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 pays for air ambulance services only if the enrollee's medical condition is such that transportation by either basic, the provision of medically necessary supplies and services or advanced life support, an emergency medical technician (EMT) intermediate or EMT-Paramedic ground ambulance is not appropriate. Air ambulance services may be covered only if:
1. certain vehicle and crew requirements are met;
2. the enrollee's medical condition needed immediate and rapid ambulance transport that could not have been provided by ground ambulance; and
3. either the point of pickup is not accessible by ground vehicle or great distances or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities.
You can find this rule in the Medicare Benefit Policy Manual, Chapter 10, Sections 10.4, and 10.4.1, and 30.1.1.
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 that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.

The rules say that the only valid parties to an appeal are an enrollee (or an appointed representative of an enrollee) or a non-contract provider who has completed a Waiver of Liability. In this case, records show that you are a contract provider with the Plan. You are requesting payment for services that you provided. Plan providers do not have appeal rights through the Medicare Managed Care Reconsideration Project. Therefore, we are dismissing this case. You may contact the Plan regarding any internal appeals process that the Plan may have.

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 network providers are the doctors and other health care professionals, medical groups, durable medical equipment (DME) suppliers, hospitals, and other health care facilities that have an agreement with us to accept the Plans payment and any plan cost-sharing as payment in full. You can see this on pages 8 and 9 of the 2020 Evidence of Coverage. 

The Plan contract says that prior authorization is required for DME services. You can see this on page
59 of the 2020 Evidence of Coverage. 

As the year has changed since this appeal began, the 2021 Evidence of Coverage should also be reviewed for rules regarding prior authorization for DME.
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 TENS unit for chronic low back pain is only covered when t he beneficiary is enrolled in 
an approved clinical study. You can find this rule in National Coverage Determination (NCD) for 
Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP) (160.27) - Effective 
June 8, 2012. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The Plan contract does not 
list crowns and core buildup as covered benefits. You can find this information on pages 80-83 of the 2020 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes one 
problem-focused oral evaluation (D0140) per plan year and one bitewing x-ray (D0270) per plan year. You can 
find this information on pages 4-61 to 4-62 of the Plan?s 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered. You can find this rule at Local Coverage Article: Wheelchair 
Options/Accessories - Policy Article (A52504) (eff. 1/1/20). 
 
The rules say that 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. Code E2313 is separately billable in addition to an expandable controller both at initial 
issue and with complete replacement of the expandable controller. Code K0108 must not be used for any 
component or feature of an expandable controller at the time of initial issue. The reimbursement for any type of 
complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. However, if 
individual components of the harness are replaced, code K0108 should be used. You can find this rule at Local 
Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504) (eff. 1/1/20). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item 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 services for the purposes of preventing conception, including services performed because a 
physician believes pregnancy would endanger the overall general health of the woman, are not considered to be 
reasonable and necessary for the diagnosis or treatment of illness or injury within the meaning of Section 
1862(a)(1) of the Social Security Act. Therefore, these services are not covered. You can find this rule at 
Medicare National Coverage Determinations Manual Section 230.3. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(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 state that RFA of the facet joint nerves may be covered when dual diagnostic facet joint injections 
produce 80% or higher pain relief. Repeat denervation procedures involving the same joint will only be 
considered medically necessary if the patient experienced at least 50% improvement in pain and functional 
status for at least six months. You can find this information in the Local Coverage Determination (LCD): Facet 
Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L35936). 
 
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 for ambulance services that meet certain origin and destination requirements. 
Medicare will cover the following ambulance transportation: 
1. From any point of origin to the nearest hospital or skilled nursing facility (SNF) capable of furnishing 
appropriate care for a patient?s illness or injury; 
2. From a hospital or SNF to a patient?s home; 
3. From a SNF to the nearest supplier of medically necessary services not available at the SNF where the 
patient resides, including the return trip; and 
4. For a patient receiving renal dialysis for end stage renal disease, from the patient?s home to the nearest 
facility that furnishes renal dialysis, including the return trip. 
 
You can find these rules at Code of Federal Regulations (CFR) Section 410.40(f). 
 
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 Medicare Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 43 and 46 of the Plan's 
2020 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 SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract lists the dental 
services that are covered. Intraoral complete series x-ray is not listed and therefore is not covered. This benefit 
includes a 50% coinsurance for dental services that you receive out of network. The contract also says benefits 
received out of network are subject to any in network benefit maximums, limitations, and/or exclusions. You 
may be billed by the out of network provider for any amount greater than the payment made by the Plan to the 
provider. You can find this information on page 94 of the Plan?s 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $40 copayment for services obtained from an in-network specialist, or 
under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician 
health care professionals in a specialist's office. You can find this information on pages 4-51 to 4-57 of the 
Plan's 2020 EOC. 
 
The Plan contract also says that enrollees must pay a $14 copayment for each in-network Medicare-covered 
standard x-ray. You can find this information on pages 4-37 to 4-31 of the Plan's 2020 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 providers must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(A). 
 
The rules state that when completing the 1500 claim form, providers must enter the correct Place of Service 
(POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider.  You 
can find this rule at Medicare Claims Processing Manual Ch. 26 ?10.6. 
 
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 state that program reimbursement for HBO therapy will be limited to that which is administered in a 
chamber (including the one man unit) and is limited to the following conditions: 
 
    1. Acute carbon monoxide intoxication, 
    2. Decompression illness, 
    3. Gas embolism, 
    4. Gas gangrene, 
    5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in 
combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened. 
    6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an 
adjunctive treatment when loss of function, limb, or life is threatened. 
    7. Progressive necrotizing infections (necrotizing fasciitis), 
    8. Acute peripheral arterial insufficiency, 
    9. Preparation and preservation of compromised skin grafts (not for primary management of wounds), 
   10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, 
   11. Osteoradionecrosis as an adjunct to conventional treatment, 
   12. Soft tissue radionecrosis as an adjunct to conventional treatment, 
   13. Cyanide poisoning, 
   14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to 
antibiotics and surgical treatment, 
   15. Diabetic wounds of the lower extremities in patients who meet the following three criteria: 
        - Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; 
        - Patient has a wound classified as Wagner grade III or higher; and 
        - Patient has failed an adequate course of standard wound therapy. 
 
You can find this information National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy 
(20.29). 
 
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 $325 copayment for outpatient surgery, including services provided at 
hospital outpatient facilities. You can find this information in Chapter 4 on page 96 of the Plan's 2020 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 SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract includes a list of covered supplemental dental services. Problem focused limited oral evaluation and 
preventive procedure are not included on this list and are not covered supplemental benefits. You can find this 
information on pages 89 and 90 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that TENS is not reasonable and necessary for the treatment of CLBP under section 
1862(a)(1)(A) of the Act. You can find this rule in the National Coverage Determination (NCD) for 
Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP) (160.27). 
 
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 $10 copayment for each in-network covered laboratory service. (This 
copayment may not apply if you visit a PCP or specialist on the same date of service that the laboratory service 
was performed, and you plan has an office visit copayment for that visit).. You can find this information on 
pages 75 to 77 of the Plan's 2020 EOC.