Persius/hicric huggingface dataset:
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 pays only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41.The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 30.3.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 contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers routine transportation for up to 24 one-way transportation trips per calendar year. You can find this information on page 4-66 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 a Medicare plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 as a member of our plan, you can choose to receive care from out-of-network providers. However, please note providers that do not contract with us are under no obligation to treat you, except in emergency situations. Our plan will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher.
 You can find this information on page 48 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 417.414.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 1 annual physical examination per calendar year. It is a more comprehensive exam than the annual wellness visit. You can find this information in Chapter 4 on pages 52 to 43 of the Plan's 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 an inpatient admission is generally appropriate when the admitting physician expects the patient to need hospital care that crosses at least two midnights. The expectation should be based on such complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and medical risk. The factors must be documented in the medical record. If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as "inpatient only"is generally appropriate, regardless of the length of stay. An inpatient admission may be appropriate if the admitting physician expects a patient to require hospital care for only a limited period of time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be supported by the medical record. You can find this rule at 42 CFR Section 412.3.
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 heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. You can find Local Coverage Determination (LCD): Hospital Beds And Accessories (L33820).
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 does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device.
This rule does not apply to:
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after
each cataract surgery with insertion of an IOL; and
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with
an IOL.
You can find this rule at 42 CFR Section 411.15(b).
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42
CFR Section 411.15(c).
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 vision coverage includes 1 routine eye exam every year and 1 pair of eyeglasses (lenses
and frames) every 2 years. There is an eye wear benefit of up to $130. You can find this information on pages
88-89 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 CMS will allow coverage for Transcutaneous Electrical Nerve Stimulation (TENS) for chronic low back pain (CLBP) only when the beneficiary is enrolled in an approved clinical study meeting all of the requirements. You can find this rule in the Medicare National Coverage Determination for Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP), 160.27.
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 rulein 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).
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 Plancovers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay 50% coinsurance for inpatient mental health care at an out-of-network inpatient hospital or inpatient psychiatric facility. You can find this information on pages 57 to 58 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 state that an extra wide/heavy duty commode chair (E0168) is covered for a beneficiary who weighs
300 pounds or more. If an E0168 commode is ordered and the beneficiary does not weigh more than 300
pounds, it will be denied as not reasonable and necessary. You can find Local Coverage Determination (LCD):
Commodes (L33736).
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 an IRF admission when the services are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week. The patient does not need to be expected to achieve complete independence in self-care nor be expected to return to his or her prior level of functioning. The patient must needsupervision by a rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. You can find these rules in the Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622.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 home blood pressure monitors (A4660) and home blood pressure cuffs (A4663) are considered home dialysis supplies. These items are only covered for patients on home dialysis. You can find this rule in the Medicare Claims Processing Manual, Chapter 8, Section 90.3.2(A).The rules also say that ambulatory blood pressure monitoring (ABPM) may be covered in some instances. This service involves the use of a non-invasive device which is used to measure blood pressure in 24-hour cycles. These 24-hour measurements are stored in the device and are later interpreted by the physician. ABPM is only covered for those patients with suspected white coat hypertension. Suspected white coat hypertension is defined as1. Office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit;2. At least two documented blood pressure measurements taken outside the office which are <140/90 mm Hg; and3. No evidence of end-organ damage.You can find this information in the National Coverage Determination (NCD) for Ambulatory Blood Pressure Monitoring (20.19).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers 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 an external infusion pump is covered for the following indications (I-V): I. Administration of deferoxamine for the treatment of chronic iron overload. II. Administration of chemotherapy for the treatment of primary hepatocellular carcinoma or colorectal cancer where this disease is unresectable or where the beneficiary refuses surgical excision of the tumor. Anticancer chemotherapy drugs used in these conditions are not required to meet the criteria described by indication V, situation A. III. Administration of morphine when used in the treatment of intractable pain caused by cancer. You can find this information as well as a list with more covered indications at Local Coverage Determination (LCD): External Infusion Pumps (L33794).
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 state that non-thermal radiofrequency (RF)modalities for facet joint denervation including chemical, low grade thermal energy (<80 degrees Celsius), as well as pulsed RF are not covered.You can find this information in the Local Coverage Determination (LCD): FacetJoint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L35936).
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 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. Codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more of the following motors from a single interface (e.g.,proportional joystick, touchpad, or non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the beneficiary to select the motor that is being controlled and an indicator feature to visually show which function has been selected.An expandable controller is capable of accommodating one or more of the following additional functions:-Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.)-Non-proportional input devices (e.g., sip and puff, head array, etc.)-Operate 3 or more powered seating actuators through the drive control.-A separate display (i.e., for alternate control devices)-Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control)-An attendant control You can find this rule in the Local Coverage Article for Wheelchair Options/Accessories, A52504 (eff 01/01/20).
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 suction-assisted lipectomy is a surgical procedure employing high vacuum pressure to suction away localized collections of unwanted fat. When the procedure is utilized to remove a lipoma, it is considered reconstructive surgery. The clinical record must clearly demonstrate medical necessity for the lipoma removal as most such tumors are benign and do not require removal. You can find this rule at Local Coverage Determination (LCD): Plastic Surgery (L37020) (eff. 10/1/19).
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 findthis rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare pays for care in a skilled nursing facility (SNF) when all of the following four factors are met:1. The patient requires skilled nursing or skilled rehabilitation services;2. The patient requires these services on a daily basis;3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and4. The services are reasonable and necessary for the treatment of the patient's illness or injury or the services must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from getting worse. You can find these rules at 42 CFR Section 409.31 and in the Medicare Benefit Policy Manual, Chapter 8, Section 30.  The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also custodial care services. You can find this rule in the Medicare Benefit Policy Manual, Chapter 16, Section 110.
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 also say that a supplemental benefit is an item or service not covered by original Medicare, that is primarily health related and for which the MA plan must incur a non-zero direct medical cost. Supplemental benefits need not be provided through Medicare providers nor at Medicare certified facilities. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 30.1.
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 also says that our plan does not cover urgently needed services or any other care if you receive the care outside of the United States. You can find this information on page 39 of the Plan's 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 indications for Stereotactic Body Radiation Therapy (SBRT) are:1. SBRT is indicated for primary tumors and tumors metastatic to the lung, liver, kidney, adrenal gland, or pancreas.2. SBRT is indicated for treatment of pelvic and head and neck tumors that have recurred after primary irradiation.3. SBRT is indicated for patients with clinically localized, low-to intermediate-risk prostate cancer.4. SBRT treatment, of any body site or internal organ, is indicated for treatment of recurrence in or near previously irradiated regions when a high level of precision and accuracy or a high dose per fraction is indicated to minimize the risk of injury to surrounding normal tissues and treatment with conventional methods is not appropriate or safe for the particular patient (medical records must describe the specific circumstances You can find this rule in the Local Coverage Determination for Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT), L35076 (eff 04/01/20).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say 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 specialist office visit. 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 findthis rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.