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 air ambulance services only if the enrollee's medical condition is such that 
transportation by either basic, the provision of medically necessary supplies and services or advanced life 
support, an emergency medical technician (EMT) intermediate or EMT-Paramedic ground ambulance is not 
appropriate. Air ambulance services may be covered only if: 
 
1. certain vehicle and crew requirements are met; 
 
2. the enrollee's medical condition needed immediate and rapid ambulance transport that could not have been 
provided by ground ambulance; and  
 
3. either the point of pickup is not accessible by ground vehicle or great distances or other obstacles are 
involved in getting the patient to the nearest hospital with appropriate facilities. 
 
You can find this rule in the Medicare Benefit Policy Manual, Chapter 10, Sections 10.4, and 10.4.1, and 
30.1.1. 
 
Occasionally, the institution to which the patient is initially taken is found to have inadequate or unavailable 
facilities to provide the required care, and the patient is then transported to a second institution having 
appropriate facilities. In such cases, transportation by ambulance to both institutions would be covered to the 
extent of the mileage to be the nearest institution with appropriate facilities. You can find this information in 
the Medicare Benefit Policy Manual Chapter 10- Ambulance Services, 10.3.2 - Institution to Institution.  
 
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 rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare 
Program Integrity Manual Chapter 3 3.3.2.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that critical care is reported with CPT codes 99291 and 99292 when all the criteria for critical 
care and critical care services are met. Critical care is defined as the direct delivery by a physician(s) medical 
care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital 
organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's 
condition. You can find these rules in the Medicare Claims Processing Manual Chapter 12, Section 30.6.12. 
 
Critical care is not a service that is paid on a 'shift' basis or a 'per day' basis. Critical care service is a time-
based service provided on an hourly or fraction of an hour basis. The CPT code 99291 is used to report the first 
30 - 74 minutes of critical care on a given calendar date of service. It should only be used once per calendar 
date per patient by the same physician or physician group of the same specialty. CPT code 99292 is used to 
report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care. You can 
find these rules in the Medicare Claims Processing Manual Chapter 12, Section 30.6.12 (F-G). 
 
The rules say that CPT codes are used to code physician services, including evaluation and management 
services. The services furnished must meet the definition of the code. Physicians should select the E/M code for 
the service based upon the content of the service. Documentation should support the level of E/M service 
reported.  You can find these rules in the Medicare Claims Processing Manual Chapter 12, Section 30.6.1. 
 
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 all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patient's medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patient's 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 
and 5.10. 
 
Before submitting a claim to the DME MAC the supplier must have on file a dispensing order, the detailed 
written order, the CMN (if applicable), the DIF (if applicable), information from the treating physician 
concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation 
statements as defined in certain DME MAC policies. The supplier should also obtain as much documentation 
from the patient's medical record as they determine they need to assure themselves that coverage criteria for an 
item have been met. If the information in the patient's medical record does not adequately support the medical 
necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed ABN of 
possible denial has been obtained. You can find this information in Medicare Program Integrity Manual 
Chapter 5 Items and Services Having Special DME Review Considerations, Supplier Documentation, 5.8. 
 
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). 
 
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 $300 deductible for all items and services, except those specifically excluded 
by the plan's contract. In-network office visits are not excluded from the deductible. You can find this 
information on pages 57 to 58 of the Plan's 2020 Evidence of Coverage (EOC). 
 
The Plan contract also says that enrollees must pay a $10 copayment for provider and professional services at 
an in-network PCP's office. You can find this information on pages 87 to 88 of the Plan's 2020 Evidence of 
Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 10 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 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 45 of the Plan's 2019 and 
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 $200 copayment for outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers. You can find this information in Chapter 4 on 
page 78 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 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 oral 
exams, routine cleanings, bitewing x-rays, and full mouth or panorax x-rays. Resin-based composites are not 
included on this list and is not a covered benefit. You can find this information on page 55 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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say continuous glucose monitoring (CGM) devices covered by Medicare under the DME benefit are 
defined in CMS Ruling 1682R as therapeutic CGMs. Refer to the Non-Medical Necessity Coverage and 
Payment Rules in the LCD-related Policy Article for additional information. Therapeutic CGMs and related 
supplies are covered by Medicare when all of the following coverage criteria (1-6) are met: 
1.   The beneficiary has diabetes mellitus (Refer to the "ICD-10 Codes that are Covered" section of the LCD-
related Policy Article, A52464, for applicable diagnoses); and, 
 
