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 Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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). 
 
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 for diagnostic and/or surveillance purposes, Colon Capsule Endoscopy (CCE) is medically 
necessary when either of the following criteria are met: 
1. Primary procedure in patients with major risks for Optical Colonoscopy (OC) or moderate sedation as 
indicated from an evaluation of the patient by a board certified or board eligible gastroenterologist, a 
surgeon trained in endoscopy, or a physician with equivalent endoscopic training and either of the 
following criteria are met: 
o Fecal Occult Blood Test (FOBT) positive (guaiac or immunochemical) OR 
o Multitarget Stool DNA (sDNA) Test positive OR 
o Other evidence of lower GI bleeding in hemodynamically stable patients 
2. Secondary procedure: 
? For the detection or surveillance of colon polyp(s) if the diagnostic OC was incomplete OR 
? When an incomplete diagnostic OC was performed for either: 
o Fecal Occult Blood Test (FOBT) positive (guaiac or immunochemical) OR 
o Multitarget Stool DNA (sDNA) Test positive OR 
o Other evidence of lower GI bleeding in hemodynamically stable patients 
Limitations 
 
The following are considered not medically reasonable and necessary: 
1. Patients with known or suspected gastrointestinal obstruction, stricture, or fistula. 
2. Patients with a cardiac pacemaker or another implanted electro-medical device that emits a 
radiofrequency or other interfering signal. 
3. Patients with swallowing disorder(s). 
4. Patients with a known contraindication or allergy to any medication or preparation agent used before or 
during the procedure. 
5. When performed in conjunction with CT Colonography (CTC). 
6. CCE is not a Medicare Benefit for colorectal cancer screening, regardless of family history or other risk 
factors for the development of colonic disease. Please refer to NCD 210.3 for colorectal cancer 
screening coverage. Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in 
this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and 
all existing CMS national coverage determinations, and all Medicare payment rules. 
 
The redetermination process may be utilized for consideration of services performed outside of the reasonable 
and necessary requirements in this LCD. 
You can find this information in the Colon Capsule Endoscopy (CCE) Local Coverage Determination (LCD) 
L38826. 
 
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 Plan 
contract says that enrollees must pay $0 copayment for in-network primary care provider and professional 
services. You can find this information in Chapter 4 on pages 77 to 78 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 there are some patients who require supplementation of their daily protein and caloric intake.
These nutritional supplements are often given as a medicine between meals to boost protein-caloric intake or
the mainstay of a daily nutritional plan. Medicare does not pay for nutritional supplements. You can find this
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare
National Coverage Determination Manual, Chapter 1, Section 180.2.
The rules state that for parenteral nutrition therapy to be covered under Part B, the claim must contain a
physician's written order or prescription and sufficient medical documentation to permit an independent
conclusion that the requirements of the prosthetic device benefit are met and that parenteral nutrition therapy is
medically necessary. An example of a condition that typically qualifies for coverage is a massive, small bowel
resection resulting in severe nutritional deficiency in spite of adequate oral intake. However, coverage of
parenteral nutrition therapy for this and any other condition must be approved on an individual, case-by-case
basis initially and at periodic intervals of no more than three months by the Medicare Administrative
Contractor (A/B MAC (B)) medical consultant or specially trained staff, relying on such medical and other
documentation as the A/B MAC (B) may require. If the claim involves an infusion pump, sufficient evidence
must be provided to support a determination of medical necessity for the pump. Program payment for the pump
is based on the reasonable charge for the simplest model that meets the medical needs of the patient as
established by medical documentation. Nutrient solutions for parenteral therapy are routinely covered.
However, Medicare pays for no more than one month's supply of nutrients at any one time. Payment for the
nutrients is based on the reasonable charge for the solution components unless the medical record, including a
signed statement from the attending physician, establishes that the beneficiary, due to his/her physical or
mental state, is unable to safely or effectively mix the solution and there is no family member or other person
who can do so. Payment will be on the basis of the reasonable charge for more expensive premixed solutions
only under the latter circumstances. You can find these rules in National Coverage Determination (NCD) for
Enteral and Parenteral Nutritional Therapy (160.2).
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 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 1 
comprehensive oral evaluation every 3 years. You can find this information on pages 84 to 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 payment for inpatient hospital services in made of the basis of a DRG (diagnosis related group). 
Hospitals must provide proper information about the patient (i.e., age, sex, discharge status, principal and 
secondary diagnoses, and procedures) in order for the correct DRG to be assigned. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 3, Section 20.2.1. 
 
