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. This benefit
includes three extraction procedures per calendar year. You pay 100% of the cost for out-of-network services.
You can find this information on page 89 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

Please note, the local coverage determination (L34229) the plan used in their decision to deny coverage has
been retired and no longer binding in this case.
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).
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 to qualify for home health services, the patient must be:
1. Confined to the home;
2. Under the care of a physician or allowed practitioner;
3. Receiving services under a plan of care established and reviewed by a physician;
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d)
continuing occupational therapy.
You can find this rule at 42 CFR Section 409.42.
The rules say that eligibility for the home health benefit will be determined based on the certifying physician's
records. If the enrollee was directly admitted to home health from an acute or post-acute care facility, the
facility records may be used instead. The medical records for the enrollee must contain information that
justifies the referral for home health services.
The certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a
face-to-face encounter with the enrollee within the required timeframe. The records must contain the actual
clinical note for the face-to-face encounter visit. You can find these rules in the Medicare Benefit Policy
Manual, Chapter 7, Section 30.5.1, 30.5.1.1, and 30.5.1.2.
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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).
The rules say that Medicare does not cover chiropractic maintenance care. When further clinical improvement
cannot be reasonably expected from ongoing care, the care is considered maintenance. You can find this rule in
the Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3.
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 for chiropractic care the Plan only covers manual manipulation of the spine to correct
subluxation. You can see this on page 4-72 of the 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 $20 copayment for Diagnostic Tests. You can find this information on
page 83 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.
Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the
beneficiary while an inpatient. The facility or hospital must furnish all necessary covered services to the
beneficiary either directly or under arrangements made between the facility and hospital and outside vendors.
You can find this rule at 42 CFR, Sections 409.3 and 412.50.
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 that only certain codes/services are covered under the Plan. The EOC lists specific services
which are a covered benefit and any service not listed in this section is not a covered benefit. You can find this
information in Chapter 4 on pages 4-14 and 4-73 to 4-77 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 $35 copayment for each in-network specialist visit for Medicarecovered
services. You can find this information on pages 97 to 99 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).
The rules say that Medicare does not cover chiropractic maintenance care. When further clinical improvement
cannot be reasonably expected from ongoing care, the care is considered maintenance. You can find this rule in
the Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3.
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 for chiropractic services only those services related to manual manipulation of the spine are
covered. You can see this on page 4-10 of the 2019 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.
Medicare rules say that the provider must notify the enrollee in writing before it ends coverage of home health
services. A Notice of Medicare Non-Coverage (NOMNC) must be issued no later than two days before the last
covered day. If the span of time between services exceeds two days, the notice should be given no later than the
next to last time services are furnished. The notice must include:
1. The date that coverage of service ends;
2. The date the enrollee becomes responsible to pay for the service; and
3. A description of the enrollee's right to a fast-track appeal and other appeal procedures. You can find this rule
at 42 CFR Section 422.624(b).
A Health Plan is financially liable for continued services until two days after the enrollee receives valid notice.
You can find this rule at 42 CFR Section 422.624(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 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 that there is one exam and cleaning every six months; one dental X-ray every year; there is a
$0 co-payment per visit for the one exam and cleaning every six months; You must use a participating plan
provider for covered dental services. You can find this information in Chapter 4 on pages 64-65 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 20% of the Medicare-allowed amount for in-network Medicare Part B
covered drugs. Covered drugs include drugs that usually aren't self-administered by the patient and are injected
or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. You can
find this information on pages 92 to 93 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 that a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints
(L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both mediallateral
and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury
to or a surgical procedure on the knee(s).
The rules also say that knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a
beneficiary who is ambulatory and has knee instability due to a condition specified in the ICD-10 Codes that
Support Medical Necessity Group 4 Codes section. Knee instability must be documented by examination of the
beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer
test). Claims will be denied as not reasonable and necessary when the beneficiary does not meet the above
criteria for coverage. You can find this rule at Local Coverage Determination (LCD): Knee Orthoses (L33318).
The rules state that equipment which the enrollee owns or is a capped rental item may be replaced in cases of
loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire,
flood). A physician's order and/or new Certificate of Medical Necessity (CMN), when required, is needed to
reaffirm the medical necessity of the item.
Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot
be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful
lifetime of the equipment. If the item of equipment has been in continuous use by the enrollee on either a rental
or purchase basis for the equipment's useful lifetime, the enrollee may elect to obtain a new piece of
equipment. Replacement may be reimbursed when a new physician order and/or new CMN, when required, is
needed to reaffirm the medical necessity of the item.
The reasonable useful lifetime of durable medical equipment is determined through program instructions. In the
absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime (RUL) of
equipment, but in no case can it be less than 5 years. Computation of the useful lifetime is based on when the
equipment is delivered to the enrollee, not the age of the equipment. Replacement due to wear is not covered
during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does
cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment
owned by the enrollee. These rules can be found in the Medicare Benefit Policy Manual Chapter 15, Section
110.2 for Repairs, Maintenance, Replacement, and Delivery.
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 as a covered entity, Medicare must use the POS codes from the National POS code set for processing its electronically submitted claims. Medicare must also recognize as valid POS codes from the POS code set when these codes appear on such a claim. Medicare must recognize and accept POS codes from the national POS code set in terms of HIPAA compliance. You can find this rule in the Medicare Claims Processing Manual, Chapter 26, Section 10.5.
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 modifier AS is billed to indicate that a PA, NP or CNS served as the assistant at surgery. Modifier 80, 81 or 82 must also be billed when modifier AS is billed. Claims submitted with modifier AS and without modifier 80, 81 or 82 are returned to the provider (RTPd). You can find this rule in the Medicare Claims Processing Manual, Chapter 4, Section 250.9.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
Medicare guidance says for any DMEPOS item to be covered by Medicare, the patient's medical record must
contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type
and quantity of items ordered and for the frequency of use or replacement (if applicable). The information
should include the patient's diagnosis and other pertinent information including, but not limited to, duration of
the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional
limitations, other therapeutic interventions and results, past experience with related items, etc. If an item
requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patient's
record. However, neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a
physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed
by the treating physician or supplier. There must be information in the patient's medical record that supports
the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if
applicable) or information on a supplier prepared statement or physician attestation (if applicable)". Also,
"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 guidance in the Medicare Program Integrity Manual,
Chapter 5 - Items and Services Having Special DME Review Considerations, Section 5.7- Documentation in
the Patient's Medical Record and Section 5.8 - Supplier Documentation.
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 a spinal orthosis (L0450 - L0651) is covered when it is ordered for one of the following
indications:
1. To reduce pain by restricting mobility of the trunk; or
2. To facilitate healing following an injury to the spine or related soft tissues; or
3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or
4. To otherwise support weak spinal muscles and/or a deformed spine.
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically
necessary. You can find this rule at Local Coverage Determination (LCD): Spinal Orthoses: TLSO and LSO
(L33790).
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 does not include coverage for Periodontal Maintenance (D4910). You can find this information on pages 93 & 94 of the Plan's 2020 Evidence of Coverage (EOC).