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 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 Plan contract includes a list of covered supplemental dental services. Topical application of fluoride varnish is not included on this list and is not a covered supplemental benefit. You can find this information on pages 92 to 94 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 that Medicare pays for an assistant at surgery only when the procedure is authorized for an assistant. The assistant must be a physician, physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS). Medicare does not pay for assistant at surgery services performed by a person who bears any title or license other than those listed. You can find this rule in the Medicare Claims Processing Manual, Chapter 4, Section 250.9. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. You can find this rule at Program Integrity Manual, Ch. 15 15.1.
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 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. The contract lists the dental services that are covered. Core build up is not listed and therefore is not a covered service. The contract says you pay a 70% coinsurance for up to 2 crowns per year when you receive them in network. The contract also says that nitrous oxide is only covered when provided with other covered services. You can find this information on pages 87 and 95 to 98 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 $375 copayment per day for days 1-4. There is a $0 copayment for additional days for inpatient hospital care/in-network. You can find this information on pages 64-66 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.
MA plans may choose to offer some benefits to enrollees in addition to the covered Medicare Part A and Part B (and Part D, as applicable) benefits they are required to offer if the item or service also meets the criteria described in sections 30 and 40 of this chapter. You can find this information in Medicare Managed Care Manual Chapter 4, Section 30.1.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that you may receive over the counter items with a $225 allowance every quarter. You can find this information on pages 105 to 106 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 a Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with Multiple Power Options (K0861, K0862, K0863, K0864) is covered if: A. The Group 3 criteria IV(A) and IV(B) are met; and B. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met. If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or (V)(B) is not met, it will be denied as not reasonable and necessary. You can find this rule at Local Coverage Determination (LCD): Power Mobility Devices (L33789) (eff. 1/1/20). 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 $350 copayment for outpatient surgery, services and procedures provided in an outpatient hospital facility. You can find this information on page 94 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 program reimbursement for HBO therapy will be limited to that which is administered in a chamber (including the one man unit) and is limited to the following conditions: 1. Acute carbon monoxide intoxication, 2. Decompression illness, 3. Gas embolism, 4. Gas gangrene, 5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened. 6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened. 7. Progressive necrotizing infections (necrotizing fasciitis), 8. Acute peripheral arterial insufficiency, 9. Preparation and preservation of compromised skin grafts (not for primary management of wounds), 10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, 11. Osteoradionecrosis as an adjunct to conventional treatment, 12. Soft tissue radionecrosis as an adjunct to conventional treatment, 13. Cyanide poisoning, 14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment, 15. Diabetic wounds of the lower extremities in patients who meet the following three criteria: a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; b. Patient has a wound classified as Wagner grade III or higher; and c. Patient has failed an adequate course of standard wound therapy. You can find this rule in National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29) - Effective June 19, 2006.
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 on pages 33-39 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.Medicare does not pay for the services of a naturopath. You can find this rule in the Medicare Financial Management Manual, Chapter 3, Section 90.1(L).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 at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that codes A9276 (SENSOR; INVASIVE (E.G., SUBCUTANEOUS), DISPOSABLE, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM, ONE UNIT = 1 DAY SUPPLY) and A9277 (TRANSMITTER; EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM) describe the supplies used with a non-therapeutic CGM. Codes A9276 and A9277 are not used to bill for supplies used with code K0554. You can find this rule in Local Coverage Article: Glucose Monitor -Policy Article (A52464) -Effective June 7, 2018.The rules say that code A9278 (RECEIVER (MONITOR); EXTERNAL,FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM) describes any CGM system that fails to meet the DME Benefit requirements as described in CMS Ruling 1682R. You can find this rule in Local Coverage Article: Glucose Monitor -Policy Article (A52464) -Effective June 7, 2018.The rules say that continuous glucose monitors that are covered by Medicare under the DME benefit are defined by CMS ruling 1682R as therapeutic monitors. You can find this rule in Local Coverage Determination (LCD): Glucose Monitors (L33822) -Effective January 1, 2020.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.ThePlan 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 payfor it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that the supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) is required to maintain proof of delivery documentation in their files. You can find this rule at the Medicare Program Integrity Manual, Chapter 5, Section 5.2.1.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the 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 routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury; and (b) examinations required by third parties such as insurance companies, business establishments, or Government agencies. You can find this information in Medicare Benefit Policy Manual Chapter 16, Section 90.
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 payment for inpatient psychiatric hospital services is to be made only for active treatment. For services to be designated as active treatment they must:

1. be provided under an individualized treatment or diagnostic plan;
2. reasonably be expected to improve the patient's condition, or for the purpose of diagnosis; and3
3. be supervised and evaluated by a physician.  
You can find these rules in the Medicare Benefit Policy Manual, Chapter 2, Sections 30.2.2 and 30.2.2.1.

The rules say that Medicare will not pay any expenses for items or services which are not medically necessary and reasonable for the diagnosis or treatment of illness or injury. This exclusion extends to claims for services which are provided in inappropriate settings. You can find this rule in the Social Security Act, Section 1862(a)(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 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 Plan
contract includes a list of covered supplemental dental services. Endodontic therapy is not included on this list
and is not a covered supplemental benefit. You can find this information on pages 87 and 88 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 also says that there is $200 copayment after the deductible is met for each advanced imaging service for outpatient diagnostic tests and therapeutic services and supplies. You can find this information on pages 92 of the Plan's 2020 Evidence of Coverage (EOC). The Plan contract also says there is a $750 deductible; this is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. You can find this information on pages 67 to 68 of the Plan's 2020 EOC.
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 not pay for services given by a physician or other practitioner who has opted out of Medicare. This rule does not apply to emergency or urgently needed services. This rule applies to all other services, as well as to supplemental benefits. A Medicare plan must pay for emergency or urgently needed services given by a physician or practitionerwho has not signed a private contract with the enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the 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 You can get your care from an out of network provider; however, in most cases that provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to participate in Medicare. If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full costof the services you receive. Check with your provider before receiving services to confirm that they are eligible to participate in Medicare. You can find this information on page 48 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 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 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 Medicare Claims Processing Manual Ch. 12 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 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. The contract lists the specific dental services that are covered. Periapical x-rays are not listed and therefore are not covered services. The contract also says any services not listed are not covered. You can find this information on pages 4-55 to 4-58 of the Plan's 2020 Evidence of Coverage (EOC)