Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health 
plan contract states, "Your deductible is $750. This is the amount you have to pay out-of-pocket before we will 
pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the 
full cost of your covered services. Once you have paid your deductible we will begin to pay our share of the 
costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the 
rest of the calendar year." You can find this information in Chapter 4 on page 67 of the plan's 2020 Evidence of 
Coverage. 
 
The health plan contract says that enrollees must pay a $10 copayment after the deductible is met for each basic 
imaging service (e.g., general x-rays or ultrasound). You can find this information in Chapter 4 on page 92 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 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 a pneumatic compression device (PCD) coded as E0675 to treat peripheral artery disease is 
not eligible for reimbursement. There is insufficient evidence to demonstrate that reimbursement is justified. 
Claims for E0675 will be denied as not reasonable and necessary. A PCD that provides intermittent limb 
compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items 
that are used for a preventative service or function are excluded from coverage under the Medicare DME 
benefit. If the base PCD is not covered, related accessories are not eligible for reimbursement. Claims for 
related items will be denied as not reasonable and necessary. You can find this rule in the Local Coverage 
Determination and Article for Pneumatic Compression Devices, L33829 and A52488 (eff 01/01/20). 
 
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. 
 
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 have a network primary care provider (PCP) who is providing and overseeing their 
care. As a member of the plan, the enrollee must choose a network PCP. In most situations, the network PCP 
must give approval in advance before the enrollee can use other providers in the plans network, such as 
specialists, hospitals, skilled nursing facilities, or home health care agencies. This is called giving the enrollee a 
?referral.? Referrals from a PCP are not required for emergency care or urgently needed services. The Point of 
Service (POS) benefit allows the enrollee to access other services from non-network providers. The enrollee 
will pay more to access services outside the network when this benefit is used. The enrollee must get a referral 
from their PCP prior to getting care from out-of-network providers via the POS benefit. If a referral is not 
obtained, the enrollee will have to pay the full cost of any services received. You can find this information on 
pages 56 and 62 of the Plans 2019 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 Molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage when ALL 
of the following criteria are met: 
&#61623; Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are 
unavailable or results are clearly equivocal; AND 
&#61623; Availability of a clinically valid test, based on published peer reviewed medical literature; AND 
&#61623; Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed test) 
or LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) of 
analytical validity and clinical utility; AND 
&#61623; Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND 
&#61623; For testing panels, including but not limited to, multiple genes or multiple conditions, and in cases where a 
tiered approach/method is clinically available, testing would be covered ONLY for the number of genes or 
test that are reasonable and necessary to obtain necessary information for therapeutic decision making; 
AND 
&#61623; Individual has not previously received genetic testing for the disease/condition. (In general, diagnostic 
genetic testing for a disease should be performed once in a lifetime.) Exceptions include clinical scenarios 
whereby repeat testing of somatically-acquired mutations (for example, pre- and post- therapy) may be 
required to inform appropriate therapeutic decision-making. 
 
You can find these rules in the Local Coverage Determination (LCD) for Molecular Pathology Procedures, 
L35000. This LCD is effective for services provided on or after October 3, 2019 and before June 30, 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 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 pages 54 and 60-61 of the 
Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that the PACE benefit package must include the following:  
(a) All Medicare-covered items and services;  
(b) All Medicaid-covered items and services, as specified in the State's approved Medicaid plan; and   
(c) Other services determined necessary by the interdisciplinary team to improve and maintain the enrollee's 
overall health status.  
You can find this rule at 42 Code of Federal Regulations (CFR) Section 460.92. 
 
The rules say that an inpatient admission is generally appropriate when the admitting physician expects the 
patient to need hospital care that crosses at least two midnights. The expectation should be based on such 
complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and 
medical risk. The factors must be documented in the medical record.  
 
If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be 
considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as 
inpatient only is generally appropriate, regardless of the length of stay. An inpatient admission may be 
appropriate if the admitting physician expects a patient to require hospital care for only a limited period of 
time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be 
supported by the medical record. You can find this rule at 42 CFR Section 412.3. 
 