The rule say that the circumstances of inpatient admission always govern the selection of principal diagnosis. 
The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as ?that condition 
established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for 
care.? For reporting purposes, the definition for ?other diagnoses? is interpreted as additional conditions that 
affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; 
or extended length of hospital stay; or increased nursing care and/or monitoring. The UHDDS item #11-b 
defines Other Diagnoses as 'all conditions that coexist at the time of admission, that develop subsequently, or 
that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which 
have no bearing on the current hospital stay are to be excluded.' You can find this information in the 
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines 
for Coding and Reporting, Sections II and III. 
 
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 Plan
contract says that enrollees must pay a $50 copayment for Part B drugs that are administered by an in-network
provider. You can find this information on page 95 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 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, Publication 100-02, 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. You 
can find this information on pages 69 to 70 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 proper coding is necessary on Medicare claims because the codes are generally used to 
determine coverage and payment amounts. CMS accepts only HIPPA approved ICD-9-CM or ICD-10-
CM/ICD-10-PCS codes, depending on the date of service. Use the diagnosis code that describes the patient?s 
diagnosis, symptom, complaint, condition or problem. Assign the code to the highest level of specificity. The 
"highest degree of specificity" refers to assigning the most precise code that most fully explains the narrative 
description of the symptom or diagnosis. You can find these rules in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 23, Sections 
10. 
 
The rules say Medicare is establishing limited coverage for CPT codes 51784, 51785, 90901, 90912, 90913, 
91117, and 91122. You can find this rule in the Centers for Medicare and Medicaid Services, Local Coverage 
Article: Billing and Coding: Anorectal Manometry, Anal Electromyography, and Biofeedback Training for 
Perineal Muscles and Anorectal or Urethral Sphincters (A56530). 
 
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 $5 copayment for specialist office or telehealth visits. You can find this 
information on page 79 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that all home health agencies (HHAs) must submit a Request for Anticipated Payments (RAP), 
which is to be paid at 0 percent, within five calendar days after the start of care and within five calendar days 
after the "from date" for each subsequent 30-day period of care. You can find this rule in 42 CFR, Section 
484.205. 
 
The rules say that when a home health agency does not file the required RAP for its Medicare patients within 
five calendar days after the end of each 30-day period of care, Medicare does not pay for those days of home 
health services based on the 'from date' on the claim to the date of filing of the RAP and the wage and case-
mix adjusted 30-day period payment amount is reduced by 1/30th for each day from the home health based on 
the 'from date' on the claim until the date of filing of the RAP. You can find this rule in 42 CFR, Section 
484.205. 
 
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 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 Plan contract includes a 
list of covered supplemental dental services. A limited oral evaluation and an implant removal are not included 
on the list and are not a covered benefit. You can find this information on pages 84-86 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 also says that 
you are covered for one comprehensive oral evaluation once every three plan years. You can find this 
information on pages 4-63 to 4-76 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. Gingival irrigation is not listed and therefore is not a covered service. 
Unspecified periodontal service is not listed and therefore is not a covered service. Take-home medication is 
not listed and therefore is not a covered service either. The contract also says any services not listed are not 
covered. You can find this information on pages 4-65 to 4-76 of the Plan?s 2021 Evidence of Coverage (EOC).