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 CFR 422.101.
The rules state that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive
control system, it will be denied as non-covered. You can find this in the Local Coverage Article: Wheelchair
Options/Accessories - Policy Article (A52504).
If you want to read these Medicare rules, you can go to this web site 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 CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A). The rules say that the use of a device, or multiple devices, is necessary to the performance of certain outpatient procedures. If any of these procedures is submitted without a code for the required device(s), the claim is returned to the provider. You can find this information in the Integrated OCE (IOCE) CMS Specification V20.2; 5.7
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 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 rule at 42 CFR Section 422.112(a)(3).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. 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 42 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.
Medicare guidance says for any DMEPOS item to be covered by Medicare, the patient's medical record must
contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type
and quantity of items ordered and for the frequency of use or replacement (if applicable). The information
should include the patient's diagnosis and other pertinent information including, but not limited to, duration of
the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional
limitations, other therapeutic interventions and results, past experience with related items, etc. If an item
requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patient's
record. However, neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a
physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed
by the treating physician or supplier. There must be information in the patient's medical record that supports
the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if
applicable) or information on a supplier prepared statement or physician attestation (if applicable)". Also,
"Before submitting a claim to the DME MAC the supplier must have on file a dispensing order, the detailed
written order, the CMN (if applicable), the DIF (if applicable), information from the treating physician
concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation
statements as defined in certain DME MAC policies. The supplier should also obtain as much documentation
from the patient's medical record as they determine they need to assure themselves that coverage criteria for an
item have been met. If the information in the patient's medical record does not adequately support the medical
necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed ABN of
possible denial has been obtained. You can find this guidance in the Medicare Program Integrity Manual,
Chapter 5 - Items and Services Having Special DME Review Considerations, Section 5.7- Documentation in
the Patient's Medical Record and Section 5.8 - Supplier Documentation
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 say that a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints
(L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both mediallateral
and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury
to or a surgical procedure on the knee(s).
The rules also say that knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a
beneficiary who is ambulatory and has knee instability due to a condition specified in the ICD-10 Codes that
Support Medical Necessity Group 4 Codes section. Knee instability must be documented by examination of the
beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer
test). Claims will be denied as not reasonable and necessary when the beneficiary does not meet the above
criteria for coverage.
You can find this rule at Local Coverage Determination (LCD): Knee Orthoses (L33318).
The rules state that a spinal orthosis (L0450 - L0651) is covered when it is ordered for one of the following
indications:
1. To reduce pain by restricting mobility of the trunk; or
2. To facilitate healing following an injury to the spine or related soft tissues; or
3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or
4. To otherwise support weak spinal muscles and/or a deformed spine.
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically
necessary.
You can find this rule at Local Coverage Determination (LCD): Spinal Orthoses: TLSO and LSO (L33790).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
Medicare guidance says for any DMEPOS item to be covered by Medicare, the patient's medical record must
contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type
and quantity of items ordered and for the frequency of use or replacement (if applicable). The information
should include the patient's diagnosis and other pertinent information including, but not limited to, duration of
the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional
limitations, other therapeutic interventions and results, past experience with related items, etc. If an item
requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patient's
record. However, neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a
physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed
by the treating physician or supplier. There must be information in the patient's medical record that supports
the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if
applicable) or information on a supplier prepared statement or physician attestation (if applicable)". Also,
"Before submitting a claim to the DME MAC the supplier must have on file a dispensing order, the detailed
written order, the CMN (if applicable), the DIF (if applicable), information from the treating physician
concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation
statements as defined in certain DME MAC policies. The supplier should also obtain as much documentation
from the patient's medical record as they determine they need to assure themselves that coverage criteria for an
item have been met. If the information in the patient's medical record does not adequately support the medical
necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed ABN of
possible denial has been obtained. You can find this guidance in the Medicare Program Integrity Manual,
Chapter 5 - Items and Services Having Special DME Review Considerations, Section 5.7- Documentation in
the Patient's Medical Record and Section 5.8 - Supplier Documentation.
