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 the annual routine physical exam includes a comprehensive exam covering four areas: 
medication history, social history, review of symptoms, and past history.  Certain services rendered during a 
routine exam may take a copayment (for example, diagnostic tests.) The contract also says that enrollees must 
pay a $2 copayment for lab services. You can find this information on pages 53 and 83 of the Plan's 2021 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $35 copayment for lab services at an out-of-network outpatient hospital 
facility. You can find this information on page 82 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 SNF payment is made based on a Health Insurance Prospective Payment System (HIPPS) 
rate code. The HIPPS rate code consists of the three-character resource utilization group (RUG) code that is 
obtained from the "Grouper" software program followed by a 2-digit assessment indicator (AI) that specifies 
the type of assessment associated with the RUG code obtained from the Grouper. Information about the 
required assessments can be found in the Resident Assessment Instrument (RAI) manual. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 4, Section 30.1. 
 
The rules say that each of the Medicare-required scheduled assessments has defined days within which the 
Assessment Reference Date (ARD) must be set. The Medicare-required standard assessment schedule includes 
5-day, 14-day, 30-day, 60-day, and 90-day scheduled assessments, each with a predetermined time period for 
setting the ARD for that assessment. The manual provides a chart which indicates that the 5-day assessment 
must have an ARD set on days 1-5 of the SNF stay and that this assessment sets the payment rate for days 1 
through 14 of the stay. It is also noted that the 5-day assessment must be completed within 14 days of the ARD 
date used. You can find this information in the Long-Term Care Facility Resident Assessment Instrument 3.0 
User's Manual, Version 1.16, on pages 2-42 through 2-50. 
 
The rules say that Medicare will pay a default rate when a SNF fails to comply with the required assessment 
schedule. The default rate is paid for the days of a patient's care for which the SNF is not in compliance with 
the assessment schedule. You can find this information in 42 CFR Section 413.343. 
 
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 $40 copayment for an in-network specialist visit. Covered services 
include medically necessary medical care or surgery services furnished in a physician's office, certified 
ambulatory surgical center, hospital outpatient department, or any other location. You can find this information 
on pages 106 to 108 of the Plan's 2021 Evidence of Coverage (EOC).  
 
The Plan contract also says a specialist is a doctor who provides health care services for a specific disease or 
part of the body. There are many kinds of specialists. Here are a few examples: 
- Oncologists care for patients with cancer. 
- Cardiologists care for patients with heart conditions. 
- Orthopedists care for patients with certain bone, joint, or muscle conditions. 
You can find this information on page 47 of the Plan's 2020 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, 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. The Plan contract says that 
you will save more when you receive care from one of the Plan's in-network dental providers. You can get care 
from an out-of-network dental provider, but you may pay more. The contract also says that you must pay a 
20% coinsurance of the covered Plan allowance after the $100 annual deductible is met. You can find this 
information on pages 66 and 102 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, 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. The contract also says that 
you are covered for one re-cement or re-bond of a crown at 50% coinsurance, once every five calendar years, 
when services are rendered by an in-network provider. You can find this information on pages 103-109 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 the applicable payments made under the prospective payment systems are payment in full for 
all facility services, as defined in 42 CFR Section 409.10. CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. The facility must furnish all necessary covered services 
to the beneficiary either directly or under arrangements (as defined in 42 CFR Section 409.3). You can find this 
rule at 42 CFR Section 412.50. 
 
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 Medicare requires that Plans cover all original Medicare services to its enrollees. For 
coordinated care plans, in-network transplant services may be provided outside of the plan service area if the 
services are accessible and available to enrollees, and that service delivery is consistent with community 
patterns of care for original Medicare beneficiaries who reside in the same area. 
 
Plans are also allowed to offer transplant care at a distant location, farther away than the normal community 
patterns of care for transplant services. In any circumstance in which an MA plan provides transplant services 
at a more distant location, the MA plan must provide reasonable transportation for the enrollee and a 
companion to the distant facility, and provide reasonable accommodations for the enrollee and a companion 
while in the distant location for medical care.  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 10.11. 
 
