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 therapeutic continuous glucose monitors (CGMs) and related supplies are covered by 
Medicare when all of the following coverage criteria (1-6) are met: 
 
1.     The beneficiary has diabetes mellitus; 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 control and determined that criteria (1-4) above are met; and, 
 
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. 
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
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 $195 copayment per one-way trip for Medicare-covered ground 
ambulance services. You can find this information on page 63 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 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 used for 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 
as grab bars. 
 
You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 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 state that a heavy duty walker (E0148, E0149) is covered for beneficiaries who meet coverage 
criteria for a standard walker and who weigh more than 300 pounds. If an E0148 or E0149 walker is provided 
and if the beneficiary weighs 300 pounds or less, it will be denied as not reasonable and necessary. 
 
You can find these rules in the Local Coverage Determination (LCD) for Walkers, L33791. This LCD is 
effective for services provided on or after January 1, 2020. 
 
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

Please note, the Local Coverage Determination (L35000) the Plan used in their decision to deny services is not 
binding in this case. The ruling does not have jurisdiction where the services were provided.  
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 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 find this rule 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 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 $35 copayment for in-network Medicare covered vision services. You can 
find this information in Chapter 4 on pages 85 to 86 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. 
 
Post-stabilization care services means covered services, related to an emergency medical condition, that are 
provided after an enrollee is stabilized in order to maintain the stabilized condition, or to improve or resolve the 
enrollee's condition. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.113. 
 
The physician treating the enrollee must decide when the enrollee may be considered stabilized for transfer or 
discharge that decision is binding on the MA organization. You can find this rule at 42 Code of Federal 
Regulations (CFR) Section 422.113. 
 
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). 
 
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 there is a $250 deductible for out-of-network services. You can find this information in 
Chapter 4 on page 49 of the Plan's 2020 Evidence of Coverage (EOC). 
 
The Plan contract also says that after the $250 deductible has been met, enrollee's must pay 20% coinsurance 
for out-of-network lab tests. You can find this information in Chapter 4 on pages 77 - 78 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 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 ofthe 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 53 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that 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 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 pages 53 and 59-60 of the Plan's2020 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 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 52 and 55-56 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 all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The supplier should alsoobtain as much documentation from the patient's medical record as they determine they need to assure themselves that coverage criteria for an item have been met. If the information in the patient's medical record does not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has been obtained. You can find this rule in the Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10.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 20% coinsurance for Medicare-covered diagnostic procedures and tests. You can find this information on page 72 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 co payments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).

The rules say that a co payment 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 there are no cost-sharing charges for colorectal cancer screenings. A diagnostic colonoscopy is performed due to a previous colonoscopy resulting in polyp removal. You can find this information in Chapter 4 on pages 70 -71 of the Plan's 2020 EOC.

The Plan contract also says that enrollees must pay a $250 co payment for outpatient surgery. You can find this information in Chapter 4 on page 101 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 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).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 withMedicare 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 itsenrollees 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 $285 copayment each day for days 1 to 6with a $0 copayment for each additional day for inpatient hospital care. You can find this information on pages 4-26 to 4-29 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 a Medicare plan may not pay for services given by a physician or other practitioner who has
opted out of Medicare. This rule does not apply to emergency or urgently needed services. This rule applies to
all other services, as well as to supplemental benefits. A Medicare plan must pay for emergency or urgently
needed services given by a physician or practitioner who has not signed a private contract with the enrollee.
You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the Medicare Managed Care Manual,
Chapter 6, Section 60.2.
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 also says that while you can get your care from an out of network provider, the provider must be
eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to
participate in Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be
responsible for the full cost of the services you receive. Check with your provider before receiving services to
confirm that they are eligible to participate in Medicare. You can find this information on page 44 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 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 ofthe 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 55 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 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 $30 copayment for each Medicare-covered visit. You can find this information on page 88 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 2020 code book states that CPT codes S9502 and S9500 are under Statutory Exclusion. These codes arenot paid by Medicare when submitted on outpatient claims(for any outpatient bill type). Codes with astatus code of "I" are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. You can find this in the 2020 National Physician Fee Scheduleand the Medicare Claims Processing Manual, Chapter 23 -Fee Schedule Administration and Coding Requirements, Section 30.2.2.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.