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 state that the Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations
Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 stipulates that ventilators (E0465, E0466, and
E0467) are covered for the following conditions:
"[N]euromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic
obstructive pulmonary disease."
Each of these disease categories are comprised of conditions that can vary from severe and life-threatening to
less serious forms. These ventilator-related disease groups overlap conditions described in this Respiratory
Assist Devices LCD used to determine coverage for bi-level PAP devices. Each of these disease categories are
conditions where the specific presentation of the disease can vary from beneficiary to beneficiary. For
conditions such as these, the specific treatment plan for any individual beneficiary will vary as well. Choice of
an appropriate treatment plan, including the determination to use a ventilator vs. a bi-level PAP device, is made
based upon the specifics of each individual beneficiary's medical condition. In the event of a claim review,
there must be sufficient detailed information in the medical record to justify the treatment selected.
Ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and payment policy
requirements preclude FSS payment for devices used to deliver continuous and/or intermittent positive airway
pressure, regardless of the illness treated by the device. (Social Security Act 1834(a)(3)(A)) This means that
products currently classified as HCPCS code E0465, E0466, or E0467 when used to provide CPAP or bi-level
PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in
the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions described in
this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP
(E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions
described in this RAD policy will be denied as not reasonable and necessary.
General principles of correct coding require that products assigned to a specific HCPCS code only be billed
using the assigned code. Thus, using the HCPCS codes for CPAP (E0601) or bi-level PAP (E0470, E0471)
devices for a ventilator (E0465, E0466, or E0467) used to provide CPAP or bi-level PAP therapy is incorrect
coding. Claims for ventilators billed using the CPAP or bi-level PAP device HCPCS codes will be denied as
incorrect coding.
You can find this information in the Local Coverage Determination (LCD): Respiratory Assist Devices
(L33800).
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 $250 copayment for Outpatient hospital services. You can find this information on page 80 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).
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 there is a $203 deductible which applies to certain Part B items and services. The Plan
deductible applies to office services. You can find this information in Chapter 4 on pages 4-2 to 4-4 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 $25 copayment for diagnostic procedures and tests in a specialist's office. You can find this information on pages 72 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). 
 
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 there is a $750 deductible which applies to certain items and services. The Plan 
deductible applies to the outpatient surgery services. You can find this information on page 101 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 state that, for services paid on a fee schedule, Medicare secondary payment amounts are determined by a formula and are the lowest of:
1) Excess of the actual charge minus the primary payment;
2) The amount Medicare would pay if the services were not covered by a primary payer;
3) The higher of the Medicare payment amount or the primary payers allowable charge minus the amount actually paid by the primary payer.
You can find this information in 42 CFR 411.33.
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 for emergency out network ambulance services there is a 4% coinsurance per date of service regardless of the number of trips. Limited to Medicare-covered transportation. You can find this information on page 73 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 state that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare Program Integrity Manual Chapter 3 ? 3.3.2.1. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. You can find this rule at 42 CFR ?424.5.
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 30 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 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 $225 copay for outpatient surgery. You can find this information on page 101 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 20% coinsurance for outpatient renal dialysis services. You can find this information on page 105 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. This benefit only includes coverage for specifically listed dental services when they are performed by a participating general dentist. You can find this information on page 67 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 also say that critical care service is a time-based service provided on an hourly or fraction of an hour basis. The CPT code 99291 is used to report the first 30 -74 minutes of critical care on a given calendar date of service. It should only be used once per calendar date per patient by the same physician or physician group of the same specialty. CPT code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 12, Section 30.6.12 (F-G).
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 when billing multiple units of a Healthcare Common Procedure Coding System
(HCPCS)/Current Procedural Terminology (CPT) code, providers must enter the actual number of units
provided on the claim form. You can find this rule in the Centers for Medicare and Medicaid Services, Internet
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.4.
The rules say for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare
Program Integrity Manual Chapter 3 Section 3.3.2.1.
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 state that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the
basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV
disease because panel testing is not specific to a given patient's lipid abnormality or disease. here is no
Medicare benefit for screening CV risk assessment testing for asymptomatic (without signs or symptoms of
disease) patients. Screening asymptomatic patients for cardiovascular risk is statutorily excluded by Medicare
and will not be addressed in this policy. You can find this rule in Local Coverage Determination (LCD):
MolDX: Biomarkers in Cardiovascular Risk Assessment (L36523).
A Medicare Administrative Contractor (MAC) outside of the plan's service area sometimes has exclusive
jurisdiction over a Medicare covered item or service. In some instances, one Medicare A/B MAC processes all
of the claims for a particular Medicare-covered item or service for all Medicare beneficiaries around the
country. This generally occurs when there is only one supplier of a particular item, medical device or
diagnostic test (for example, certain pathology and lab tests furnished by independent laboratories). In this
situation, MA plans must follow the coverage requirements or LCD of the MAC that enrolled the supplier and
processes all of the Medicare claims for that item, test or service. You can find this rule in the Centers for
Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual,
Chapter 4, Section 90.2.
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 A standard electric heating pad (E0210) is covered to relieve certain types of pain, decrease joint and soft tissue stiffness, relax muscles, or reduce inflammation. 

A heating pad is not reasonable and necessary to treat pain due to peripheral neuropathy, including but not limited to diabetic neuropathy. 

It has not been established that a moist electric heating pad (E0215) or water circulating heat pad with pump (E0217) is reasonable and necessary compared to a standard electric heating pad (E0210); therefore, if code E0215 or E0217 is provided it will be denied as not reasonable and necessary. 

Heating pads that do not meet the definitions listed in the Coding Guidelines section of the related Policy Article and that are billed with code E1399 will be denied as not reasonable and necessary. 

Because a water circulating heating pad system is not medically necessary, a replacement pump (E0236) or pad (E0249, A9999) will be denied as not reasonable and necessary. 

You can find this information in the Local Coverage Determination (LCD) - Heating Pads and Heat Lamps (L33784).

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 $100 copayment for other Medicare-covered diagnostic procedures and
tests. You can find this information on page 76 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 does not pay for gym benefits. Gym benefits include exercise classes, such as Tai Chi, yoga, and dance classes. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that the plan reimburses you up to $300 each calendar year towards your cost for membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs, memory fitness activities, acupuncture, and/or covered nutritional counseling sessions with a licensed nutritional counselor or registered dietician. Reimbursement requests must be received by the Plan by no later than March 31st of the following year. You can find this information on pages 76-77 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.
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 $250 copay for outpatient surgery at a hospital facility. You can find this information on page 81 of the Plan's 2021 Evidence of Coverage (EOC).