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 at42 Code of Federal  Regulations  (CFR) Section 422.101.The  rules  say that  Medicare  payment  for  home  use of  the air-fluidized  bed for treatment  of pressure  sores can be made  if  such  use is  reasonable  and necessary  for the  individual  patient.  A decision  that  use  of an air-fluidized  bed is  reasonable  and necessary  requires  that:-The patient  has a stage  3 (full  thickness  tissue  loss)  or stage  4 (deep tissue  destruction)  pressure  sore;-The patient  is bedridden  or chair  bound  as a result  of severely  limited  mobility;-In the absence  of an air-fluidized  bed, the patient  would  require  institutionalization;-The air-fluidized  bed is  ordered in  writing  by the patient's  attending  physician  based upon  a comprehensive assessment  and evaluation  of the  patient  after  completion  of a course  of conservative  treatment  designed  to optimize  conditions  that  promote  wound  healing.  This  course  of treatment  must  have  been at least  one month  in duration  without  progression  toward wound  healing.  This  month  of  prerequisite  conservative  treatment  may include  some  period  in  an institution  as long  as there  is  documentation  available  to verify  that  the necessary conservative  treatment  has  been rendered.-Use of  wet-to-dry dressings  for wound  debridement,  begun  during  the period  of  conservative  treatment  and which  continue  beyond  30 days,  will  not preclude  coverage  of air-fluidized  bed. Should  additional  debridement again  become necessary,  while  a patient  is  using  an air-fluidized  bed (after  the first  30-day course  of conservative  treatment)  that  will  not cause  the air-fluidized  bed to become  non-covered.  In all  instances documentation  verifying  the continued  need  for the  bed must  be available.-A trained  adult  caregiver  is  available  to assist  thepatient  with  activities  of daily  living,  fluid  balance,  dry skin care, repositioning,  recognition  and management  of altered  mental  status,  dietary  needs,  prescribed  treatments, and management  and support  of the  air-fluidized  bed system  and its  problems  such  as leakage;-A physician  directs  the home  treatment  regimen,  and reevaluates  and recertifies  the  need for  the air-fluidized bed on a monthly  basis;  and-All  other  alternative  equipment  has been considered  and ruled  out.You  can find  this  rule  in  National  Coverage  Determination  (NCD) for  Air-Fluidized  Bed (280.8) -Effective November  1, 2000.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.The Appeal Number is:1-9614280226The Appeal Number is:1-9614280226
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1.The rules say that a contract plan provider is an agent of the plan. Services and referrals obtained from a plan provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service. For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 160.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 $35 copay perMedicare-covered outpatient rehab services. You can find this information on pages 77-78 of the Plan's 2020 Evidence of Cove
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, 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. Plan provides some coverage for preventative dental services when purchased as an optional supplemental benefit. You can find this on Page 81 of the Plan's 2019 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 itin 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 comprehensive oral evaluation (D0150) and is limited to one procedure every three plan years. You can find this information on page 4-54 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,  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 9 of  the 2020 Evidence  of Coverage.  The  Plan  contract  says  that  outpatient  mental  health  care requires  prior  authorization. You  can see this  on page  74 of the 2020 Evidence  of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41.

The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 30.3.

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 contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers 36 one-way trips every year to plan approved locations. You can find this information on page 101 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare 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 coverage of 1 root canal procedure per calendar year. The benefit does not include coverage of cone beam three-dimensional imaging. You can find this information on page 81 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 at42 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,  and cases in  which  the Plan authorizes  the use  of out-of-network  providers.  You  can find  this  information  on page 1-8 of  the 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare 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. Unspecified preventive procedure is not included on this list and is not a covered supplemental benefit. You can find this information on pages 87 and 88 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 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).Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426): As a condition for payment, 42 CFR 410.38 and Final Rule 1713 (84 Fed. Reg Vol 217) require that a treating practitioner have a face-to-face encounter with a beneficiary within the six (6) months prior to prescribing items that appear on the Required List. The face-to-face encounter must support payment for the item(s) ordered/prescribed, and be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, progress notes, treatment plans or other sources of information that may be appropriate). The supporting documentation must include subjective and objective beneficiary specific information used for diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.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 $20 copayment for lab services at an in-network freestanding laboratory.
You can find this information on pages 76 and 77 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:1-9716712626The Appeal Number is:1-9716712626
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 Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1.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 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 a $300
allowance per year for preventive dental services. You can find this information on page 68 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 at42 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 arenot 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 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.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 8 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 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 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 a 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 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 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 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 Plancontract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $25 copayment for each specialist visit. You can find this information in Chapter 4 on page 97 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)

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.