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 directions which discuss the required elements to be entered onto an 
institutional claim form, CMS-1450. Form Locators (FL) 01 and 02 are for entering the billing provider's 
information, and the billing provider's pay-to information, respectively. It is noted that the billing provider's 
pay-to information is not required on this claim form and is ignored if submitted. You can find thsi information 
in the Medicare Claims Processing Manual, Chapter 25, Section 75.1. 
 
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 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. The Plan contract says that 
dentures are covered once per arch every 5 years, including a full denture, partial denture, or immediate 
denture. You can find this information on page 59 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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 36 one-way routine transportation trips per year. You can find this information on pages 4-65 
through 4-66 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 $60 copayment for radiation therapy. You can find this information in 
Chapter 4 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 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 rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. You can find this information in the ICD-10-CM Official Guidelines for Coding and Reporting FY 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 Plan covers items and services in accordance with Medicare rules. The health 
plan contract says dentures are covered one (1) per arch every five (5) years, including a full denture, partial 
denture, or immediate denture and are not applied to the combined preventive and comprehensive maximum 
plan coverage amount. You can find this information in Chapter 4 on page 59 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 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 in Chapter 3 on pages 3-5 to 3-6 
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 for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 
90%, there is a rebuttable presumption of non-coverage for home oxygen. You can find this rule in the 
Medicare National Coverage Determinations Manual, Section 240.2(D)(3)(c). 
 
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 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. 
 
Medicare guidance says to receive payment for covered Medicare items or services from either Medicare (in 
the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or 
supplier must be enrolled in the Medicare program. You can find this guidance in Medicare Code of Federal 
Regulations 42 CFR Section 424.505. You can find this document on the Centers for Medicare & Medicaid 
Services' website, www.cms.gov. 
 
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 you can get your care from an out-of-network provider, however, in most cases that provider 
must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who has 
opted out of or been excluded or precluded from the Medicare Program. If you receive care from a provider 
who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you 
receive. Check with your provider before receiving services to confirm that they are eligible to participate in 
Medicare. You can find this information in Chapter 3 on page 3-4 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. 
 
A pneumatic compression device (PCD) coded as E0652 is covered for the treatment of lymphedema extending 
onto the chest, trunk and/or abdomen when all of the following are met: 
 
? The beneficiary has lymphedema of an extremity. 
? The coverage criteria for an E0650 or E0651 PCD are met. 
? The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the 
limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to 
improve with a four-week trial. 
 
A four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651 
PCD is required. The four-week trial of conservative therapy must include all of the following: 
 
? At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 PCD after 
careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and 
successfully uses the appliance provided 
? Compliant use of an appropriate compression bandage system or compression garment to provide 
adequate graduated compression 
? Elevation where appropriate 
? Manual lymphatic drainage (where available) and self-manual lymphatic drainage (MLD) for at least 30 
minutes per day 
? Evaluation of diet and implementation of any necessary change 
? Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.) 
? Correction (where possible) of anemia and/or hypoproteinemia 
 
You can find this information at Local Coverage Determination (LCD): Pneumatic Compression Devices 
(L33829). 
 
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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract also includes a 
list of the covered supplemental dental benefits. The core buildup (D2950) is not on this list and is not a 
covered supplemental benefit. You can find this information on pages 90 to 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 requests for power mobility devices must include an evaluation by a Licensed Physical 
Therapist that determines the enrollee's need for the device and determines if the enrollee can safely operate the 
device in the home. The evaluation should be tailored to the individual beneficiary's conditions. The history 
should paint a picture of the beneficiary's functional abilities and limitations on a typical day. It should contain 
as much objective data as possible. The physical examination should be focused on the body systems that are 
responsible for the beneficiary's ambulatory difficulty or impact on the beneficiary's ambulatory ability. The 
written report of this encounter must be available upon request. This rule can be found in Local Coverage 
Determination (LCD): Power Mobility Devices (L33789). 
 
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 the applicable payments made under the prospective payment systems are payment in full for 
all facility or hospital services, as defined in 42 CFR Section 409.10. CMS does not pay any provider or 
supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must 
furnish all necessary covered services to the beneficiary either directly or under arrangements (as defined in 42 
CFR Section 409.3). You can see this in 42 CFR Section 412.50 Furnishing of inpatient hospital services 
directly or under arrangements.
 
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 S codes are used by the Blue Cross/Blue Shield Association (BCBSA) and the Health Insurance 
Association of America (HIAA) to report drugs, services, and supplies for which there are no national codes 
but for which codes are needed by the private sector to implement policies, programs, or claims processing. 
They are for the purpose of meeting the particular needs of the private sector. These codes are also used by the 
Medicaid program, but they are not payable by Medicare. You can find this information in Medicare's 42 CFR 
Section 414.40 (a). 
 
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 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 41 of the Plan's 2020 
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 patient's medical records must establish medical necessity for a hospital bed due to one of the following 
reasons: 
 
1. The patient's condition requires positioning of the body; e.g., to alleviate pain, promote good body 
alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or  
 
2. The patient's condition requires special attachments that cannot be fixed and used on an ordinary bed.  
You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.7(A). 
 
In order to qualify for a semi-electric hospital bed, the patient's condition must require frequent change in body 
position and/or there may be an immediate need for a change in body position (i.e., no delay can be tolerated) 
and the patient can operate the controls and cause the adjustments. Exceptions may be made to this last 
requirement in cases of spinal cord injury and brain damaged patients. You can find this rule in the Medicare 
National Coverage Determinations Manual, Section 280.7(D). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 applicable payments made under the prospective payment systems are payment in full for 
all facility or hospital services, as defined in 42 CFR Section 409.10. CMS does not pay any provider or 
supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must 
furnish all necessary covered services to the beneficiary either directly or under arrangements (as defined in 42 
CFR Section 409.3). You can see this in 42 CFR Section 412.50 Furnishing of inpatient hospital services 
directly or under arrangements. 
 
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 consistent with Sections 1852(a)(2) and 1852(k)(1) of the Social Security Act, non-contract 
providers must accept as payment in full payment amounts applicable in Original Medicare. Thus, this 
provision of law imposes a cap on payment to non-contract providers of provider payment amounts plus 
beneficiary cost-sharing amounts applicable in Original Medicare. In addition, under Federal law, non-contract 
providers are subject to penalties if they accept more than Original Medicare amounts. You can find this 
information in the Medicare Managed Care Manual, Chapter 6, Section 100. 
 
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 $20 copayment for lab services. You can find this information on page 
75 of the Plan's 2020 Evidence of Coverage (EOC).