and detailed instructions for the claim in the Medicare Claims Processing Manual, Chapter 10, Section 40.2.The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid information for all of these elements may be returned as unprocessable. You can find this rule in the Medicare Claims Processing Manual, Chapter 1, Section 80.3.1.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR 422.2.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $65 copayment for each Medicare-covered urgent care visit received at an urgent care facility. You can find this information on page 34 of the Plan's 2019 Schedule of Cost Sharing.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 CFR 422.101.
The rules say that facet Joint Interventions are considered medically reasonable and necessary for the diagnosis
and treatment of chronic pain in patients who meet ALL of the following criteria:
- Duration of pain of at least three (3) months
- Pain is intermittent or continuous with average pain levels of 6 or greater on a visual-numerical analogue pain
scale (VNAS) of 0 to 10 (primary [index] pain), or functional disability
- Documented failure to respond to conservative care such as nonsteroidal anti-inflammatory drugs (NSAIDS),
acetaminophen, physical therapy for a minimum of 6 weeks (as tolerated)
- History of pain that is predominantly axial and, with the possible exception of facet joint cysts, not associated
with radiculopathy or neurogenic claudication
- Physical examination with documented signs that the facet joint is the primary suspected source of pain
- There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of
the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity
You can find this rule in the Local Coverage Determination for Facet Joint Interventions for Pain Management,
L34892 (eff 11/21/19).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR 422.2.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $10 copayment for Part B prescription drugs when purchased through a retail pharmacy and 15% coinsurance for Part B drugs that are administered by a provider. You can find this information in Chapter 4 on page 93 of the Plan's 2019 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR 422.111(a) and (b).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that there is a $1,340 deductible for inpatient hospital care. You can find this information in Chapter 4 on page 56 of the Plan's 2019 Evidence of Coverage. The Plan contract also says that after the $1,340 deductible has been met, enrollee's pay a $0 copayment for days 1-60 for inpatient hospital care. You can find this information in Chapter 4 on pages 68 - 69 of the Plan's 2019 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who: 1. Require stabilization for medical reasons, and, 2. Have the potential to benefit functionally. These rules can be found in the Local Coverage Determination (LCD): Ankle-Foot/Knee-Ankle-Foot Orthotics (L33686).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item ifregular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that Medicare pays for therapeutic continuous glucose monitors (CGMs) when they are medically reasonable and necessary. Therapeutic CGMs are defined in CMS Ruling 1682R. You can find these rules in Local Coverage Article A52464, effective on and after January 12, 2017.CGMs consist of three components: a glucose sensor, a transmitter, and a receiver. CGMs are considered therapeutic CGMs if they are:-approved by the FDA for use in place of a blood glucose monitor for making diabetes treatment decisions (for example, changes in diet and insulin dosage);-generally not useful to the individual in the absence of an illness or injury;-appropriate for use in the home; and-those which include a durable component that can withstand repeated use, are expected to last at least three years, and are capable of displaying the trending of the continuous glucose measurements.The rules also say that a CGM which does not replace a blood glucose monitor for making diabetes treatment decisions is not covered. You can find these rules in CMS Ruling 1682R.The rules say therapeutic CGMs and related supplies are covered by Medicare when all of the following coveragecriteria (1-6) are met:1.The beneficiary has diabetes mellitus (Refer to the "ICD-10 Codes that are Covered" section of the LCD-related Policy Article for applicable diagnoses); and,2.The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and,3.The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and,4.The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,5.Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes controland determined that criteria (1-4) above are met; and,6.Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.When a therapeutic CGM (code K0554) is covered, the related supply allowance (code K0553) is also covered. If any of coverage criteria (1-6) are not met, the CGM and related supply allowance will be denied as not reasonable and necessary.Youcan find this rule in the Local Coverage Determination (LCD): Glucose Monitors (L33822) effective January 1, 2019.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR 422.111(a) and (b).The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR 422.2.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $30 copayment for outpatient rehabilitation services. You can find this information in Chapter 4 on page 32 of the Plan's 2019 Evidence of Coverage.The Plan contract also says that enrollees must pay 20% coinsurance for prosthetic devices and related supplies. You can find this information in Chapter 4 on page 39 of the Plan's 2019 Evidence of Coverage
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that only services not covered by Original Medicare may be covered under supplemental benefits. You can find this rule at CMS Managed Care Manual Ch. 4 30.The rules say that health plans may offer mandatory supplemental benefit coverage for home infusion services and supplies. You can find this rule at CMS Medicare Prescription Drug Benefit Manual Ch. 6 10.12.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at42 CFR 422.101.The rules say that an expandable controller is capable of accommodating one or more of the following additional functions:-Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.)-Non-proportional input devices (e.g., sip and puff, head array, etc.)-Operate 3 or more powered seating actuators through the drive control. (Note: Controlof the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)You can find this rule in Local Coverage Article: Wheelchair Options/Accessories -Policy Article (A52504) -Effective January 1, 2020.The rules say that an expandable controller may also be able to operate one or more of the following:-A separate display (i.e., for alternate control devices)-Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control)-An attendant controlYou can find this rule in Local Coverage Article: Wheelchair Options/Accessories -Policy Article (A52504) -Effective January 1, 2020.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules