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 for care in a skilled nursing facility (SNF) when all of the following four factors are met:1. The patient requires skilled nursing or skilled rehabilitation services;2. The patient requires these services on a daily basis;3. As a practical matter, the daily skilled services canbe provided only on an inpatient basis in a SNF; and4. The services are reasonable and necessary for the treatment of the patient's illness or injury or the services must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from getting worse. You can find these rules at 42 CFR Section 409.31 and in the Medicare Benefit Policy Manual, Chapter 8, Section 30.  The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also custodial care services. You can find this rule in the Medicare Benefit Policy Manual, Chapter 16, Section 110.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that whole gland HIFU is considered medically necessary as a local treatment for recurrent PCa following radiation therapy (RT) when ALL of the following criteria are met :
1. Biochemical recurrence (BCR) according to the Phoenix definition (PSA nadir + 2 ng/mL)
2. Positive post-RT transrectal ultrasound guided (TRUS) biopsy
3. Candidate for local curative therapy as evidenced by favorable clinical and pathologic factors (BOTH of the following)
a.	Original (pre-RT)- clinical stage T1-T2, NX or N0
b.	Current (ALL are required)
i.	PSA < 10 ng/mL
ii.	absence of distant metastases per National Comprehensive Cancer Network (NCCN) imaging guidelines
iii.	no lymph node involvement
iv.	interval to biochemical failure > 18 months
v.	International Society of Urological Pathology (ISUP) grade < 4
vi.	local recurrence amenable to entire destruction
4. Multi-disciplinary consensus (surgeon, oncologist, radiologist)
5. Hi comorbidity (i.e., not a candidate for radical prostatectomy (RP)) (3) 
You can find these rules in the Local Coverage Determination (LCD) for Salvage High-intensity Focused Ultrasound (HIFU) Treatment in Prostate Cancer (PCa), L38262. This LCD is effective for services provided on or after April 1, 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 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 Plancovers 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 2 routine exams a year, 2 standard cleanings a year, 2 fluoride treatmentsa year, and dental x-rays. You can find this information on page 4-72 through 4-76 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 that a Medicare plan may restrict members to anetwork of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3).The rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You canfind this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 28 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 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. This benefit includes
bitewing and panoramic x-rays only. You can find this information on page 4-73 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 state that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. You can find this information in the Local Coverage Article: Wheelchair Options/Accessories -Policy Article (A52504).
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 care. You can find this information on pages 66 to 67 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 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 page 302 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 a Medicare plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 14 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.Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the health plan sufficient information to determine whether payment is due and the amount of payment. You can find this rule at 42 CFR Section 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 Section 3.3.2.1.The rules say that an order is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. While a physician order is not required to be signed,the physician must clearly document, in the medical record, his or her intent that the test be performed. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 80.6.1.
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 says prosthodontics are covered services when they are medically reasonable and necessary. You can find this information on pages 78 and 122 of the Plan's 2020 Evidence of Coverage. The contract also says that criteria for crowns includes at least one abutment tooth requires a crown (based on traditional requirements of medical necessity and dental disease). The space cannot be filled with a removable partial denture. You can find this information on page 97 of the Plan's supplemental dental coverage 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 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 per specialist visit. You can find this information on
page 101 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 state that the following services, as described below and billed with any CPT and or HCPCS code,
are considered not proven effective or not medically reasonable and necessary and will be denied as such:
0232T: Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation
when performed.
You can find this rule in Local Coverage Determination (LCD): Non-Covered Services (L35008).
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 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 blood banking codes are 86077, 86078, and 86079 and represent professional component-only services. These codes do not have a technical component. You can find this information at Medicare Claims Processing Manual Chapter 12, Section 60.The rules say that reporting of HCPCS/CPT codes is required of acute care hospitals. The HCPCS codes are required for all outpatient hospital services unless specifically excepted in manual instructions. The CPT codes generally are created to describe and report physician services, but are also used by other providers/suppliers to describe and report services that they provide. Therefore, the CPT code descriptors do not necessarily reflect the facility component of a service furnished by the hospital. In cases where there are separate codes for the technical component, professional component, and/or complete procedure, hospitals should report the code that represents the technical component for their facility services. If there is no separate technical component code for the service, hospitals should report the code that represents the complete procedure. You can find this information in the Medicare Claims Processing Manual, Chapter  4, Section 20.1 and 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.
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 $14 copayment for X-rays. You can find this information on page 4-37
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 state that for a diagnosis of obstructive sleep apnea (OSA) to be made, the following criteria must be met: A. Prior to sleep testing, the patient has a face-to-face clinical evaluation by the treating physician to assess the patient for OSA which must include, at a minimum, the following: 1. Sleep history and symptoms including, but not limited to, snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches; and, 2. Epworth Sleepiness Scale; and, 3. Physical examination that documents body mass index, neck circumference and a focused cardiopulmonary and upper airway system evaluation. B. The patient has a covered sleep test that meets either of the following criteria: 1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or, 2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of: a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, b. Hypertension, ischemic heart disease, or history of stroke. You can find this information in the Local Coverage Determination (LCD): Polysomnography and Sleep Testing (L33405).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $270 copayment for advanced imaging services. You can find this information on page 77 of the Plan's 2019 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 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 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 health plan contract also states that 12 one-way transportation trips are covered per year with a one-way 50 mile limit. You can find this on page 4-62 of the 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 $400 copayment for an outpatient hospital facility. You can find this information on page 97 of the Plan's 2020 Evidence of Coverage (EOC).