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 health
plan contract says that enrollees must pay a $60 copayment for each Medicare-covered radiation therapy
service. You can find this information in Chapter 4 on pages 4-31 to 4-34 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 PGx tests are indicated when medications are being considered for use (or already being
administered) that are medically necessary, appropriate, and approved for use in the patient's condition and are
known to have a gene(s)-drug interaction that has been demonstrated to be clinically actionable as defined by
the FDA (PGx information required for safe drug administration) or Clinical Pharmacogenetic Implementation
Consortium (CPIC) guidelines (category A and B).

The selection of the medications in question must be derived from clinical factors/necessity rather than from a
PGx test. Once the putative therapeutic agents are selected, and those agents are known to have gene-drug
interactions as identified above, then a PGx test may be considered reasonable and necessary when the result of
that test is necessary for the physician's decision-making process regarding safely administering or dosing the
drug.

PGx testing is not considered reasonable and necessary merely on the basis of a patient having a particular
diagnosis. Unless the record reflects that the treating clinician has already considered non-genetic factors to
make a preliminary drug selection, PGx testing is not considered reasonable and necessary.

You can find this rule at Local Coverage Determination (LCD): MolDX: Pharmacogenomics Testing (L38394)
(eff. 8/3/20).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that claims or claim lines that have been determined to be exact duplicates of another claim or
claim line are denied. An exact duplicate for physician and other supplier claims submitted to a MAC or carrier
is a claim or claim line that exactly matches another claim or claim line with respect to the following elements:

- Medicare beneficiary identifier;
- Provider Number;
- From Date of Service;
- Through Date of Service;
- Type of Service;
- Procedure Code;
- Place of Service; and
- Billed Amount.

You can find this rule in the Center for Medicare and Medicaid Services, Internet Only Manual, Medicare
Claims Processing Manual, Chapter 1, Section 120.2.

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.
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 quantity of ostomy supplies needed by a beneficiary is determined primarily by the type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will be variation according to individual beneficiary need and their needs may vary over time. The table below lists the maximum number of items/units of service that are usually reasonable and necessary. The actual quantity needed for a particular beneficiary may be more or less than the amount listed depending on the factors that affect the frequency of barrier and pouch change. 

The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the beneficiary's medical record. If adequate documentation is not provided when requested, the excess quantities will be denied as not reasonable and necessary.

The usual maximum quantity of supplies for irrigation sleeves (A4397) is four per month. You can find this rule at Local Coverage Determination (LCD): Ostomy Supplies (L33828) (eff. 1/1/20).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that an inpatient admission is generally appropriate when the admitting physician expects the patient to need hospital care that crosses at least two midnights. The expectation should be based on such complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and medical risk. The factors must be documented in the medical record. 

If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as "inpatient only" is generally appropriate, regardless of the length of stay. An inpatient admission may be appropriate if the admitting physician expects a patient to require hospital care for only a limited period of time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be supported by the medical record. You can find this rule at 42 CFR Section 412.3. 

The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 

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.
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 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 Centers for Medicare and
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance Manual, Section 50.12.1.

The rules also say that Part B covers mental health services and visits with these types of health professionals:

Psychiatrist or other doctor
Clinical psychologist
Clinical social worker
Clinical nurse specialist
Nurse practitioner
Physician assistant

You can find this information in Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare
Benefit Policy Manual Chapter 15, Sections 160 to 210.

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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1. 

The rules also say that Part B covers mental health services and visits with these types of health professionals: 

Psychiatrist or other doctor 
Clinical psychologist 
Clinical social worker 
Clinical nurse specialist 
Nurse practitioner 
Physician assistant 

You can find this information in Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual Chapter 15, Sections 160 to 210.

