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 mandibular partial denture (D5214) and is limited to one procedure every five plan years. You can find this information on page 4-62 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o). Use for Walking in Patients with Spinal Cord Injury (SCI) The type of NMES that is use to enhance the ability to walk of SCI patients is commonly referred to as functional electrical stimulation (FES). These devices are surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence. Coverage for the use of NMES/FES is limited to SCI patients for walking, who have completed a training program which consists of at least 32 physical therapy sessions with the device over a period of three months. The trial period of physical therapy will enable the physician treating the patient for his or her spinal cord injury to properly evaluate the person's ability to use these devices frequently and for the long term. Physical therapy necessary to perform this training must be directly performed by the physical therapist as part of a one-on-one training program. You can find this information in National Coverage Determination (NCD) for Neuromuscular Electrical Stimulation (NMES) (160.12).
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 Plan contract includes a list of covered supplemental dental services. The contract specifically says that any procedure not listed is not covered. Core buildup, including any pins when required (D2950), bone graft at time of implant placement (D6104), and fixed partial denture sectioning (D9120) are not included on this list and are not covered supplemental benefits. You can find this information on pages 21 to 29 of the Plan's 2020 Preventive & Comprehensive Customer Handbook.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicarewould 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.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service oritem 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 MDCT angiography of the chest for non-cardiac assessment will be considered medically reasonable and necessary for the following signs or symptoms of disease:-Assessment of a symptomatic patient when presentation is suspicious for pulmonary emboli;-Abnormalities of the thoracic vasculature such as aortic dissection, aortic aneurysm, pulmonary arterio-venous malformation (AVM) and other abnormalities of the systemic circulation, excluding the heart;-Assessment of suspected congenital anomalies of the heart or great vessels; and-Assessment of cardiac, mediastinal or lung parenchymal lesions, the vascularity of which is unknown or ill defined, but is critical to the diagnosis.MDCT angiography of the chest for cardiac assessment will be considered medically reasonable and necessary for the following signs or symptoms of disease:-Cardiac evaluation of a patient with chest pain syndrome (e.g. anginal equivalent, angina), who is at a low to moderate risk for coronary artery disease (CAD), if use of MDCT is expected to avoid performing diagnostic cardiac catheterization. MDCT and coronary angiography are not expected to be performed on the same patient for diagnostic purposes prior to the application of anticipated therapy. (If a high pre-test probability of disease exists, as if the patient has known CAD, it is assumed the patient would go to coronary angiography as the definitive test, where possible angioplasty and/or stenting could be performed at the same time).-Assessment of suspected congenital anomalies of coronary circulation.-Assessment of symptomatic patients with equivocal stress test results, with or without cardiac imaging, if MDCT is expected to avoid performing diagnostic coronary angiography. (Again, if a high pre-test probability of disease exists, as if the patient has known CAD, it is not expected that CT coronary angiography would be done in addition to a subsequent coronary catheterization and angiogram).-Evaluation of pulmonary veins prior to arrhythmia ablation procedures-Evaluation of cardiac veins prior to insertion of biventricular pacemaker.The rules also say that this test is never covered for screening.You can find this rule in the Local Coverage Determination (LCD) for Computed Tomographic Angiography of the Chest, Heart and Coronary Arteries (L33282).If you want to read these Medicare rules, youcan go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that your combined deductible is $500, which applies to all items and services except those specifically excluded by the Plan's contract. 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 combined deductible amount, you must pay the full cost for most of your covered services. Outpatient therapy isn't excluded from the deductible. You can find this information on pages 65 and 66 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 Plan contract says that comprehensive dental care benefits are available for purchase under Optional Supplemental Benefits. You can find this information on page 62 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  ifregular  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  Part B generally  does not  pay for drugs  that  are usually  self-administered  by the patients  who take them.  Examples  of  self-administered  drugs  are drugs  in  pill  form  and those  used for  self-injection.  The  only  exceptions  are:1. blood-clotting  factors; 2. drugs  used in  immunosuppressive  therapy;3. erythropoietin  for dialysis  patients; 4. osteoporosis  drugs  for certain  homebound  patients;5. certain  oral cancer  drugs; 6. oral  anti-emetics  used in  certain  situations; 7. drugs  treated as supplies  during  an outpatient  hospital  procedure;  and 8. drugs  required  for  the effective  use of  durable  medical  equipment.You  can find  this  rule  in  the  Medicare  Benefit  Policy  Manual,  Chapter  15, Sections  50, 50.2, 50.5, and 110.3.
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 ahealth 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.
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 after thorough review and reconsideration of the existing national noncoverage determination for MRS, as well as the available evidence for the use of MRS as a diagnostic tool for distinguishing indeterminate brain lesions, and/or as an aid in conducting brain biopsies, CMS has determined that the evidence is not adequate to conclude that MRS is reasonable and necessary within the meaning of section 1862(a)(1)(A) of the Social Security Act, for use in the diagnosis of brain tumors. Therefore, CMS reaffirms its current national noncoverage determination for all indications of MRS. You can find this rule in National Coverage Determination (NCD) for Magnetic Resonance Spectroscopy (220.2.1) - Effective September 10, 2004.
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 20% coinsurance for prosthetic devices and medical supplies. You can find this information on page 98 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 pay for durable medical equipment (DME) that is reasonable and necessary for treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment already available to an enrollee. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1(C).The rules state that replacement refers to the provision of an identical or nearly identical item. Equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. 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, which may be no less than five years. 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 beneficiary. You can find this information in the Medicare Benefit Policy Manual, Chapter 15, Section 110.2.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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that your out-of-network (POS) deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered out-of-network (POS) medical services. Until you have paid the out-of-network deductible amount, you must pay the full cost of your covered out-of-network services. You can find this information on pages 58 and 59 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 diagnostic breath analyses are tests performed to measure either the hydrogen or carbon dioxide content of the breath after the ingestion of certain compounds. The analyses are performed to diagnose certain gastrointestinal disease states. The following breath tests are excluded from coverage: -Lactulose breath hydrogen for diagnosing small bowel bacterial overgrowth and measuring small bowel transit time. -CO2 for diagnosing bile acid malabsorption. -CO2 for diagnosing fat malabsorption. You can find this rule in National Coverage Determination (NCD) for Diagnostic Breath Analyses (100.5) - Effective June 12, 1984.
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 pay for durable medical equipment that is mainly used to serve a medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly used for medical purposes. Medicare will not pay for: 1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners; 2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. You can find this rule in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). The rules state that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. You can find this rule in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). 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 covers preventive dental services including periodic oral evaluation (D0120), comprehensive oral evaluation (D0150) and prophylaxis (D1110). Bitewings (D0274) are not included on this list and is not a covered benefit. You can find this information on page 54 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 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 informationon page 40 of the Plan's 2018 and 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.
The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for selfinjection.
The only exceptions are:
1. blood-clotting factors;
2. drugs used in immunosuppressive therapy;
3. erythropoietin for dialysis patients;
4. osteoporosis drugs for certain homebound patients;
5. certain oral cancer drugs, when the drug has an equivalent injectable form;
6. oral anti-emetics used in certain situations;
7. drugs treated as supplies during an outpatient hospital procedure; and
8. drugs required for the effective use of durable medical equipment.
You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.