2.   The beneficiary has been using a blood glucose monitor (BGM) and performing frequent (four or more 
times a day) testing; and, 
 
3.   The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump; and, 
 
4.   The beneficiary?s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results; and, 
 
5.   Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the 
beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and, 
 
6.   Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
When a therapeutic CGM (code K0554) is covered, the related supply allowance (code K0553) is also covered. 
If any of coverage criteria (1-6) are not met, the CGM and related supply allowance will be denied as not 
reasonable and necessary.  
You can find this information in Local Coverage Determination, Glucose Monitors, L33822. 
 
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 the following are criteria for the BRCA testing:
Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR) negative,
and human epidermal growth factor receptor 2 (HER2) negative) breast cancer diagnosed; 60 y
 Diagnosed at; 50 y with:
o An additional breast cancer primary
o 1 first, second, or third degree relative5 with breast cancer at any age, or
o 1 first, second, or third degree relative5 with prostate cancer (Gleason score), or
o An unknown or limited family history
Breast cancer diagnosed at any age, and
o 1 first, second, or third degree relative5 with breast cancer;50 y, or
o 1 first, second, or third degree relative5 with ovarian cancer at any age, or
o 1 first, second, or third degree relative5 with metastatic prostate cancer or pancreatic cancer at
any age
o 2 additional diagnoses of breast cancer at any age in patient and/or in close blood relative5,
o A first, second, or third degree male relative with breast cancer
o For an individual of ethnicity associated with higher mutation frequency (e.g. Ashkenazi
Jewish4) no additional family history may be required.
Male breast cancer
-Personal history of prostate cancer (Gleason score) at any age with
1 first, second, or third degree relative5 with ovarian cancer at any age, or
1 first, second, or third degree relative5 with breast cancer 50 y, or
1 first, second, or third degree relative5 with pancreatic cancer at any age, or
1 first, second, or third degree relative5 with metastatic prostate cancer at any age, or
2 first, second, or third degree relatives5 with breast cancer and/or pancreatic cancer and/or prostate
cancer (Gleason score or metastatic) at any age, or
Ashkenazi Jewish ancestry
-Personal history of pancreatic cancer at any age
-Personal history of metastatic prostate cancer (radiographic evidence of or biopsy-proven disease)
-BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of germline
mutation analysis.
You can find these rules in the Local Coverage Determination (LCD) for MolDX: BRCA1 and BRCA2
Genetic Testing, L36082. This LCD is effective for services provided on or after December 4, 2019.
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 LS tumor screening with IHC or MSI is considered medically necessary and covered by Medicare for the following indications:
- All individuals with colorectal cancer regardless of age OR - Individuals with endometrial cancer - *Hereditary nonpolyposis colorectal cancer (HNPCC)-related tumors include colorectal, endometrial, gastric, ovarian, pancreas, ureter and renal pelvis, biliary tract, brain (usually glioblastomas as seen in Turcot syndrome), small intestinal cancers, and sebaceous gland adenomas and keratoacanthomas as seen in Muir-Torre syndrome. - For patients with unresectable or metastatic solid tumors, either MSI or IHC or a multigene NGS or other multi-analyte methodology panel inclusive of MSI microsatellite loci, and MLH1, MSH2, MSH6 and PMS2 genes is medically reasonable and necessary. Testing for Known Familial Variant Testing for a specific known familial variant is considered medically necessary and covered only when the individual being tested has signs and symptoms of a Lynch-associated cancer AND has a blood relative with the specific disease-causing mutation for LS. You can find this rule in the Local Coverage Determination (LCD): MolDX: Genetic Testing for Lynch Syndrome (L36793) effective December 26, 2019.
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 says that there is 
a maximum plan benefit coverage amount of $1,000 per year, which applies to all supplemental (i.e., routine) 
dental services - both preventive and additional comprehensive- covered by the plan. You can find this 
information on page 81 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 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 includes a list of covered supplemental dental services. The contract specifically says that any procedure not listed is not covered. Post and core in addition to crown (D2952) is not included on this list and is not a covered supplemental benefit. You can find this information on pages 21 to 29 of the Plan's 2020 Preventive & Comprehensive Dental Coverage Customer Handbook.