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 crowns once per tooth, per 60 months. You can find this information on page 82 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 Indications and Limitations of Coverage: A form-fitting conductive garment (and medically
necessary related supplies) may be covered under the program only when: 1. It has received permission or
approval for marketing by the Food and Drug Administration; 2. It has been prescribed by a physician for use
in delivering covered TENS or NMES treatment; and 3. One of the medical indications outlined below is met:
The patient cannot manage without the conductive garment because there is such a large area or so many sites
to be stimulated and the stimulation would have to be delivered so frequently that it is not feasible to use
conventional electrodes, adhesive tapes and lead wires; The patient cannot manage without the conductive
garment for the treatment of chronic intractable pain because the areas or sites to be stimulated are inaccessible
with the use of conventional electrodes, adhesive tapes and lead wires; The patient has a documented medical
condition such as skin problems that preclude the application of conventional electrodes, adhesive tapes and
lead wires; The patient requires electrical stimulation beneath a cast either to treat disuse atrophy, where the
nerve supply to the muscle is intact, or to treat chronic intractable pain; or, The patient has a medical need for
rehabilitation strengthening (pursuant to a written plan of rehabilitation) following an injury where the nerve
supply to the muscle is intact. A conductive garment is not covered for use with a TENS device during the trial
period specified in Section 160.3 unless: 4. The patient has a documented skin problem prior to the start of the
trial period; and 5. The B/Medicare Administrative Contractor's medical consultants are satisfied that use of
such an item is medically necessary for the patient. You can find this information in Medicare's National
Coverage Determination (NCD) for Supplies Used in the Delivery of Transcutaneous Electrical Nerve
Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES) (160.13).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).

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 there is a $250 deductible that applies towards certain items and services. Laboratory pathology work is not excluded from the deductible. You can find this information on page 1 of the Plan's 2020 Schedule of Cost Sharing.

The Plan contract also says enrollees must pay 20% of the cost for Medicare-covered laboratory services. You can find this information on pages 20 to 21 of the Plan's 2020 Schedule of Cost Sharing.
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 spinal orthosis (L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651) is covered when it is ordered for one of the following indications: 

To reduce pain by restricting mobility of the trunk; or 

To facilitate healing following an injury to the spine or related soft tissues; or 

To facilitate healing following a surgical procedure on the spine or related soft tissue; or 

To otherwise support weak spinal muscles and/or a deformed spine. If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary. 

You can find this rule at Local Coverage Determination (LCD): Spinal Orthoses: TLSO and LSO (L33790).

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 $30 copayment for each Medicare-covered visit with a specialist. Additionally, enrollees must pay a $150 copayment for Medicare-covered outpatient hospital surgery services. You can find this information on pages 95 and 98 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 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. You may receive your care from either an in-network or out-of-network dentist. If you use an out-of-network dentist, your share of the cost may be higher. The Plan requires 55% coinsurance for amalgams, up to two procedure codes per calendar year, when received from an out-of-network provider. You can find this information on pages 94 - 95 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). 

The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $40 copayment for each Medicare-covered outpatient mental health care individual or group therapy visit. You can find this information on pages 79-80 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 state that a Group 3 Multiple Power Option power wheelchair is covered if the beneficiary meets
coverage criteria for a power tilt and recline seating system. You can find this rule at Local Coverage
Determination (LCD): Power Mobility Devices (L33789).

A power seating system - tilt only, recline only, or combination tilt and recline - with or without power
elevating leg rests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:

1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility
Devices LCD; and

2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical
therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in
rehabilitation wheelchair evaluations of the beneficiary's seating and positioning needs. The PT, OT,
or practitioner may have no financial relationship with the supplier; and

3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional
(ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection
for the beneficiary.

4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional
weight shift; or

5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently
transfer from the wheelchair to bed; or

6. The power seating system is needed to manage increased tone or spasticity.

If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.

You can find this rule at Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792).

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. The contract lists the dental services that are covered. Topical application of fluoride is not listed and therefore is not a covered service. This benefit includes 1 complete series x-ray or panoramic x-ray every 3 years. You can find this information on pages 69 to 70 of the Plan's 2021 Evidence of Coverage (EOC).