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 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 $150 copayment for Medicare-covered, in-network, outpatient hospital
services. You can find this information on page 90 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 $325 copayment for each Medicare-covered outpatient hospital visit.
You can find this information on page 95 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 $90 copayment for emergency services at an in-network emergency room. You can find this information on page 63 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 includes oral exams, prophylaxis, bitewing x-rays, fillings and anesthesia. Periapical x-rays are not listed as covered services. You can find this information on pages 83 to 84 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that for services performed on or after January 21, 2020, Medicare will now provide limited coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may be provided by a physician in accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 30.3.3.
Effective for services performed on and after October 24, 2006, the Centers for Medicare & Medicaid Services has determined that there is sufficient evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act (the Act). The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. You can find this information in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Publication 100-03, National Coverage Determinations Manual 270.6, Infrared Therapy Devices.
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 offers additional coverage for acupuncture beyond what is covered by Medicare. This benefit covers up to 12 visits in 90 days for the purpose of chronic low back pain. You can find this information on page 4-7 of the Plan's 2021 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 may cover a drug or biological if it is safe and effective and otherwise reasonable
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1.
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or
other harm to the enrollee.
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42
CFR Sections 422.2 and 422.136.
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals.
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You
can find this information on page 74 of the 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 Local Medicare coverage of such biomarkers must be predicated upon four fundamental principles: 

1. First, the biomarkers must have proven clinical validity/utility (CVU). 
2. Second, to support the medical necessity of the service, there must be acceptance/uptake of specific testing into patient management. It is essential that physicians be familiar enough with all specific biomarkers, which they order, such that all test results may become clinically actionable. 
3. Providers managing oncological conditions must demonstrate that the use of biomarkers will be used to assist in the management/treatment of the beneficiary. 
4. Peer-reviewed full manuscript evidence is required to support combination panels for multiple biomarkers, particularly regarding their alleged composite clinical validity/utility. For example; such potential billing for multiple, diverse biomarkers (e.g., diagnostic/monitoring/prognostic/predictive) can only achieve medical necessity when it is clearly evident how each requested biomarker can be individually contributory. 

The OVA1 proteomic assay will be considered reasonable and necessary when performed according to the FDA label. You can find this information in the Local Coverage Determination (LCD): Biomarkers for Oncology (L35396).

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 $160 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-network physician's office or at an in-network free-standing facility (such as a radiology center or medical clinic). You can find this information on pages 4-29 to 4-32 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 a $150 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You can find this information on pages 4-37 to 4-39 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. 
 
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion 
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the 
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find 
this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 15, Section 290(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 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. The Plan contract also includes a list of covered supplemental dental benefits. The extraction (D7140) is not on this list and is not a covered supplemental benefit. You can find this information on pages 4-56 to 4-60 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 $40 copayment for services obtain from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. Covered services include some telehealth services including consultation, diagnosis, and treatment by a physician or practitioner, for patients in certain rural areas or other places approved by Medicare. You can find this information on pages 4-41 to 4-45 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 for services performed on or after January 21, 2020, Medicare will now provide limited
coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage,
CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause,
such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This
benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year if there is demonstrated
improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may
be provided by a physician in accordance with state requirements, or by physician assistants, nurse
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements.
Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician,
physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage
Determinations Manual, Section 30.3.3.
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 the Plan covers up to 12 visits in 90 days for acupuncture for chronic low back pain. An
additional 8 sessions will be covered for those patients demonstrating an improvement. No more than 20
acupuncture treatments may be administered annually. You can find this information in Chapter 4 on page 71
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 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). A postoperative period of 10 days in the global surgery package applies to some minor surgeries. The postoperative period for these procedures is indicated in Field 16 of the Medicare Physician's Fee Schedule. If the Field 16 entry is 010, the Plan does not allow separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure. If a diagnostic biopsy with a 10-day global period precedes a major surgery on the same day or in the 10-day period, the major surgery is payable separately. Services by other physicians are not included in the global fee for a minor procedures except as otherwise excluded. If the Field 16 entry is 000, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. Separate payment is made in this instance. You can find this rule in You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 12, Section 40.
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, 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. The contract lists the specific dental services that are covered. Porcelain crown is not listed and therefore is not a covered service. Core build up is not listed and therefore is not a covered service either. You can find this information on pages 92 to 111 of the Plan's 2021 Evidence of Coverage (EOC).