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 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 $275 copayment for outpatient hospital services including diagnostic radiology. You can find this information on pages 95-99 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 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 your combined in-network and out-of-network medical deductible is $250. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. You can find this information on pages 4-2 to 4-4 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 Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL the following criteria:

1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale*
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative management (as tolerated)
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity.

You can find this rule at Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L38803) (eff. 4/25/21).

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 special supplemental benefits for the chronically ill (SSBCI) applies to a chronically ill enrollee who is enrolled in the Medicare Advantage (MA) plan who has one or more comorbid and medically complex chronic conditions that meet all of the following: 

(1) Is life threatening or significantly limits the overall health or function of the enrollee;

(2) Has a high risk of hospitalization of other adverse health outcomes; and 

(3) Requires intensive care coordination. You can find this rule at 42 CFR Section 422.102(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. The contract says that to be eligible for these additional benefits, you must meet the following requirements: You must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. You can find this information on pages 99 to 102 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 the Cologuard test is covered for Medicare beneficiaries aged 50-85 years. You can find this rule in Local Coverage Article: Billing and Coding: Colorectal Cancer Screening - Medical Policy Article (A52378) - Effective October 1, 2019.

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, 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 partial dentures once every 5 plan years. You can find this information on page 4-63 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 a seat lift mechanism is covered if all of the following are met: 

1. The enrollee must have severe arthritis of the hip or knee or have a severe neuromuscular disease. 

2. The seat lift mechanism must be a part of the treating practitioner's course of treatment and be prescribed to improve, or stop deterioration of, the enrollee's condition. 

3. The enrollee must be completely unable to stand up from a regular armchair or any chair in the home. 

4. Once standing, the enrollee must have the ability to walk. 

You can find this information in the Local Coverage Determination (LCD): Seat Lift Mechanisms (L33801).

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 special supplemental benefits for the chronically ill (SSBCI) applies to a chronically ill enrollee who is enrolled in the Medicare Advantage (MA) plan who has one or more comorbid and medically complex chronic conditions that meet all of the following: 

(1) Is life threatening or significantly limits the overall health or function of the enrollee; 

(2) Has a high risk of hospitalization of other adverse health outcomes; and 

(3) Requires intensive care coordination. 

You can find this rule at 42 CFR Section 422.102(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. The contract says that o be eligible for these additional benefits, you must meet the following requirements: You must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning - see the list of applicable conditions below. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. You can find this information on pages 115 to 119 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 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, 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 page 98 of the Plan's 2021 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, 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. Removal of torus mandibularis is not listed and therefore is not a covered service. The contract also says that any services not listed are not covered. 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 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 a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the panel. You can find this rule in Local Coverage Article: Billing and Coding: MolDX: Testing of Multiple Genes (A58120).

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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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 page 39 of the Plan's 2021 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 the following indications for electrocardiographic services are covered nationally unless otherwise indicated:

1. Computer analysis of EKGs when furnished in a setting and under the circumstances required for coverage of other EKG services. 
2. EKG services rendered by an IDTF, including physician review and interpretation. Separate physician services are not covered unless he/she is the patient's attending or consulting physician. 
3. Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance at the time the service is performed or immediately thereafter. 
4. Home EKG services with documentation of medical necessity. 
5. Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications described below, when performed with equipment meeting the standards described below, subject to the limitations and conditions specified below. Coverage is further limited to the amounts payable with respect to the physician's service in interpreting the results of such transmissions, including charges for rental of the equipment. 

The device used by the beneficiary is part of a total diagnostic system and is not considered DME separately. Covered uses are to:

a. Detect, characterize, and document symptomatic transient arrhythmias; 
b. Initiate, revise, or discontinue arrhythmic drug therapy; or, 
c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); (only if 24-hour coverage is provided).

Certain uses other than those specified above may be covered if, in the judgment of the local Medicare Administrative Contractor (MAC), such use is medically necessary. You can find this rule in National Coverage Determination (NCD) for Electrocardiographic Services (20.15) - Effective August 26, 2004.

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 home blood pressure monitors and home blood pressure cuffs are considered home dialysis supplies. These items are only covered for patients on home dialysis. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 8, Section 90.3.2(A). 

The rules also say that ambulatory blood pressure monitoring (ABPM) may be covered in some instances. This service involves the use of a non-invasive device which is used to measure blood pressure in 24-hour cycles. These 24-hour measurements are stored in the device and are later interpreted by the physician. ABPM is only covered for those patients with suspected white coat hypertension. Suspected white coat hypertension is defined as:

1. Office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit; 
2. At least two documented blood pressure measurements taken outside the office which are <140/90 mm Hg; and 
3. No evidence of end-organ damage. 

You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National Coverage Determination (NCD) for Ambulatory Blood Pressure Monitoring (20.19).

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, 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 maximum plan benefit coverage amount of $500 per year, which applies to all supplemental (i.e., routine) dental services covered by the plan. You are responsible for any cost above the $500 maximum. You can find this information on page 82 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 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 to benefit from an intensive rehabilitat ion 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 complete independence 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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.