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 pays only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41(a). 

The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers up to 48 one-way trips per year. Each trip must not exceed 50 miles of driving distance. You can find this information on page 4-58 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 medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o). The rules say that a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral 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). Knee orthosis L1852 are also covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the Group 4 ICD-10 Codes in the LCD-related Policy Article. For code L1852, knee instability must be documented by examination of the beneficiary and objective description of joint laxity. Claims for L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented. You can find this information in the Local Coverage Determination (LCD): Knee Orthoses (L33318).
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 $200 copayment for each covered diagnostic radiology service. You can find this information on page 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 state that preventative vitamin assays and metabolic function tests are not a covered benefit. This rule can be found in Medicare Local Coverage Determination (LCD): - Assays for Vitamins and Metabolic Function (L34914).
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 only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41(a). The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers a maximum of 48 one-way trips per calendar year to plan approved locations. You can find this information on page 4-52 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 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 the 2021 Evidence of Coverage in Chapter 4.
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 MIS fusion of the SI joint is considered medically necessary for enrollees with moderate to severe pain with functional impairment and pain that persists despite a minimum six months of intensive nonoperative treatment that must include medication optimization, activity modification, bracing, and active therapeutic exercise. There must also have been at least 75% pain reduction following anesthetic SI joint injections, and a trial of at least one SI joint steroid injection. You can find this information in the Local Coverage Determination (LCD): Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint (L36494).
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 as a National Provider Identifiers (NPI) is required by HIPAA regulations to track healthcare services and reimbursement, any claim submitted without a valid, registered NPI, will be rejected by any health plan.

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 risk assessment testing / panels, except the
basic lipid panel, for symptomatic patients for suspected or documented cardiovascular-respiratory disease.
This rule can be found in Local Coverage Determination: MolDX: Biomarkers in Cardiovascular Risk
Assessment (L36139).

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.

Therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria (1-5) are met:
1.	The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses); and,
2.	The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
3.	The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,
4.	Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-3) above are met; and,
5.	Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.

You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822).

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 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 lists anesthesia as an excluded service. You can find this information on page 33 of the Plan's third-party dental vendor's 2021 Preventive & Comprehensive Dental Coverage Customer Handbook.
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). The rules say subluxation may be shown by x-ray or physical exam. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.2. The rules say that Medicare does not cover chiropractic maintenance care. When further clinical improvement cannot be reasonably expected from ongoing care, the care is considered maintenance. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3.
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
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 non-coverage of procedure codes 0012M and 0013M for CxBladder was reaffirmed by Medicare. You can find this rule at Local Coverage Determination L35396 entitled "Biomarkers for Oncology", effective date December 13, 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 medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 

The rules say that services that are not medically necessary are not covered. You can find this rule at 42 CFR Section 411.15.

The rules say that providers must have access to and provider records showing written orders and records for the services provided. You can find this rule at 42 CFR Section 424.516(f).

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 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 some preventative and comprehensive dental services as a supplemental (extra) benefit. You can find this information on page 44 of the Plan's 2021 Evidence of Coverage (EOC). Specific services are listed with procedure codes in the Plan's 2021 Preventative and Comprehensive Dental Coverage Customer Handbook. Only listed services and codes are eligible for 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 does not pay for hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that the Plan's hearing benefit is limited to 2 hearing aids every 2 years. Hearing aid accessories are not covered by the Plan but are available for members to buy at an additional cost. You can find this information on page 4-21 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 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 includes oral exams, routine cleanings, and bitewing x-rays. You can find this information on page 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 state that for lab services, the Place of Service code billed should reflect the location where the specimen is collected. If an independent lab bills, the place where the sample was physically taken should be entered as the Place of Service. An independent lab should only bill Place of Service 81 if the lab takes the sample themselves. You can find this rule at Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Internet Only Manual 100-04, Chapter 26, Section 10.6.

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 evaluation and management services, providers must bill Current Procedural Terminology (CPT) codes based upon the content of the service provided. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.
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 therapeutic continuous glucose monitors (CGMs) and related supplies are covered by
Medicare when all of the following coverage criteria are met:
1. The beneficiary has diabetes mellitus,
2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a
Medicare-covered continuous subcutaneous insulin infusion (CSII) pump,
4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of
BGM or CGM testing results,
5. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an inperson
visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822).
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 no more than two transforaminal injections may be performed at a single setting (e.g., single level bilaterally or two levels unilaterally). You can find this information in Local Coverage Determination (LCD): Lumbar Epidural Injections (L34980).
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.