Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The benefit includes reimbursement up to $175 for the purchase of supplemental preventive dental and other routine dental services each calendar year. The contract also says that Medicare covered dental services are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. You can find this information on page 60 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 lumbar ESI is indicated for:
1. Pain associated with Herpes Zoster and/or Suspected radicular pain, based on radiation of pain along the dermatome (sensory distribution) of a nerve and/or Neurogenic claudication and/or Low back pain, numeric pain rating scale (NPRS) ; 3/10 (moderate to severe pain) associated with significant impairment of activities of daily living (ADLs) and one of the following:
a. substantial imaging abnormalities such as a central disc herniation.
b. severe degenerative disc disease or central spinal stenosis.
2. Failure of four weeks (counting from onset of pain) of non-surgical, non-injection care, which may include appropriate oral medication(s) and physical therapy/modalities to the extent tolerated. Exceptions to the 4-week wait may include:
a. pain from Herpes Zoster
b. at least moderate pain with significant functional loss at work or home.
c. severe pain unresponsive to outpatient medical management.
d. inability to tolerate non-surgical, non-injection care due to co-existing medical condition(s)
e. prior successful injections for same specific condition with relief of at least 3 months' duration.
You can find this rule at Local Coverage Determination (LCD): Lumbar Epidural Injections (L36521) (eff. 11/1/19).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract lists the specific
dental services that are covered. Complete lower denture is not listed and therefore is not a covered service.
The contract says any services not listed are not covered. The contract also says there is an annual maximum of
$500. You can find this information on page 4-71 to 4-75 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 at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than the close of the period ending 1 calendar year after the date of service. You can find this rule at42 CFR Section 424.44(a).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 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 amountpaid 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 durable medical equipment. You can find this information on page 42 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 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 each urgent care visit. You can find this information on page 101 of the Plan's2020 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 quantity of test strips (code A4253) and lancets (code A4259) that are covered depends
on the usual medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin,
regardless of their diagnostic classification as having Type 1 or Type 2 diabetes mellitus. Coverage of testing
supplies is based on the following guidelines:
Usual Utilization
-For a beneficiary who is not currently being treated with insulin injections, up to 100 test strips and up to 100
lancets every 3 months are covered
-For a beneficiary who is currently being treated with insulin injections, up to 300 test strips and up to 300
lancets every 3 months are covered
High Utilization
-For a beneficiary who is not currently being treated with insulin injections, more than 100 test strips and more
than 100 lancets every 3 months are covered
-For a beneficiary who is currently being treated with insulin injections, more than 300 test strips and more
than 300 lancets every 3 months are covered if the criteria a-c below are met:
A. Basic coverage criteria (1)-(2) listed above for all home glucose monitors and related accessories and
supplies are met; and,
B. Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization
guidelines, the treating practitioner has had an in-person visit with the beneficiary to evaluate their diabetes
control and their need for the specific quantity of supplies that exceeds the usual utilization amounts described
above; and,
C. Every six (6) months, for continued dispensing of quantities of testing supplies that exceed the usual
utilization amounts, the treating practitioner must verify adherence to the high utilization testing regimen.
You can find this rule in Local Coverage Determination (LCD): Glucose Monitors (L33822) - Effective
January 1, 2020.
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 ICD code that describes the diagnosis. You can find this information in ICD-10-CM Official Guidelines for Coding and Reporting.
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 $225 copayment each day for days 1-7 and a $0 copayment for additional days for inpatient hospital care. You can find this information on pages 4-20 to 4-23 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 Medicare pays for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins upon admission to a hospital or SNF and ends after 60 days in a row without the patient receiving hospital or skilled SNF services. You can find this rule in the Social Security Act, Section 1862(a)(18), at 42 CFR Sections 409.60(a) and (b) and Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, Section 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. The Plan contract says that the Plan covers up to 100 days each benefit period for inpatient services in a Skilled Nursing Facility, in accordance with Medicare guidelines. A benefit period begins on the first day an enrollee goes into a covered inpatient hospital or Skilled Nursing Facility. The benefit period ends when the enrollee has not been an inpatient at any hospital or SNF for 60 days in a row. You can findthis information on pages 4-49 to 4-50 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 $20 copayment for outpatient diagnostic tests/x-rays. You can find this information on page 75 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 at42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that a PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone. A PCD coded as E0652, is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when all of the following are met:

1. The beneficiary has lymphedema of an extremity as defined above

2. The coverage criteria for an E0650 or E0651 are met

3. The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial.

You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).

The rules say that the only time that a segmented, calibrated gradient pneumatic compression device (HCPCS code E0652) would be coveredis when the individual has unique characteristics that prevent them from receiving satisfactory pneumatic compression treatment using a non-segmented device in conjunction with a segmented appliance or a segmented compression device without manual control of pressure in each chamber.

You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).

The rules say that a four-week trial of conservative therapy demonstrating failed response to treatment with and E0650 orE0651 is required for coverage of E0652. You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the 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 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 when a Skilled Nursing Facility (SNF) resident receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, only the service's professional component (representing the physician's interpretation of the test results) is a separately billable physician service under Part B. By contrast, the technical component representing the procedure itself, including any associated transportation and setup costs, would be subject to consolidated billing, and must be included on the SNF's Part A bill for the resident's covered stay rather than being billed separately under Part B. You can find this information in the Medicare Claims Processing Manual, Chapter 13, 90.5.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. Scaling in presence of generalized moderate or
severe gingival inflammation and unspecified preventive procedure are not included on this list and are not
covered supplemental benefits. You can find this information on pages 87 to 88 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 state that a standard written order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an orthosis item L0457 without first received a completed SWO, the claim shall be denied as not reasonable and necessary. In order to justify payment for this item, the supplier must meet the following documentation requirements:-Standard Written Order (SWO)-Medical Record Information-Correct coding-Proof of DeliveryYou can find this rule in Local Coverage Determination (LCD) Spinal Orthoses: TLSO and LSO (L33790).The rules state that Medicare may select Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items on the master listof DMEPOS items potentially subject to a face-to-face encounter and include them on a required list. Items appearing on the required list are subject to the face-to-face encounter and written order prior to delivery (WOPD). You can find this rule in LocalCoverage Article (LCA) Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).The rules state that thoracic lumbar-sacral orthosis L0457 is not among those items which is subject to face-to-face encounter requirements. You canfind this rule in Final Rule CMS-1713-F, included in 42 Code of Federal Regulations Parts 405, 413, and 414.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 say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2. If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 46 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 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 MACs subject all line items for the same beneficiary, same NPI, and same date of service to NCCI edits. You can find this information in Medicare Claims Processing Manual Chapter 23, Section 20.9.1.1.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in
the Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care
and services. The only exceptions are emergencies, urgently needed care when the network is not available
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan
authorizes the use of out-of-network providers. You can find this information on pages 27-29 of the Plan's 2019
EOC.