Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).

The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that enrollees must pay a $30 copayment for x-rays. You can find this information on page 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 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 $395 copayment for each Medicare covered outpatient hospital visit after
you meet the $395 deductible. You can find this information on page 85 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 plans may choose the networks of providers available to enrollees and may require enrollees
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in
the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual,
Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care
and services. The only exceptions are emergencies, urgently needed care when the network is not available
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan
authorizes the use of out-of-network providers. You can find this information on pages 44-52 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 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(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 60 one-way trips per calendar year. You can find this information on pages 4-57 and 4-58 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. This benefit does not list
limited oral exams as a covered service. You can find this information on page 84 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual,
Chapter 1, Section 20.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that the Plan will cover services from either in-network or out-of-network providers, as long as
the services are covered benefits and medically necessary. You can find this information on pages 10 to 11 of
the Plan's 2021 EOC.

The Plan contract also says that enrollees don't need to get a referral or prior authorization to get care from outof-
network providers. You can find this information on page 56 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.
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 that the Plan covers eyeglass frames and eyeglass lenses including single, bifocal, trifocal, and lenticular lenses. You can find this information on page 101 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 state that TENS is covered for chronic, intractable pain other than chronic low back pain when all of the following criteria are met: 1. The presumed etiology of the pain must be a type that is accepted as responding to TENS therapy. Examples of conditions for which TENS therapy is not considered to be reasonable and necessary are (not all-inclusive): headache, visceral abdominal pain, pelvic pain, temporomandibular joint (TMJ) pain 2. The pain must have been present for at least three months. Chronic Low Back Pain (CLBP) TENS therapy for is only covered when all of the following criteria are met: 1. The beneficiary has an approved diagnosis. 2. The beneficiary is enrolled in an approved clinical study that meets all of the requirements set out in NCD  160.27. These rules can be found in Local Coverage Determination (LCD): Transcutaneous Electrical Nerve Stimulators (TENS) (L33802).
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 only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b). Vertebral axial decompression is performed for symptomatic relief of pain associated with lumbar disk problems. The treatment combines pelvic and/or cervical traction connected to a special table that permits the traction application. There is insufficient scientific data to support the benefits of this technique. Therefore, VAX-D is not covered by Medicare. You can find this information in National Coverage Determination (NCD) for Vertebral Axial Decompression (VAX-D) (160.16). S codes are a set of Healthcare Common Procedure Coding System (HCPCS) codes. The codes are listed by the Centers for Medicaid & Medicare Services (CMS), but they are never for use on claims filed to Medicare. S codes have a coverage code of I, Not Payable by Medicare.
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 only manual manipulation of the spine to correct subluxation is covered by the Plan. You can find this information on page 65 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. Section 1861(s)(2) of the Social Security Act extends coverage to oral anti-emetic drugs that are used as full replacement for intravenous dosage forms of a cancer regimen under the following conditions: a. Coverage is provided only for oral drugs approved by the Food and Drug Administration (FDA) for use as anti-emetics; b. The oral anti-emetic must either be administered by the treating physician or in accordance with a written order from the physician as part of a cancer chemotherapy regimen; c. Oral anti-emetic drugs administered with a particular chemotherapy treatment must be initiated within 2 hours of the administration of the chemotherapeutic agent and may be continued for a period not to exceed 48 hours from that time; d. The oral anti-emetic drugs provided must be used as a full therapeutic replacement for the intravenous anti-emetic drugs that would have otherwise been administered at the time of the chemotherapy treatment. You can find this information in Chapter 15 - Covered Medical and Other Health Services, 50.5.4 - Oral Anti-Nausea (Anti-Emetic) Drugs.
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 0623 is for Medical/Surgical Supplies. Only service units and a charge must be reported with this revenue code.If also reporting revenue code 027x to identify nonroutine supplies other than those used for wound care, the HHA must ensure that the charge amounts for the two revenue code lines are mutually exclusive. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 10, 40.2. The rules say that the fifth position of the HIPPS code indicates a severity group for non-routine supplies (NRS). The HH PPS grouper software assigned each episode into one of 6 NRS severity levels and created the fifth position of the HIPPS code with the values S through X. If the HHA was aware that supplies were not provided during an episode, they changed this code to the corresponding number 1 through 6 before submitting the claim. You can find this information in the CMS Division of Institutional Claims Processing Definition and Uses of Health Insurance Prospective Payment System Codes (HIPPS Codes). The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid information for all of these elements may be returned as unprocessable. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 1, Section 80.3.1.
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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes a Calendar Year Maximum of up to $1,000. The Plan contract also says that you must pay a 50% coinsurance for Class 3 Major Services, which includes root canal treatment. You can find this information on pages 110 to 112 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 for patients enrolled in a Medicare Advantage Plan in 2020 and 2021, submit COVID-19 vaccine administration claims to Original Medicare through your Medicare Administrative Contractor (MAC). Use your patients' Medicare Beneficiary Identifiers (MBIs) (not their Medicare Advantage Plan Member IDs) to bill Original Medicare.
The rules also say that Original Medicare pays for COVID-19 vaccines. All COVID-19 vaccine claims for Medicare enrollees should be submitted to fee-for-service (FFS) Medicare. You can find these rules in the CMS publication located at https://www.cms.gov/medicare/covid-19/medicare-billing-covid-19-vaccine-shot-administration
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 thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet ALL the following criteria: a. Initial thermal radiofrequency ablation (RFA): i. After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used) AND ii. Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale; Frequency Limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L35936).
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 state Medicare cannot cover services which are not reasonable and necessary for the treatment of illness or injury or to improve the functioning of a malformed body member. The following interventional treatments are not considered medically reasonable or necessary and are denied as such: 

Interventional treatment of symptomatic varicosities without documentation of a failed six week trial ofconservative therapy. 
Sclerotherapy for vessels larger than 4 mm in diameter. 
Reinjection following recanalization or failure of vein closure without recurrent signs or symptoms. 
Sclerotherapy of the saphenous vein at its junction with the deep system. 
Noncompressive sclerotherapy. 
Compressive sclerotherapy for large, extensive or truncal varicosities.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 1, Section 20.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that as a member of our plan, you can choose to receive care from out-of-network providers.
However, please note providers that do not contract with us are under no obligation to treat you, except in
emergency situations. Our plan will cover services from either network or out-of-network providers, as long as
the services are covered benefits and are medically necessary. However, if you use an out-of-network provider,
your share of the costs for your covered services may be higher. You don't need to get a referral or prior
authorization when you get care from out-of-network providers. You can find this information on pages 57-58
of the Plan's 2021 EOC.