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 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 
you will save more when you receive care from one of the Plan's in-network dental providers. You can get care 
from an out-of-network dental provider, but you may pay more. You can find this information on page 67 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 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 $360 copayment per day for days 1-5 for inpatient hospital care. You 
can find this information on page 65 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 pages 34-35 of the Plans 
2019 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 Below is a list of individuals and entities that frequently attempt to enroll in Medicare, but 
are not eligible to do so.  If the contractor receives an enrollment application from any of these individuals or 
entities, the contractor shall deny the application, with the exception of entities eligible to enroll using the Form 
CMS-20134, which is specific to the furnishing of MDPP services. An assisted living facility, for example, that 
also provides the DPP and is eligible to enroll as an MDPP supplier may enroll through the CMS-20134, 
however, this enrollment only pertains to the rendering of MDPP services.    
 
Acupuncturist ?Assisted Living Facility ?Birthing Center ?Certified Alcohol and Drug Counselor ?Certified 
Social Worker ?Drug and Alcohol Rehabilitation Counselor ?Hearing Aid Center/Dealer ?Licensed Alcoholic 
and Drug Counselor ?Licensed Massage Therapist ?Licensed Practical Nurse  ?Licensed Professional Counselor 
?Marriage Family Therapist  ?Master of Social Work ?Mental Health Counselor ?National Certified Counselor 
?Occupational Therapist Assistant ?Physical Therapist Assistant ?Registered Nurse ?Speech and Hearing Center 
?Substance Abuse Facility. You can find this information in the Medicare Program Integrity Manual, Chapter 
15, Section 15.4.8 - Suppliers Not Eligible to Participate. 
 
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 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. The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract lists the specific dental services that are covered by the Plan. Core build up is not listed and therefore is not a covered service. The Plan contract also says if a dental item or service is not listed in the benefit chart then it is not covered. You can find this information on pages 21 to 29 of the Plan's 2020 supplemental dental Customer 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 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. The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan supplemental dental contract says the Plan offers a dental benefit that exceeds Medicare coverage. Members must utilize a dentist in the dental network. To be covered in-network, you need to use a provider that is contracted with the plan's supplemental dental network to provide supplemental dental services. Care rendered by a provider that is not part of the supplemental dental network is not covered. You can find this information on page 56 in the Plan's 2019 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 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. The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says the following services are covered when medically necessary and based on the benefit limitations and clinical criteria described in the supplemental dental Office Manager Reference Manual found online. You can find this information on page 66 of the Plan's 2020 Evidence of Coverage. The office reference manual (ORM) lists the specific dental services that are covered by the Plan. Gum medication is not listed and therefore is not a covered service. Mouth guard for teeth grinding is not listed and therefore is not a covered service either. You can find this information on pages 289 through 326 of the ORM.
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 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. The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract lists the specific dental services that are covered by the Plan. Core build up is not listed and therefore is not a covered service. Prefabricated post and core is not listed and therefore is not a covered service either. The Plan contract also says if a dental item or service is not listed in the benefit chart then it is not covered. You can find this information on pages 21 to 28 of the Plan's 2020 supplemental dental Customer 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 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. The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that prior authorization (approval in advance) may be required. The contract also says that extraction: unlimited removal of erupted or exposed roots every year are covered but limitations and exclusions apply. You can find this information on page 85 and 86 of the Plan's 2020 Evidence of Coverage. The contract provides a list of covered dental benefits. Extraction (code D7140) is not included on this list and is not a covered benefit. You can find this information on pages 44 to 50 of the Plan's 2020 supplemental dental network Exhibit A Benefits Covered for UAM Dental 1000 document.
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 $155 copayment for each Medicare-covered radiological diagnostic 
service, not including X-rays, performed in a physician's office or a freestanding facility.  Diagnostic radiology 
services for which this copayment applies includes specialized scans, CT, SPECT, PET, MRI, MRA, nuclear 
studies, ultrasounds, diagnostic mammograms and interventional radiological procedures. You can find this 
information on page 4-32 of the Plan's 2020 Evidence of Coverage (EOC).