The rules also say that Medicare does not reimburse separately for sales tax. You can find this the Centers for 
Medicare and Medicaid Services, Internet Only Manual (IOM), Publication 100-04, Medicare Claims 
Processing Manual, Chapter 23, 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. The Plan 
contract also says that if you need a transplant services at a distance location, the Plan will arrange or pay for 
appropriate lodging and transportation costs for you and a companion. You can find more information on page 
3 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 percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for painful, debilitating, 
osteoporotic vertebral collapse/compression fractures, defined as those that have not responded to non-surgical 
medical management (e.g., narcotic and/or non- narcotic medication, physical therapy modalities) with and 
without methods of immobility (e.g., rest, bracing). Both procedures will be considered reasonable and 
necessary when ALL of the following criteria are met: 
 
1. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1- 
L5), based on symptom onset, and documented by advanced imaging demonstrating bone marrow edema on 
magnetic resonance imaging (MRI) or bone-scan/single-photon emission computerized tomography 
(SPECT)/CT uptake, and 
2. The beneficiary is symptomatic, and is hospitalized with severe pain (Numeric Rating Scale [NRS] or Visual 
Analog Scale [VAS] pain score 8 or more) or is non-hospitalized with moderate to severe pain (NRS or VAS 5 
or more) despite optimal  non-surgical management (NSM) with one of the following: 
 
a. . Worsening pain 
b. . Stable to improved pain when two or more of the following are present 
 
-Progression of vertebral body height loss 
-More than 25% of vertebral body height reduction 
-Kyphotic deformity 
-Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] more than 17) 
 
You can find this rule in the Local Coverage Determination (LCD) - Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) - Effective July 11, 2021. 
 
The rules say that the exclusion criteria for the requested procedure is: 
 
a. Absolute contraindication 
  
1. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
2. Osteomyelitis, discitis or active systemic infection 
3. Pregnancy 
4. Active surgical site infection 
  
b.  Relative contraindication 
  
1. Allergy to bone cement or opacification agents 
2. Coagulopathy 
3. Spinal instability 
4. Myelopathy from the fracture 
5. Neurologic deficit 
6. Neural impingement 
7. Fracture retropulsion/canal compromise 
8. Greater than three vertebral fractures per procedure 
  
You can find this rule in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation (PVA) 
for Vertebral Compression Fracture (VCF) (L34976) - Effective July 11, 2021. 
 
 
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 Medicare specifies the indications and limitations for incision and drainage services. 
Incision and drainage is a covered procedure for treating abscesses. Podiatrists are limited in scope of practice 
by State law. Only those diagnosis codes that are appropriate for the scope of practice will be accepted as 
reimbursable. For podiatrists, codes 10060, 10061 or 10160 are payable for diagnosis codes L02.611, L02.612, 
L98.8 only. You can find this information in the Local Coverage Determination (LCD): Incision and Drainage 
(I & D) of Abscess of Skin, Subcutaneous and Accessory Structures (L33563) and the related article Billing 
and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures 
(A56766). 
 
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). 
 
If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered 
part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the 
panel. You can find this information in Local Coverage Article: Billing and Coding: MolDX: Testing of 
Multiple Genes (A58120). 
 
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 $50 copayment for urgent care services. You can find this information 
on page 122 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $150 copayment for outpatient hospital services. Enrollees also pay 20% 
coinsurance for Medicare Part B drugs. You can find this information on pages 74 and 71 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. 
 
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 routine vision services with a $175 vision allowance for routine contact 
lenses or eyewear every year. You can find this information on page 111 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 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 services 
provided by an out-of-network provider. If an out-of-network provider is used, you may pay more. You can 
find this information on pages 103-104 of the Plan's 2021 Evidence of Coverage (EOC).