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 state that on March 22, 1994, CMS considered MRS an investigational procedure and issued a
national non-coverage determination for all indications of MRS. CMS has determined that the evidence is not
adequate to conclude that MRS is reasonable and necessary within the meaning of section 1862(a)(1)(A) of the
Social Security Act, for use in the diagnosis of brain tumors. Therefore, CMS reaffirms its current national
non-coverage determination for all indications of MRS. You can find this rule in the National Coverage
Determination (NCD) for Magnetic Resonance Spectroscopy (220.2.1).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
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).
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 we cover more vision care than what Medicare covers, but you must use a doctor in our vision
network. 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 molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage when ALL
of the following criteria are met:
-Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are
unavailable or results are clearly equivocal; AND
-Availability of a clinically valid test, based on published peer reviewed medical literature; AND
-Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed test) or
LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) of analytical
validity and clinical utility; AND
-Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND
-For testing panels, including but not limited to, multiple genes or multiple conditions, and in cases where a
tiered approach/method is clinically available, testing would be covered ONLY for the number of genes or test
that are reasonable and necessary to obtain necessary information for therapeutic decision making; AND
-Individual has not previously received genetic testing for the disease/condition. (In general, diagnostic genetic
testing for a disease should be performed once in a lifetime.) Exceptions include clinical scenarios whereby
repeat testing of somatically-acquired mutations (for example, pre- and post- therapy) may be required to
inform appropriate therapeutic decision-making.
You can find this rule in Local Coverage Determination (LCD): Molecular Pathology Procedures (L35000) -
Effective July 1, 2020.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

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 specifically listed dental services/codes as a supplemental (extra) benefit. This benefit
does not include coverage for the denture being requested, nor does it list CPT code D5226 as a covered
service. You can find this information on pages 20-29 of the Plan's 2020 Preventive and Comprehensive
Dental Coverage Customer Handbook.
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. The contract says that we cover the following services when medically necessary and based on the benefit limitations and clinical criteria described in the Office Manager Reference Manual (ORM) found online. You can find this information on page 66 of the Plan's 2020 Evidence of Coverage (EOC).
The contract also says that provisions for a fixed prosthesis may be considered when there is one missing maxillary anterior tooth or two missing mandibular anterior teeth and the member's overall status would justify consideration. The placement of a fixed prosthetic appliance will only be considered for the anterior segment of the mouth in those exceptional cases where there is a documented physical or neurological disorder that would preclude placement of a removable prosthesis, or in those cases requiring cleft palate stabilization. You can find this information on page 305 and 311 of the Plan's 2020 Office Reference Manual.
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 implantation of an infusion pump is contraindicated in the following patients:-With a known allergy or hypersensitivity to the drug being used (e.g., oral baclofen, morphine, etc.);or,-Who have an active infection; or,-Whose body size is insufficient to support the weight and bulk of the device; or,-With other implanted programmable devices since crosstalk between devices may inadvertently change the prescription.You can find this rule in National Coverage Determination (NCD) for Infusion Pumps (280.14) -Effective December 17, 2004.The rules say that infusion pumps are medical devices used to deliver solutions containing parenteral drugs under pressure at a regulated flow rate. Determinations may be made on coverage of other uses of implanted infusion pumps if the MAC medical staff verifies that:-The drug is reasonable and necessary for the treatment of the individual patient;-It is medically necessary that the drug be administered by an implanted infusion pump; and,-The Food and Drug Administration-approved labeling for the pump must specify that the drug being administered and the purpose for which it is administered is an indicated use for the pump.You can find this rule in National Coverage Determination (NCD) for Infusion Pumps (280.14) -Effective December 17, 2004.
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. Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718) - Continued coverage of a PAP device (E0470 or E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy. For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is demonstrated by: 1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive sleep apnea are improved; and, 2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner.
Adherence to therapy is defined as use of PAP 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as not reasonable and necessary. 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 facet joint blocks will be considered reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. Facet joint block is one of the methods used to document/confirm suspicions of posterior element biomechanical pain of thespine. Hallmarks of posterior element biomechanical pain are:-The pain does not have a strong radicular component.-There is no associated neurological deficit and the pain is aggravated by hyperextension, rotation or lateral bending of the spine, depending on the orientation of the facet joint at that level.You can find this rule in Local Coverage Determination (LCD): Paravertebral Facet Joint Blocks (L33930) -Effective January 8, 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 state that, effective for dates of service on or after October 9, 2014, the Cologuard test is covered
once every three years for Medicare beneficiaries that meet all of the following criteria:
- Age 50 to 85 years, and,
- Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower
gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test (gFOBT) or fecal
immunochemical test (iFOBT)), and,
- At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal
cancer, or inflammatory bowel disease, including Crohn's Disease and ulcerative colitis; no family
history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary
nonpolyposis colorectal cancer).
All other indications for colorectal cancer screening not otherwise specified in the Act and regulations, or
otherwise specified above remain nationally non-covered. You can find these rules in National Coverage
Determination (NCD) for Colorectal Cancer Screening Tests (210.3).
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 say that providers must report services correctly. Procedures should be reported with the 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.
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 $265 copayment for surgery services at an in-network outpatient hospital. You can find this information on page 79 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 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 health
plan contract says that only certain codes/services are covered under the Plan. The EOC lists specific services
which are a covered benefit and any service not listed in this section is not a covered benefit. You can find this
information in Chapter 4 on page 72-73 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 a Medicare plan may restrict members to a network of providers in order to receive innetwork
cost sharing 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.
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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for a person who meets the following criteria: 1.The person must have a personal mobility deficit; 2.The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, groomingand bathing in customary locations within the home; 3.The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and4.The person must be capable of safely operating the PMD. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.3(B).
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 $0 copayment per day, days 1-20 and a $150 copayment per day,
days 21-100 for SNF care. You can find this information in Chapter 4 on page 77 of the plan's 2020 Evidence
of Coverage.
The health plan contract says that as a member of the Plan, the most you will have to pay out-of-pocket for innetwork
covered Part A and Part B services in 2020 is $3,000.The amounts you pay for copayments and
coinsurance for in-network covered services count toward this maximum out-of-pocket amount. (The amount
you pay for your plan premium does not count toward your maximum out-of-pocket amount.) In addition,
amounts you pay for some services do not count toward your maximum out-of-pocket amount. These services
are marked with an asterisk in the Medical Benefits Chart. If you reach the maximum out-of-pocket amount of
$3,000, you will not have to pay any out-of-pocket costs for the rest of the year for in-network covered Part A
and Part B services. However, you must continue to pay your plan premium and the Medicare Part B premium
(unless your Part B premium is paid for you by Medicaid or another third party).You can find this information
in Chapter 4 on page 44 of the plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in
the Medicare Managed Care Manual, Chapter 1, Section 20.2.
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 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 in Chapter 3 on page 49 of the
plan's 2020 Evidence of Coverage.
The health plan contract says that enrollees must pay 100% for out-of-network dental services. You can find
this information in Chapter 4 on pages 87-89 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 health
plan contract says you have a $1,000 calendar year benefit maximum (the most the Plan pays for covered
dental services each calendar year). You can find this information in Chapter 4 on page 104 of the plan's 2019
Evidence of Coverage.