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 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 $10 for Medicare-covered laboratory tests. You can find this information on page 92 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 there are a number of services/supplies that are covered under Medicare and that have
HCPCS codes, but they are services for which Medicare bundles payment into the payment for other related
services. If A/B MACs (B) receive a claim that is solely for a service or supply that must be mandatorily
bundled, the claim for payment should be denied by the A/B MAC (B). Separate payment is never made for
routinely bundled services and supplies. The CMS has provided RVUs for many of the bundled
services/supplies. However, the RVUs are not for Medicare payment use. A/B MACs (B) may not establish
their own relative values for these services. All services integral to accomplishing a procedure are considered
bundled into that procedure and, therefore, are considered a component part of the comprehensive code. Many
of these generic activities are common to virtually all procedures and, on other occasions, some are integral to
only a certain group of procedures, but are still essential to accomplish these particular procedures.
Accordingly, it is inappropriate to separately report these services based on standard medical and surgical
principles. Because many services are unique to individual CPT coding sections, the rationale for rebundling is
described in that particular section of the detailed coding narratives that are transmitted to A/B MACs (B)
periodically. You can find this information in the Medicare Claims Processing Manual Chapter 12, Section
20.3 - Bundled Services/Supplies, Medicare Claims Processing Manual Chapter 12, Section 30 A. - Coding
Based on Standards of Medical/Surgical Practice, Medicare Claims Processing Manual Chapter 12, Section 30
- Correct Coding Policy and Medicare Claims Processing Manual Chapter 23 Section 10 - Reporting ICD
Diagnosis and Procedure Codes.
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 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 on pages 33-34 of the plan's 2019
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.
Medicare guidance says durable medical equipment and supplies are included in the skilled nursing facility
payment. You can find this guidance in the * Medicare Benefit Policy Manual Chapter 8 0 - Coverage of
Extended Care (SNF) Services under Hospital Insurance.
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 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 20% coinsurance for chemotherapy drugs and 20% coinsurance for all
other drugs covered under Medicare Part B from an in-network provider. You can find this information on page
71 of the Plan's 2019 Evidence of Coverage (EOC) and page 79 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 pay for an IRF admission when the services are reasonable and medically
necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing
rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of
the therapies must be physical therapy or occupational therapy. The patient must need and be expected to
actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive
rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per
week. The patient does not need to be expected to achieve complete independence in self-care nor be expected
to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation
physician. The physician must see the patient at least three days per week throughout the stay. You can find
these rules in the Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR
Section 412.622.
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. You may use a
dentist not in the Delta Dental Medicare Advantage network. Services rendered by dentists who have opted out
or been excluded from Medicare are not eligible for reimbursement. You can find this information on page 106
of the Plan's 2019 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 $200 copayment for each in-network Medicare-covered ambulatory
surgical center visit. You can find this information on pages 99 to 100 of the Plan's 2019 Evidence of Coverage
(EOC).
The Plan contract also says that a diagnostic colonoscopy is performed in order to explain symptoms identified
by your physician (for example, blood in stools, change in bowel movements, iron deficiency due to anemia,
persistent abdominal pain, etc.) or other colorectal related conditions. If your physician orders a diagnostic
colonoscopy see "Outpatient diagnostic tests and therapeutic services and supplies" and/or "Outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers" for cost-share.
You can find this information on pages 74 to 75 of the Plan's 2019 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health
plan contract says that only certain codes/services are covered under the Plan. The EOC lists specific services
which are a covered benefit and any service not listed in this section is not a covered benefit. one (1) set of 2
bitewings per calendar year, limited to the following codes: D0270 or D0272. You can find this information in
Chapter 4 on pages 85-86 of the plan's 2019 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 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).
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 for chiropractic care, the Plan only covers manual manipulation of the spine to correct
subluxation. You can see this on page 52 of the 2020 Evidence of Coverage.