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 Medicare provides limited coverage of multiplex PCR respiratory viral panels. Panels of 3-5 pathogens are covered under limited circumstances. Specifically, the test must be ordered either in a healthcare setting that is equipped to care for and routinely does care for critically ill patients, or it must be ordered by an infectious disease specialist, unless an infectious disease specialist is not available. Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. Code 87633 is listed as a noncovered code. You can find this information in the Local Coverage Determination (LCD): MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels (L37713) and related Policy Article for Billing and Coding (A56851).
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 $200 for each in-network, Medicare covered outpatient hospital facility visit. You can find this information on page 96 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 $30 copayment per retail clinic visit. You can find this information in Chapter 4 on page 85 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 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 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. 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 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 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 $175 copayment for each Medicare-covered visit to an outpatient hospital facility. You can find this information on page 76 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 to qualify for home health services, the patient must be: 1. Confined to the home; 2. Under the care of a physician or allowed practitioner; 3. Receiving services under a plan of care established and reviewed by a physician; 4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) continuing occupational therapy. You can find this rule at 42 CFR Section 409.42. The rules say that eligibility for the home health benefit will be determined based on the certifying physician's records. If the enrollee was directly admitted to home health from an acute or post-acute care facility, the facility records may be used instead. The medical records for the enrollee must contain information that justifies the referral for home health services. The certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face encounter visit. You can find these rules in the Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1, 30.5.1.1, and 30.5.1.2.
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 replacement of equipment due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment. If the item of equipment has been in continuous use by the patient on either a rental or purchase basis for the equipment's useful lifetime, the beneficiary may elect to obtain a new piece of equipment. Replacement may be reimbursed when a new physician order and/or new CMN, when required, is needed to reaffirm the medical necessity of the item. In the absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years. You can find this in the Medicare Benefit Policy Manual, Chapter 15, Section 110.The rules also say that a power seating system -tilt only, recline only, or combination tilt and recline -with or without power elevating leg rests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; and2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary's seating and positioning needs. The PT, OT, or practitioner may have no financial relationship with the supplier; and3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or6. The power seating system is needed to manage increased tone or spasticity.If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.Elevating leg rests (E0990, K0046, K0047, K0053, K0195) are covered if:1. The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or2. The beneficiary has significant edema of the lower extremities that requires an elevating leg rest; or 3. The beneficiary meets the criteria for and has a reclining back on the wheelchair.You can find this in the Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792).
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 CMS has established units of service edits referred to as Medically Unlikely Edits (MUEs). An MUE for a HCPCS/CPT code is the maximum number of units of service under most circumstances allowable by the same provider for the same enrollee on the same date of service. Claims submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(V). The rules say that Medicare regulations require that each practice location of a supplier of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) (if it has more than one) must, by law, be separately enrolled in Medicare and have its own unique Medicare identification number. Suppliers of DMEPOS include but are not limited to pharmacies, oxygen suppliers, and outpatient physical therapy agencies. (Any organization that sells equipment or supplies that are billed to Medicare through the DME MAC must be enrolled as a supplier of DMEPOS through the NSC. Sometimes, these are organizations that also furnish services that are covered by Medicare, such as ambulatory surgical centers. In order to be reimbursed for the DME supplies that they sell, they must separately enroll in Medicare as a supplier of DME.) You can find this information in the Medicare Program Integrity Manual, Chapter 15, Section 15.3.
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 say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health
plan contract says that only certain codes/services are covered under the Plan. The EOC lists specific services
which are a covered benefit and any service not listed in this section is not a covered benefit. You can find this
information in Chapter 4 on pages 54 and 90-95 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 $35 copayment for Medicare-covered specialist visit. You can find this information on page 84 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 acupuncture as an anesthetic, as an analgesic, or for other therapeutic purposes. You can find this rule in the Medicare National Coverage Determinations Manual, Chapter 1, Sections 30.3, 30.3.1, and 30.3.2.
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 acupuncture is not covered under any condition. You can find this information on page 91 of the 2020 Evidence of Coverage (EOC) and on page 87 of the 2019 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say 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 each non-routine Medicare-covered foot care visit. This is for diagnosis and the medical or surgical treatment of injuries and diseases of the feet (such as hammer toe or heel spurs). You can find this information on page 88 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).
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 your deductible is $198, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before the Plan will pay its share for your covered Medicare Part A and B services. You can find this information on page 1 of the Plan's 2020 Schedule of Cost Sharing.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that the only chiropractic service covered by the Plan is manual manipulation of the spine to correct a subluxation. You can find this information in the Schedule of Cost Sharing on page 9 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 providers must report services correctly. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A).The rules say that a RAP and a claim must be submitted for all episodes for which Medicare makes payment based on HIPPS codes. You can find this rule in Medicare Claims Processing Manual, Chapter 10, 40.3.
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 3-4 and 3-7 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 plans must make reasonable and diligent efforts to gather and forward information
to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances,
Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1.
The rules say that a contract plan provider is an agent of the plan. Services and referrals obtained from a plan
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan,
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or
item is never covered, the plan does not have to hold the enrollee harmless.
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless.
You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 160.
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 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:Acute carbon monoxide intoxication,Decompression illness,Gas embolism,Gas gangrene,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.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.Progressive necrotizing infections (necrotizing fasciitis),Acute peripheral arterial insufficiency,Preparation and preservation of compromised skin grafts (not for primary management of wounds),Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management,Osteoradionecrosis as an adjunct to conventional treatment,Soft tissue radionecrosis as an adjunct to conventional treatment,Cyanide poisoning,Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment,Diabetic wounds of the lower extremities in patients who meet the following three criteria:Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;Patient has a wound classified as Wagner grade III or higher; and Patient has failed an adequate course of standard wound therapy.You can find these rules in the National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29).