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 the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet ALL the following criteria: Initial thermal RFA: After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used) AND Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale; Frequency Limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. You can find this information in the Local Coverage Determination (LCD) Facet Joint Interventions for Pain Management (L35936).
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 $35 copayment per visit for podiatry services. You can find this information on page 101 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 Outpatient diagnostic tests and therapeutic services and supplies. You can find this information on page 55 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 $40 copayment for telehealth visits with a specialist. You can find this information on page 101 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).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract also says that there is a $750 deductible which applies to certain items and services. The Plan
deductible applies to diagnostic imaging services. You can find this information on pages 67 and 68 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 $30 copayment for Medicare covered vision services at an in-network
specialist's office. You can find this information on page 84 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 state that all SNF Part A inpatient services are paid under a prospective payment system (PPS). This
involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code. Under the new
Patient-Driven Payment Model (PDPM), which is effective for services provided on or after 10/1/2019, the
HIPPS code is structured differently, as a result of there being five case-mix adjusted rate components under
the revised model. The first position represents the Physical and Occupational Therapy case-mix group. The
second position represents the Speech-Language Pathology (SLP) case-mix group. The third character
represents the nursing case-mix group. The fourth character represents the Non-Therapy Ancillary (NTA) casemix
group. The fifth character represents the assessment indicator code. You can find this information in the
Centers for Medicare and Medicaid Service (CMS), Internet-Only Manual, Medicare Claims Processing
Manual, Chapter 6, Sections 10, 30, and 120.
The CMS has published a PDPM Calculation Worksheet for SNFs in which it describes the steps involved in
determining the letter to be used in the HIPPS code for each position. The nursing-case mixed group "HBCI,"
which corresponds to a third digit of P in the HIPPS code, is used for patients in the Clinically complex
classification with a nursing function score of 6-14 and no depression. Conditions classified as Clinically
Complex include open lesions (other than ulcers, rashes, and cuts) with any selected skin treatment or surgical
wounds. Selected Skin Treatments are M1200F Surgical wound care, M1200G Application of nonsurgical
dressing (other than to
feet), or M1200H Application of ointments/medications (other than to feet). You can find this information on
the CMS website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/SNFPPS/Downloads/MDS_Manual_Ch_6_PDPM_508.pdf.
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 a form-fitting conductive garment (and medically necessary related supplies) may be covered under the program only when: 1. It has received permission or approval for marketing by the Food and Drug Administration; 2. It has been prescribed by a physician for use in delivering covered TENS or NMES treatment; and 3. One of the medical indications outlined is met: The patient cannot manage without the conductive garment because there is such a large area or so many sites to be stimulated and the stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes and lead wires; The patient cannot manage without the conductive garment for the treatment of chronic intractable pain because the areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes and lead wires; The patient has a documented medical condition such as skin problems that preclude the application of conventional electrodes, adhesive tapes and lead wires; The patient requires electrical stimulation beneath a cast either to treat disuse atrophy, where the nerve supply to the muscle is intact, or to treat chronic intractable pain; or The patient has a medical need for rehabilitation strengthening (pursuant to a written plan of rehabilitation) following an injury where the nerve supply to the muscle is intact. A conductive garment is not covered for use with a TENS device during the trial period specified in 160.3 unless: 4. The patient has a documented skin problem prior to the start of the trial period; and 5. The B/Medicare Administrative Contractor's medical consultants are satisfied that use of such an item is medically necessary for the patient. You can find this in the National Coverage Determination for Supplies Used in the Delivery of Trans-cutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES)160.13.
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 $250 copayment for advanced imaging services. You can find this
information on pages 86 to 87 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 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, Publication 100-16, 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 38 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 $50 copayment in a specialist's office. The Plan contract also says that enrollees must pay a 20% coinsurance for Medicare Part B covered drugs in a specialist's office. You can find this information on pages 60 and 70-71 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 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). The rules also 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, Section 424.5. The rules also 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 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 state that effective January 1, 1998, Medicare also covers self-administered anti-emetics, which are
necessary for the administration and absorption of the anti-neoplastic chemotherapeutic agents when a high
likelihood of vomiting exists. The anti-emetic drug is covered as a necessary means for administration of the
anti-neoplastic chemotherapeutic agents. Oral drugs prescribed for use with the primary drug, which enhance
the anti-neoplastic effect of the primary drug or permit the patient to tolerate the primary anti-neoplastic drug in
higher doses for longer periods, are not covered. Self-administered anti-emetics to reduce the side effects of
nausea and vomiting brought on by the primary drug are not included beyond the administration necessary to
achieve drug absorption.
Section 1861(s)(2) of the Social Security Act extends coverage to oral anti-emetic drugs that are used as full
replacement for intravenous dosage forms of a cancer regimen under the following conditions:
- Coverage is provided only for oral drugs approved by the Food and Drug Administration (FDA) for use as
anti-emetics;
- The oral anti-emetic must either be administered by the treating physician or in accordance with a written
order from the physician as part of a cancer chemotherapy regimen;
- Oral anti-emetic drugs administered with a particular chemotherapy treatment must be initiated within 2 hours
of the administration of the chemotherapeutic agent and may be continued for a period not to exceed 48 hours
from that time;
- The oral anti-emetic drugs provided must be used as a full therapeutic replacement for the intravenous anti-
emetic drugs that would have otherwise been administered at the time of the chemotherapy treatment.
Only drugs pursuant to a physician's order at the time of the chemotherapy treatment qualify for this benefit.
The dispensed number of dosage units may not exceed a loading dose administered within two hours of the
treatment, plus a supply of additional dosage units not to exceed 48 hours of therapy.
You can find this information in the Medicare Benefit Policy Manual Chapter 15 Section 50.5.4.
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 that, contingent upon the patient's consent, the clinical psychologist (CP) will attempt to consult
with the patient's attending or primary care physician in accordance with accepted professional ethical norms,
taking into consideration patient confidentiality. If the patient assents to the consultation, the CP must attempt
to consult with the patient's physician within a reasonable time after receiving the consent. If the CP's attempts
to consult directly with the physician are not successful, the CP must notify the physician within a reasonable
time that he or she is furnishing services to the patient. Additionally, the CP must document, in the patient's
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or,
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception
to the consultation requirement for CPs is in cases where the patient's primary care or attending physician refers
the patient to the CP. 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 160(e).
The rules say that a clinical social worker must comply with the same consultation requirements as a clinical
psychologist. You can find this rule at 42 CFR Section 410.73.
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.
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device.
This rule does not apply to:
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after
each cataract surgery with insertion of an IOL; and
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with
an IOL.
You can find this rule at 42 CFR Section 411.15(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 also says that the Plan covers a routine vision benefit with a Frames and Lens Package. You have a
choice of a $100 (combined in and out-of-network) benefit toward the purchase and fitting of eyeglasses and
pair of lenses or contact lenses (1 per calendar year). You can find this information on page 93 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 $0 copayment for outpatient surgery received in an outpatient hospital or ambulatory surgical center. You can find this information on page 72 of the Plan's 2021 Evidence of Coverage (EOC).