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 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 a contract plan provider is an agent of the plan. Services and referrals obtained from a plan provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service. If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or item is never covered, the plan does not have to hold the enrollee harmless. For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 160.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 Medicarerules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract also says that bridges (excluding third molars) are covered to replace one (1) upper front tooth or two (2) adjacent lower front teeth and there cannot be any missing back teeth. 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 fora 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 73 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 $45 copayment for lab services received in an outpatient hospital setting. You can find this information on page 82 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 copayment per visit to a specialist. Covered services include medically-necessary medical care of surgery services furnished in a physician's office. If other medical services or covered drugs are provided during the visit, a separate cost-sharing for those items will apply. You can find this information on pages 79 to 80 of the Plan's 2020 Evidence of Coverage (EOC).The Plan contract also says that enrollees must pay 20% coinsurance for Medicare Part B prescription 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. A separate physician office copayment may apply if other services are rendered at the time of the visit. You can find this information on page 73 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 a long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of
stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the
diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need
medical care. You can find this rule in the Medicare Program Integrity Manual, Chapter 6, Section 6.5.2.
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.
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 all services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code. Many of these generic activities are common to virtually all procedures and, on other occasions, some are integral to only a certain group of procedures, but are still essential to accomplish these particular procedures. Accordingly, it is inappropriate to separately report these services based on standard medical and surgical principles. You can find this information in the Medicare Claims Processing Manual, Chapter 12, Section 30(a).
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 also says that there is a $1,000 deductible for certain items and services, except those specifically excluded by the plan's contract. Physician specialist services (excluding psychiatric services) are excluded from the deductible. You can find this information on pages 54 to 56 of the Plan's 2020 Evidence of Coverage (EOC).
The Plan contract says that enrollees must pay a $25 copayment for each in-network Medicare-covered specialist visit. Covered services include medically-necessary or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location. You can find this information on page 87 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 must pay for ambulance services when an emergency exists or when other means of
transport would endanger the patient's health. An emergency is defined as when a prudent layperson would
believe that without immediate medical attention there would be serious jeopardy to his or her health. You can
find these rules in the Medicare Managed Care Manual, Chapter 4, Sections 20.1 and 20.2.
The rules say that a patient transported from one hospital to another hospital is covered only if the hospital to
which the patient is transferred is the nearest one with appropriate facilities and the treatment the enrollee
requires is not available at the current hospital. Coverage is not available for transport from a hospital capable
of treating the patient because the patient and/or the patient's family prefer a specific hospital, location or
physician. You can find this rule in the Medicare Benefit Policy Manual, Ch. 10 10.4.
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 specific
items and services listed in the supplemental dental benefit category. Tooth implantation is not among the
covered dental services and is excluded from the supplemental dental benefit. You can find this information in
Chapter 4 on pages 87 to 92 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 one biomarker test (4Kscore) is covered once in men 45 years or older prior to initial biopsy,
with confirmed moderately elevated PSA (more than 3 and less 10 ng/ml) with both of the following:
1. No other relative indication for prostate biopsy including ANY of the following:
a. DRE suspicious for cancer
b. Persistently elevated PSA
c. Positive multiparametric MRI (if done)
d. Other major risk factor for prostate cancer including:
i. Ethnicity at higher risk for prostate cancer
ii. First-degree relative with prostate cancer
iii. High-penetrance prostate cancer risk gene(s) per NCCN (if known)
2. No other relative contraindication for prostate biopsy including ANY of the following:
a. less than 10 year life expectancy
b. Benign disease not ruled out
You can find this rule in Local Coverage Determination (LCD): Biomarker Testing (Prior to Initial Biopsy) for
Prostate Cancer Diagnosis (L37733) - Effective December 1, 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 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, Sect ion 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 state that items and services furnished outside the United States are excluded from coverage except
for the following services, and certain services rendered on board a ship:
Emergency inpatient hospital services where the emergency occurred:
o While the beneficiary was physically present in the United States; or
o In Canada while the beneficiary was traveling without reasonable delay and by the most direct route
between Alaska and another State.
Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the United
States, if the hospital was closer to, or substantially more accessible from, the beneficiary's United States
residence than the nearest participating United States hospital which was adequately equipped to deal with and
available to provide treatment of the illness or injury;
Physician and ambulance services furnished in connection with a covered foreign hospitalization. Program
payment may not be made for any other Part B medical and other health services, including outpatient services
furnished outside the United States;
Services rendered on board a ship in a United States port, or within 6 hours of when the ship arrived at, or
departed from, a United States port, are considered to have been furnished in United States territorial waters.
Services not furnished in a United States port, or within 6 hours of when the ship arrived at, or departed from, a
United States port, are considered to have been furnished outside United States territorial waters, even if the
ship is of United States registry.
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 you can also receive emergency or urgently needed services from a provider outside the
United States. If you receive emergency or urgently-needed services outside of the United States, the provider
may require that you pay for the cost of the services in full. You can find this information on page 5-2 of the
Plan's 2019 EOC.
The Health Plan contract also says while you can get your care from an out-of-network provider, the provider
must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not
eligible to participate in Medicare. If you go to a provider who is not eligible to participate in Medicare, you
will be responsible for the full cost of the services you receive. Check with your provider before receiving
services to confirm that they are eligible to participate in Medicare. You can find this information on page 3-3
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 the clinical use of contract echocardiography is appropriate in selected patients to:
- Evaluate myocardial ischemia
- Quantify myocardial perfusion during stress
- Identify the "area at risk" during acute myocardial infarction (AMI)
- Determine the success of reperfusion interventions
- Assess myocardial viability
The medically necessary and appropriate applications of transthoracic echocardiography (TTE) include evaluation of:
- Ventricular Function and Cardiomyopathies
- Hypertensive Cardiovascular (CV) Disease
- AMI and Coronary Insufficiency
- Exposure to Cardiotoxic Agents (chemotherapeutic and external)
- Cardiac Transplant and Rejection Monitoring
- Native Valvular Heart Disease
- Prosthetic Heart Valves (Mechanical & Bio-prostheses)
- Acute Endocarditis
- Pericardial Disease
- Aortic Pathology
- Congenital Heart Disease (CHD)
- Suspected Cardiac Thrombi and Embolic Sources
- Cardiac Tumors and Masses
- Critically Ill and Trauma Patients
- Arrhythmias and Palpitations
- Syncope
- Pulmonary Disease
You can find these rules in Local Coverage Determination (LCD) Echocardiography (L37379).
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 Therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria (1-6) are met: 1. 1. The beneficiary has diabetes mellitus; and, 2. 2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and, 3. 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. 4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and, 5. 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. 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. If any of coverage criteria (1-6) are not met, the CGM and related supply allowance will be denied as not reasonable and necessary. Regardless of utilization, a supplier must not dispense more than a three (3) - month quantity of BGM testing supplies at a time. You can find this rule in the Local Coverage Determination for Glucose Monitors, L33822 (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 health 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 422.101.
The rules say that Therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria (1-6) are met:
1. 1. The beneficiary has diabetes mellitus; and,
2. 2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and,
3. 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. 4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,
5. 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. 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.
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 rule in the Local Coverage Determination for Glucose Monitors, L33822 (eff 01/01/20).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.