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

The rules say that plans must pay fora medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that a Medicare plan may restrict members to a network of providers 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 Section 422.112(a)(3).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers 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 29 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  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 Section  422.112(a)(3).If  youwant  to read these  Medicare  rules,  you  can go to this  website www.medicareappeal.com.The  Plan  contract  says that  the  Plan  covers  items  and services  in  accordance  with  Medicare  rules. The  Plan contract  says that,  with  limited  exceptions,  members  of the  Plan  must  use network  providers  to get  medical  care and services.  The  only  exceptions  are emergencies,  urgently  needed  care when  the  network  is  not available (generally,  when  the enrollee  is out  of the  area), out-of-area  dialysis  services,  and cases in  which  the Plan authorizes  the use  of out-of-network  providers.  You  can find  this  information  on page 40 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 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 $200 copayment  for outpatient  hospital  observation.  You can find  this information  on page 91 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  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).The  rules  say that  services  that  are not  medically  necessary  are not covered.  The  rules  also  say that experimental  and investigational  devices  are notcovered.  You can find  this  rule  at 42 CFR Sections  411.15 and 411.15(o).The  rules  also  say that  the  provider,  supplier,  or beneficiary,  as appropriate,  must  furnish  to the  intermediary  or carrier  sufficient  information  to determine  whether  payment  is  due and the amount  of  payment.  You can  find this  rule  at 42 CFR, Section  424.5.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, Section  3.3.2.1.If  you  want  to read these  Medicare  rules,  you  can go to this  websitewww.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 $200 copayment for surgery services in an outpatient hospital facility. You can find this information 79 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.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).The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).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 says covered, non-routine dental care is limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. You can find this information on page 87of the Plan's 2020Evidence 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 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 say that miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific HCPCS code and are not included in another code should be coded K0108. You can find this information in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). The rules say that 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.
Appeal type: unknown
Decision: unknown

he 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 20% coinsurance for Medicare Part B prescription drugs. You can find this information on pages 79-80 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 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 servicethat 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 lab services. You can find this information in Chapter 4 on page 69 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 Appeal Number is:1-9668917606The Appeal Number is:1-9668917606
The rules say that CT scans are covered if there is literature to support its use for the patient's condition and the scan is reasonable and necessary for the patient. You can find this rule in the Medicare National Coverage Determinations Manual, Section 220.1(A).The rules say that for purposes of Medicare coverage of lung cancer screening with low dose computed tomography (LDCT), beneficiaries must meet all of the following eligibility criteria:1. Age 55 -77 years;2. Asymptomatic (no signs or symptoms of lung cancer);3. Tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes);4. Current smoker or one who has quit smoking within the last 15 years; and5. Receive a written order for lung cancer screening with LDCT. Written orders for lung cancer LDCT screenings must be appropriately documented in the beneficiary's medical records, and must contain the following information:-Beneficiary date ofbirth;-Actual pack -year smoking history (number);-Current smoking status, and for former smokers, the number of years since quitting smoking;-Statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer); and-National ProviderIdentifier (NPI) of the ordering practitioner.You can find this rule in National Coverage Determination (NCD) for Lung Cancer Screening with Low Dose Computed Tomography (LDCT) (210.14) -Effective February 5, 2015.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 Medi
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 pay for durable medical equipment that is mainly used to serve a medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly usedfor medical purposes. Medicare will not pay for:1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners;2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1. The rules say that Telephone Alert Systems are non-covered because they are emergency communications systems and do not serve a diagnostic or therapeutic purpose. You can find this information in the National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1).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 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 Section 422.112(a)(3).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, andcases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 29 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 Medicarewill 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 asa supplemental (extra) benefit. The contract lists the specific dental services that are covered. Periapical x-rays are not listed and therefore are not covered services. Incision and drainage of an abscess 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 4-72 to 4-75 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 state that oximeters (E0445) and replacement probes (A4606) will be denied as non-covered because they are monitoring devices that provide information to the treating practitioner to assist in managing the beneficiary's treatment. You can find this information in the Local Coverage Article: Oxygen and Oxygen Equipment - Policy Article (A52514).
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 at42 Code of Federal  Regulations  (CFR) Section 422.101.The  rules  say that  Medicare  will  pay for an  IRF admission  when  the  services  are reasonable  and medically necessary.  The  patient  must  require  an intensive  and coordinated  interdisciplinary  approach to providing rehabilitation.  The  patient  must  need active  and ongoing  treatment  by more  than  one therapy  discipline.  One of the  therapies  must  be physical  therapy  or occupational  therapy.  The  patient  must  need and be expected  to actively  participate  in  and tobenefit  from  an intensive  rehabilitation  therapy  program.  This  intensive rehabilitation  therapy  program  generally  consists  of at least  three  hours  of therapy  per day  at least  five  days per week. The  patient  does not need to be expected  to achieve  completeindependence  in  self-care  nor  be expected to return  to his  or her  prior  level  of functioning.  The  patient  must  need supervision  by a rehabilitation physician.  The  physician  must  see the  patient  at least  three  days  per week throughout  the  stay. You  can find these  rules  in  the  Medicare  Benefit  Policy  Manual,  Chapter  1, Sections  110.2 and 110.2.5 and  at 42 CFR Section  412.622.If  you  want  to read these  Medicare  rules,  you  can go to this  website www.medicareappeal.com.ThePlan  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 Code of Federal Regulations (CFR) Section 422.101.Therules 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 11-12 of the Plan's 2020 EOC
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 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, cementumof 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 a $200 allowance per year for preventive dental services. You can find this information on page 70 of the Plan's 2020 Evidence of Coverage (EOC)