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 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 the 
Plan covers up to a maximum of $300 per calendar year for any dental services. You are responsible for 100% 
of the costs of all dental services once the $300 annual allowance is reached. The Plan contract also says that 
generally, your costs will be lower if you are treated by a Plan dentist. If you choose to go to any other state-
licensed dentist, you may pay more. You can find this information in the Plan's Dental Rider.
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 lists the specific 
dental services that are covered. Topical application of fluoride varnish is not listed and therefore is not a 
covered service. Periodontal maintenance is not listed and therefore is not a covered service. Gingival irrigation 
is not listed and therefore is not a covered service either. You can find this information on pages 94 and 95 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. The contract lists the specific 
dental services that are covered. Lower denture rebase is not listed and therefore is not a covered service. The 
contract also says any services not listed are not covered. You can find this information on page 4-73 to 4-84 of 
the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that for each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal 
RF sessions will be reimbursed in any rolling 12 month year, involving no more than four (4) joints per session, 
e.g., two (2) bilateral levels or four (4) unilateral levels. 
You can find these rules in the Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch 
Blocks, and Facet Joint Radiofrequency Neurotomy, L36471. This LCD is effective for services provided on or 
after October 10, 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 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 for Medicare to consider coverage and payment for any item or service, the information 
submitted by the provider must corroborate the documentation in the beneficiary's medical documentation and 
confirm that Medicare coverage criteria have been met. You can find this in the National Correct Coding 
Initiative Policy Manual For Medicare Services, Chapter I - General Correct Coding Policies, Section A. and 
the Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Action, 
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 say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances, 
Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that the services of a nurse practitioner (NP) may be covered under Part B if all of the following 
conditions are met:  
 
- They are the type that are considered physician's services if furnished by a doctor of medicine or osteopathy 
(MD/DO); 
- They are performed by a person who meets the definition of an NP; 
- The NP is legally authorized to perform the services in the State in which they are performed; 
- They are performed in collaboration with an MD/DO and 
- They are not otherwise precluded from coverage because of one of the statutory exclusions. 
 
You can find this information in the Medicare Benefit Policy Manual, Chapter 15, Section 200. 
 
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 $315 copayment for days 1-5 for inpatient hospital care. You can find 
this information in Chapter 4 on page 65 of 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 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. You can find 
this in the Medicare National Coverage Determinations Manual, Chapter 1, Section 280.6. 
 
The rules also say that 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 as defined above 
    The coverage criteria for an E0650 or E0651 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 is required. 
 
PCD related accessories (E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, 
E0672, E0673) are eligible for reimbursement only when the appropriate, related base PCDs (E0650, E0651, 
E0652, E0675) meets the applicable coverage criteria for that type of PCD. 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 these rules in 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. This benefit includes 
complete maxillary denture (D5110) and complete mandibular denture (D5120) and are each limited to one 
procedure every five plan years. You can find this information on page 4-58 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 an 
annual maximum benefit of $1,000. After the annual maximum is exhausted, any remaining charges are your 
responsibility. You can find this information on page 4-74 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 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 20% coinsurance for Medicare Part B prescription drugs. You can find 
this information in Chapter 4 on page 75 of 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 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Medicare covers one ultrasound screening for an abdominal aortic aneurysm provided to 
eligible beneficiaries. Payment may not be made for an ultrasound screening for an abdominal aortic aneurysm 
that is performed for an individual that has previously had an ultrasound screening for an abdominal aortic 
aneurysm covered by Medicare. You can find this rule in 42 Code of Federal Regulations (CFR), Section 
410.19. 
 
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 the Plan covers a one-time screening ultrasound for people at risk of abdominal aortic 
aneurysm. You can find this information in the Schedule of Cost Sharing of the Plan's 2020 Evidence of 
Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare covers medical nutrition therapy services (MNT) for certain enrollees who have 
diabetes or a renal disease. You can find this rule at 42 CFR Section 410.132(b)(4) and in the National 
Coverage Determinations Manual, Chapter 1, Section 180.1. 
 
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. The Plan 
contract says that medical nutrition therapy is a benefit for people with diabetes, renal (kidney) disease (but not 
on dialysis), or after a kidney transplant when referred by a doctor. You can find this information in Chapter 4 
on page 74 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 on pages 12 through 13.
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 If the supplier utilizes a shipping service or mail order, the POD documentation must be a 
complete record tracking the item(s) from the DMEPOS supplier to the beneficiary. An example of acceptable 
POD would include both the supplier's own detailed shipping invoice and the delivery service's tracking 
information. The supplier's record must be linked to the delivery service record by some clear method like the 
delivery service's package identification number or supplier's invoice number for the package sent to the 
beneficiary. The POD document must include: 
 
- Beneficiary's name 
- Delivery address 
- Delivery service's package identification number, supplier invoice number, or alternative method that links 
the supplier's delivery documents with the delivery service's records 
- A description of the item(s) being delivered. The description can be either a narrative description (e.g., 
lightweight wheelchair base), a HCPCS code, the long description of a HCPCS code, or a brand name/model 
number 
- Quantity delivered 
- Date delivered 
- Evidence of delivery 
 
You can find this rule in the Local Coverage Article for Standard Documentation Requirements for All Claims 
Submitted to DME MACs (A55426). 
 
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. This benefit includes 
comprehensive oral evaluation (D0150) and is limited to one procedure every three plan years. You can find 
this information on page 4-54 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 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% coinsurance for Medicare-covered chemotherapy drug and its 
administration. You can find this information on pages 4-26 and 4-27 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 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 20% coinsurance for Medicare Part B prescription drugs. You can find 
this information in Chapter 4 on pages 25 - 26 of the Plan's 2019 EOC.  
 
The Plan contract also says that enrollees must pay a $295 copayment for outpatient surgery and other medical 
services provided at hospital outpatient facilities and ambulatory surgical centers. You can find this information 
in Chapter 4 on page 35 of the Plan's 2019 EOC.