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

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3. 
 
The rules say that a status indicator of N represents a non-covered service. You can find this rule in the 
Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
The rules say sales taxes where appropriate were included in the calculation of reasonable charges computed. 
They were also accounted for in the calculation of the base fee schedules for DME and orthotic/prosthetic 
devices. The Consumer Price Index used to update fee schedules also accounts for sales tax. Therefore, 
contractors do not make any additional payment for sales taxes and do not make adjustments in fees to reflect 
local changes in tax rates. You can find this rule in the Medicare Claims Processing Manual Chapter 23, 
Section 80.3.1(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 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. 
 
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 the 2020 Evidence of Coverage 
Chapter 4, page 45 and Chapter 3, section 1.2 on page 30.
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 pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patient?s comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You 
can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1.  
 
The rules say that additional expenses for "deluxe" features, or items that are rented or purchased for aesthetic 
reasons or added convenience, do not meet the reasonableness test. Thus, where a service or item is medically 
necessary and covered under the Medicare program, and the patient or provider wishes to obtain such deluxe 
features, the payment is based upon the payment amount for the kind of service or item normally used to meet 
the intended purpose (i.e., the standard item or the least costly item). You can find this in the Medicare Claims 
Processing Manual Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. 
 
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 $45 copayment for physician specialist services (including surgery second 
opinion, Medicare covered telehealth or urgently needed services). You can find this information on pages 88-
89 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 does not pay for nutritional supplements. Some patients require supplementation of 
their daily protein and caloric intake. Nutritional supplements are often given as a medicine between meals to 
boost protein-caloric intake or the mainstay of a daily nutritional plan. Nutritional supplementation is not 
covered under Medicare Part B. You can find this rule in the Medicare National Coverage Determination 
Manual, Chapter 1, Section 180.2. 
 
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 Home oxygen therapy is reasonable and necessary only if all of the following conditions are 
met: 
 
The treating practitioner has determined that the beneficiary has a severe lung disease or hypoxia-related 
symptoms that might be expected to improve with oxygen therapy, and 
 
The beneficiary's blood gas study meets the criteria stated below, and 
The qualifying blood gas study was performed by a treating practitioner or by a qualified provider or supplier 
of laboratory services, and 
 
The qualifying blood gas study was obtained under the following conditions: 
If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the 
one obtained closest to, but no earlier than 2 days prior to the hospital discharge date, or 
 
If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be 
performed while the beneficiary is in a chronic stable state ? i.e., not during a period of acute illness or an 
exacerbation of their underlying disease, and 
 
Alternative treatment measures have been tried or considered and deemed clinically ineffective. 
 
A portable oxygen system is covered if the beneficiary is mobile within the home and the qualifying blood gas 
study was performed while at rest (awake) or during exercise. If the only qualifying blood gas study was 
performed during sleep, portable oxygen will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Oxygen and Oxygen Equipment 
(L33797) 
 
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 medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).2.Invasive procedures for the treatment of varicose veins are considered medically reasonable and necessary when ALL of the following criteria have been met:-An evaluation of the patient has been performed including a history and physical examination, the CEAP clinical classification and the revised Venous Clinical Severity Score (VCSS), AND-A duplex scan of the deep and superficial venous systems supports the examination findings,3 AND-A duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers in the saphenous, or perforator veins is 500 milliseconds or greater3 and absence of deep venous obstruction, AND-The documentation supports signs and/or symptoms that interfere with activities of daily living and/or quality of life, AND-The CEAP clinical classification is C1 to C6 with the following criteria:-Treatment of C1 disease (telangiectasia and their feeding reticular veins) is considered medically reasonable and necessary for patients with spontaneous and/or traumatic venous hemorrhage.-For patients with C2 or C3 disease and VCSS <6, the plan of care shall include documentation of a period of conservative therapy (2 to 4 weeks) including graduated compression 20-30 mmHg or greater, ambulation, elevation, and avoiding prolonged sitting and standing.-For patients who meet any one of the following criteria, the mandatory conservative therapy prior to the invasive procedure may be waived.-VCSS &#8805;6-C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, and active venous leg ulceration)-Hemorrhage-Recurrent superficial thrombophlebitisYou can find this information in Local Coverage Determination (LCD): Treatment of Chronic Venous Insufficiency of the Lower Extremities (L34924).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers 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 certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage of oral exams, cleanings, x-rays, fluoride, scaling and root planing, diagnostic services, restorative 
services, extractions, root canals, crowns, dentures, and oral surgery. You can find this information on pages 80 
and 81 of the Plans 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that the PACE benefit package must include the following:  
(a) All Medicare-covered items and services;  
(b) All Medicaid-covered items and services, as specified in the State's approved Medicaid plan; and  
(c) Other services determined necessary by the interdisciplinary team to improve and maintain the enrollee's 
overall health status.  
You can find this rule at 42 Code of Federal Regulations (CFR) Section 460.92. 
 
The rules say that PACE (Program of All-inclusive Care for the Elderly) benefits must include all services and 
items covered by Medicare and Medicaid. The benefits must also include all other services determined 
necessary by the interdisciplinary team (IDT) to improve and maintain the enrollee's overall health status. You 
can find this rule at 42 CFR Section 460.92.  
 
The rules also say that enrollees in a PACE program must have a written plan of care. This plan must meet 
their needs in all care settings 24 hours a day every day of the year. You can find this rule at 42 CFR Section 
460.98. 
 
The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relative?s home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 
110.1(D). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The PACE 
Enrollment Agreement describes all of the PACE services available and how to get services from the PACE 
organization. This Agreement also describes how to get emergency and urgently needed services out-of-
network.
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. This benefit includes oral 
exams, cleanings, fluoride treatment and dental x-rays. You can find this information on page 4-50 to 4-63 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 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 $310 copayment per day for days 1-7. There is a $0 copayment for 
additional days. for inpatient hospital care/in-network. You can find this information on pages 72-74 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 plans can restrict members to using contract providers except for emergency care (including 
ambulance services), out-of-area urgently needed care, post-stabilization care, and pre-approved care. You can 
find this rule at 42 CFR Section 422.112(a)(9). 
 
The rules say that a Medicare plan must pay for emergency care regardless of whether the care is provided by a 
contract provider or a non-contract provider. Emergency care ends when the patient is stabilized.  
 
Post-stabilization care is care that is administered to maintain, improve, or resolve the enrollee's stabilized 
condition. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is 
obtained from a non-contract provider, approval is required from the plan. However, the requirement for pre-
approval does not apply if: 
 
1. The Plan does not respond to a request for pre-approval within one hour, 
 
2. The Plan cannot be contacted, or 
 
3. The Plan representative and the treating physician cannot reach an agreement concerning the enrollee's care 
and a plan physician is not available for consultation. 
You can find this rule at 42 CFR Section 422.113(c). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract 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 3 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 ifregular 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 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 ruleat 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. 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 3-4 to 3-7 of the Plan's 2021 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $50 copayment for physician/practitioner services/in-network/provider 
services/specialist/s office. You can find this information on pages 85-86 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 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 $45 copayment for Podiatry services. You can find this information on 
page 97 of the Plan's 2020 EOC.