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 $295 copayment per day for days 1-7 for inpatient hospital care. You
can find this information on pages 78-79 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 there is no separate charge for medical supplies routinely used in the course of an office visit and included in the provider's charges for that visit (such as bandages, cotton swabs, and other routine supplies.) However, supplies for which an appropriate separate charge is made by providers (such as chemical agents used in certain diagnostic procedures), are subject to separate cost sharing. The contract says that enrollees must pay 20% coinsurance for medical supplies. You can find this information on page 4-30 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 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 state that institutional providers, including home health agencies, use one of two institutional claim formats to bill Original Medicare. In the great majority of cases, these providers are required to use the electronic HIPAA standard institutional claim transaction, the 837I. The minority of providers that are eligible for an exception to electronic claim submission use the paper Form CMS-1450, also known as the UB-04. You can find this information in the Centers for Medicare and Medicaid Services Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 10(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 state that a skin protection seat cushion (E2603, E2604, E2622, E2623) is covered for a beneficiary who meets both of the following criteria: The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and The beneficiary has either of the following (a or b): Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface; or Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift. You can find this information in the Local Coverage Determination L33312: Wheelchair Seating. The rules say that elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if: The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
The beneficiary has significant edema of the lower extremities that requires an elevating legrest; or The beneficiary meets the criteria for and has a reclining back on the wheelchair. You can find this information in the Local Coverage Determination L33792: Wheelchair Options/Accessories.
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 for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. You can find this rule at Local Coverage Determination (LCD) L34892: Facet Joint Interventions for Pain Management (eff. 4/25/21).
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 coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. Local Coverage Determination (LCD) for MolDX: Biomarkers in Cardiovascular Risk Assessment (L36358)
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 $200 copayment per day for days 1-5 for inpatient hospital care. You can find this information on page 70 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 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, Publication 100-16, 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 30 one-way trips per calendar year. 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 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 say that coverage of services incident to the professional services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct supervision of auxiliary personnel. Direct supervision in the office setting means the physician must be present in the office suite and immediately available and able to provide assistance and direction throughout the time the service is performed. The rules also say that Therapy services provided and billed incident to the services of a physician/NPP also must meet all incident-to requirements in Section 60 of Chapter 15 of the Benefit Policy Manual. For example, when therapy services are billed as incident to a physician/NPP services, the requirement for direct supervision by the physician/NPP and other incident to requirements must be met, even though the service is provided by a licensed therapist who may perform the services unsupervised in other settings. You can find this information in the Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Chapter 15, Section 60.
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 modifier -59 is used to indicate a distinct procedural service. This may represent a different session or patient encounter, different procedure or surgery, different site, or organ system, separate incision/excision, or separate injury. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9.1.1B. The rules say that the Correct Coding Initiative was developed to promote correct coding and to control improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9.
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, Publication 100-02, 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 pays up to the Calendar Year Maximum of $1000. You can find this information on page 121 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 no provider or supplier shall receive payment for services furnished to a Medicare
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare
Program Integrity Manual, Chapter 15, Section 15.1.
The rules say that for oxygen and oxygen equipment, contractors pay a monthly fee schedule amount per
beneficiary. Unless otherwise noted below, the fee covers equipment, contents and supplies. Payment is not
made for purchases of this type of equipment. You can find this information in the Centers for Medicare and
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter
20, 30.6.
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 $35 copayment for specialist visits. You can find this information on page 1 of the Plan's 2021 Cost Sharing Guide.
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, Publication 100-02, 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 the
services listed in the Plan's benefit chart; any service listed is not covered. You can find this information on
page 4-56 to 4-70 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 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 say that to report home health visits, the home health agency must report a Healthcare Common
Procedure Coding System (HCPCS) starting with G to represent a visit by each care discipline. You can find
this rule in the Medicare and Medicaid Services, Medicare Claims Processing Manual, Chapter 10 - Home
Health Agency Billing, Section 40.2.
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 state that an expandable Controller - An electronic system that is capable of accommodating one or
more of the following additional functions:
a. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head
control, etc.) other than a standard proportional joystick.
b. Non-proportional input devices (e.g., sip and puff, head array, etc.)
c. Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)
An expandable controller may also be able to operate one or more of the following:
d. A separate display (i.e., for alternate control devices)
e. Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's
drive control)
f. An attendant control
The approved power options come with their own switches. Local Coverage Article:
Wheelchair Options/Accessories - Policy Article (A52504) confirms this:
A power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a solid back; any
frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway
detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable
speed programmability; a switch control which is independent of the power wheelchair drive control interface.
A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or
without variable speed programmability which allows the legrest to be raised and lowered independently of the
recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with
the power tilt and/or recline control(s)."
You can find these rules in the Local Coverage Article Wheelchair Options/Accessories - Policy Article,
A52504
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, Publication 100-16, 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 page 28 of the Plan's 2021 Evidence of Coverage.