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 will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit does not list a cone beam computed tomography scan as a covered service. If a service is not listed, it is not covered. You can find this information on page 43 of the Plan's 2021 Evidence of Coverage (EOC) and in the Plan's Dental Care Plan Information 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 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 $300 copay for outpatient surgery. You can find this information on
page 86 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 whole gland high intensity focused ultrasound is medically necessary as a local treatment for recurrent prostate cancer following radiation therapy when ALL of the following criteria are met: 

1. Biochemical recurrence (BCR) according to the Phoenix definition (PSA nadir + 2 ng/mL) 
2. Positive post-RT transrectal ultrasound guided (TRUS) biopsy 
3. Candidate for local curative therapy as evidenced by favorable clinical and pathologic factors (BOTH of the following)

a. Original (pre radiation therapy) - clinical stage T1-T2, NX or N0 
b. Current (ALL ARE REQUIRED)

i. PSA less than 10 ng/mL 
ii. absence of distant metastases per National Comprehensive Cancer Network (NCCN) imaging guidelines 
iii. no lymph node involvement 
iv. interval to biochemical failure more than 18 months 
v. International Society of Urological Pathology (ISUP) grade < 4 
vi. local recurrence amenable to entire destruction

4. Multi-disciplinary consensus (surgeon, oncologist, radiologist) 
5. High comorbidity (i.e., not a candidate for radical prostatectomy

You can find this rule in Local Coverage Determination (LCD): Salvage High-intensity Focused Ultrasound (HIFU) Treatment in Prostate Cancer (PCa) (L38262) - Effective April 1, 2020.

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 to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Section 240.2(E).

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 generally, the plan covers any DME covered by Original Medicare from the brands and manufacturers on a specific list. We will not cover other brands and manufacturers unless the doctor or other provider tells the plan that the brand is appropriate for your medical needs. You can find this information on page 63 of the 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 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 outpatient diagnostic tests/diagnostic tests. You can find this information on page 84 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that plans may require enrollees to obtain authorization before receiving services or equipment. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 1, Section 20.2.

The rules say that a Medicare plan may not pay for services or equipment given by a physician or other practitioner who has opted out of Medicare. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 6, Section 60.2.

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 while you can get your care from an out-of-network provider, the provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who has opted out of or been excluded or precluded from the Medicare Program. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. You can find this information on page 3-4 of the Plans 2021 Evidence of Coverage.

The Plan contract says that durable medical equipment requires prior authorization. You can see this on page 4-21 of he Plans 2021 Evidence of Coverage.

The Plan contract says that as a member of this Plan it is your responsibility to get familiar with your covered services and the rules you must follow to get these covered services. Use this Evidence of Coverage booklet to learn what is covered for you and the rules you need to follow to get your covered services. Chapters 3 and 4 give the details about your medical services, including what is covered, what is not covered, rules to follow, and what you pay. You can see this on page 6-16 of the Plans 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 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 20% coinsurance for Medicare Part B prescription drugs. You can find this information on page 57 of the Plan's 2021 Evidence of Coverage (EOC).

The Plan contract says that enrollees must pay a $360 copay for outpatient surgery at an outpatient hospital. You can find this information on page 63 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 preoperative visits are included in the global surgical package. You can find this rule in the Medicare Claims Processing Manual, Chapter 12, Section 40.1.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Section 240.2(D)(3)(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
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 for ambulance services that meet certain origin and destination requirements.
In order to meet this requirement, the ambulance supplier must transport the patient for whom the emergency
call was placed. If an ambulance responds to a call but does not transport the person for whom the call was
placed, Medicare does not pay for the service. You can find this rule at 42 CFR Section 410.40(f) and in the
Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter
10, Section 10.
The rules also say that pursuant to authority granted under section 9832 of the American Rescue Plan Act of
2021, Medicare has waived the requirement that an ambulance service include transport for cases involving a
911 call. This requirement is waived in cases where an individual would have been transported to a covered
destination, but such transport did not occur as a result of community-wide emergency medical service (EMS)
protocols in place due to the COVID public health emergency. The beneficiary's condition must have required
both the ambulance transportation itself and the level of service provided in order for the billed service to be
considered medically necessary. You can find this information the Medicare article entitled, "COVID-19
Emergency Declaration Blanket Waivers for Health Care Providers", available on the Centers of Medicare and
Medicaid Service (CMS) website.
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 $20 copay for each Medicare-covered primary care doctor visit. You can find this information on page 28 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 for medically necessary ambulance transport services. Medicare makes separate payment for paramedic intercept services only when they are furnished:

1. in a rural area, 
2. by a provider that is under a contract with 1 or more volunteer ambulance services. You can find this rule at 42 CFR Section 410.40(d).

The rules say that for the purposes of Paramedic Intercept coverage, an area is a rural area if: 
- It is designated as a rural area by any law or regulation of a State; 
- It is located outside of a Metropolitan Statistical Area (MSA) or New England County Metropolitan Area (NECMA); or 
- It is located in a rural census tract of an MSA as determined under the most recent Goldsmith modification.

Presently, only the State of New York meets these requirements. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 15, Section 20.1.4(a)(5).

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 Medicare pays for ambulance services that meet certain origin and destination requirements. In order to meet this requirement, the ambulance supplier must transport the patient for whom the emergency call was placed. If an ambulance responds to a call but does not transport the person for whom the call was placed, Medicare does not pay for the service. You can find this rule at 42 CFR Section 410.40(f) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 10, Section 10. 

The rules also say that pursuant to authority granted under section 9832 of the American Rescue Plan Act of 2021, Medicare has waived the requirement that an ambulance service include transport for cases involving a 911 call. This requirement is waived in cases where an individual would have been transported to a covered destination, but such transport did not occur as a result of community-wide emergency medical service (EMS) protocols in place due to the COVID public health emergency. The beneficiary's condition must have required both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary. You can find this information the Medicare article entitled, "COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers", available on the Centers of Medicare and Medicaid Service (CMS) website.

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 protective outer surface covering systems (L5962) are specialized covers intended to be worn over an existing prosthesis. They are used by a beneficiary who has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707. They are not for cosmetic or convenience reasons, or for everyday usage in a typical environment. Protective outer surface coverings are different from the covering that is already reimbursed as part of L5704, L5705, L5706, and L5707. You can find this rule in Local Coverage Article: Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020.

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 occupational therapy visit from a network provider. You can find this information on page 74 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 plans may choose the networks of providers available to enrollees and may require enrollees
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in
the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual,
Chapter 1, Section 20.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care
and services. The only exceptions are emergencies, urgently needed care when the network is not available
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan
authorizes the use of out-of-network providers. You can find this information on page 51 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.
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). Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR Section 411.15(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 also says that standard lenses and frames are limited to one pair every 2 years. Standard lenses that are covered in full include standard single vision, lined bifocal, lined trifocal, lenticular, and standard progressive lenses. After Plan paid benefits for eyeglasses (lenses and frames) or contact lenses, you are responsible for the cost. You can find this information on pages 4-77 to 4-78 of the Plan's 2021 Evidence of Coverage.