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 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 lifesaving
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(a).
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 Centers for Medicare and Medicaid
Services, Internet Only Manual, 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 up to 20 one-way trips to plan-approved locations every year. You can find this information on page 64
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 high frequency chest wall oscillation devices (HFCWO) (E0483) are covered for
beneficiaries who meet:

A. Criterion 1, 2, or 3, and
B. Criterion 4
1. There is a diagnosis of cystic fibrosis.
2. There is a diagnosis of bronchiectasis which has been confirmed by a high resolution, spiral, or
standard CT scan and which is characterized by:

a. Daily productive cough for at least 6 continuous months; or
b. Frequent (i.e., more than 2/year) exacerbations requiring antibiotic therapy.
c. Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of
a confirmed diagnosis of bronchiectasis do not meet this criterion.

3. The beneficiary has one of the following neuromuscular disease diagnoses:
a. Post-polio
b. Acid maltase deficiency
c. Anterior horn cell diseases
d. Multiple sclerosis
e. Quadriplegia
f. Hereditary muscular dystrophy
g. Myotonic disorders
h. Other myopathies
i. Paralysis of the diaphragm

There must be well-documented failure of standard treatments to adequately mobilize retained secretions. If all
of the criteria are not met, the claim will be denied as not reasonable and necessary. It is not reasonable and
necessary for a beneficiary to use both a HFCWO device and a mechanical in-exsufflation device (E0482).
Replacement supplies, A7025 and A7026, used with beneficiary owned equipment, are covered if the
beneficiary meets the criteria listed above for the base device, E0483. If these criteria are not met claims will be
denied as not reasonable and necessary. You can find these rules in Local Coverage Determination (LCD) High
Frequency Chest Wall Oscillation Devices (L33785).

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 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 also obtain 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10.

The rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient's diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. You can find this rule in the Medicare Program Integrity Manual, Chapter 5, Section 5.7.

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 $120 emergency room copayment. You can find this information on page 64 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 Prometheus IBD sgi Diagnostic test is denied as not medically necessary. You can find this rule in the Local Coverage Determination (LCD) L37299: MolDX: Prometheus IBD sgi Diagnostic Policy (eff. 1/30/18).
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 says that for
services obtained out-of-network the Plan only pays up to a certain amount. If you choose to see an out-ofnetwork
dentist you might be billed for any amount greater than what the plan pays. The contract also says that
a comprehensive exam (D0150) is covered once every three plan years, a prophylaxis is covered two
procedures per plan year, fluoride application (D1208) is covered two procedures per plan year, bitewing xrays
(D0274) are covered once per plan year, and the intraoral x-rays (D0220 and D0230) are not covered
benefits. You can find this information on pages 4-55 to 4-58 of the Plan's 2021 Evidence of Coverage (EOC).
The dental contract you enrolled in on March 1, 2021 says that a crown (D2740) is covered one procedure per
tooth every five plan years with 50% coinsurance. You can find this information on page 4-67 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 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 $750 annual deductible. 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 of your covered services. Once you have paid your deductible, we will begin to pay our share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the calendar year. Additionally, enrollees pay a $125 copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You can find this information on pages 67 and 101 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 the correct coding edit table contains edits which are pairs of HCPCS/CPT codes that in
general should not be reported together. Each edit has a column one and column two HCPCS/CPT code. If a
provider reports the two codes of an edit pair, the column two code is denied, and the column one code is
eligible for payment. You can find this rule in the National Correct Coding Initiative Policy Manual for
Medicare Services, Chapter 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 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). 

The rules also say that code 81479 is used to report Guardant360 testing. You can find this rule in Local Coverage Article: Billing and Coding: Guardant360? (A58192).

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 does not pay for hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d).
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 hearing aids are not covered under any condition. You can find this information on page 106 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.
Medicare may cover the use of a Food and Drug Administration (FDA) approved drug or biological if it is safe
and effective and otherwise reasonable and necessary for the patient. FDA-approved drugs used for indications
other than what is indicated on the official label may be covered if the use is determined to be medically
accepted, taking into consideration the major drug compendia, authoritative medical literature and/or accepted
standards of medical practice. You can find this rule in the Centers for Medicare and Medicaid Services,
Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Sections 50.4.1 and 50.4.2.
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).
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that enrollees must pay a $200 copayment for in-network outpatient surgery. You can find this
information on page 90 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. The contract says that only dental services from a network provider are covered. You can find this information on pages 84 and 85 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 Medicare Part B generally does not pay for drugs that are usually self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are: 

1. blood-clotting factors; 
2. drugs used in immunosuppressive therapy;
3. erythropoietin for dialysis patients; 
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs; 
6. oral anti-emetics used in certain situations; 
7. drugs treated as supplies during an outpatient hospital procedure; and 
8. drugs required for the effective use of durable medical equipment. 

You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.

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.
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 Group 2 POVs (K0806, K0807, K0808) have added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary. You can find this in the Local Coverage Determination (LCD): Power Mobility Devices (L33789).
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 Parts C & D Enrollee Grievances,
Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1.
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. The health
plan contract says Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts.
You can find this information in Chapter 4 on page 91 of the plan's 2020 Evidence of Coverage.
The health plan contract says that enrollees must pay any amount over $75 for out-of-network routine eye exam
(1 per calendar year) eye exam will include refraction and dilation. Your routine exam charge will not exceed
$75 at a Network supplemental optical provider. Please inform the network provider that you are part of the
supplemental vision vendor network. When using an out-of-network provider, you will be responsible for costs
above the plan approved amount. You are responsible for submitting a supplemental vision vendor out-ofnetwork
claim form with itemized receipt when seeing a non-supplemental vision provider. You can find this
information in Chapter 4 on page 96 of the plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. The rules also say that Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. This rule does not apply to: 1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed; 2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL; and 3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with an IOL. You can find this rule at 42 CFR Section 411.15(b). Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR Section 411.15(c).
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 offers a supplemental routine vision and eyewear benefit. One routine eye exam including refraction and dilation is provided. A $200 benefit is provided toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses at a network optical provider (1 per calendar year). You can find this information on page 89 of the Plan's 2020 Evidence of Coverage (EOC).