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 CFR 422.101.The rules state that shoes, inserts, and modifications are covered in limited circumstances. They are covered in selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers. However, different codes (A5500-A5511) are used for footwear provided under this benefit. See the medical policy on Therapeutic Shoes for Persons with Diabetes for details.Shoes are also covered if they are an integral part of a covered leg brace described by codes L1900, L1920, L1980-L2030, L2050, L2060, L2080, or L2090. Oxford shoes (L3224, L3225) are covered in these situations. Other shoes, e.g. high top, depth inlay or custom for non-diabetics, etc. (L3649), are also covered if they are an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. Heel replacements (L3455, L3460), sole replacements (L3530, L3540), and shoe transfers (L3600-L3640) involving shoes on a covered brace are also covered. Inserts and other shoe modifications (L3000-L3170, L3300-L3450, L3465-L3520, L3550-L3595) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. Shoes and related modifications, inserts, heel/sole replacements or shoe transfers billed without a KX modifier will be denied as noncovered because coverage is statutorily excluded. According to a national policy determination, a shoe and related modifications, inserts, and heel/sole replacements, are covered only when the shoe is an integral part of a brace. A matching shoe which is not attached to a brace and items related to that shoe must not be billed with a KX modifier and will be denied as noncovered because coverage is statutorily excluded. Shoes which are incorporated into a brace must be billed by the same supplier billing for thebrace. Shoes which are billed separately (i.e., not as part of a brace) will be denied as noncovered. A KX modifier must not be used in this situation.Shoes are denied as noncovered when they are put on over a partial foot prosthesis or other lower extremity prosthesis (L5010-L5600) which is attached to the residual limb by other mechanisms because there is no Medicare benefit for these items. With the exception of the situations described above, orthopedic footwear billed using codes L3000-L3649 will be denied as noncovered. You can find this information in the Local Coverage Article for Orthopedic Footwear (A52481).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules. The Plan contract also says that supportive devices for the feet are only covered for people with diabetic foot disease. You can find this information in Chapter 4, Section 3.1 of the 2019 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for a person who meets the following criteria: 1.The person must have a personal mobility deficit; 2.The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, grooming and bathing in customary locations within the home; 3.The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and4.The person must be capable of safely operating the PMD. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.3(B).The treating practitioner may refer the beneficiary to a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), who has experience and training in mobility evaluations to perform part of the face-to-face encounter. The treating practitioner completing the face-to-face requirements must write the 7-element order. The 7-element order may only be written after the completion of the face-to-face exam requirements. Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site evaluation of the beneficiary's home to verify that the beneficiary can adequately maneuver the device that is provided considering physicallayout, doorway width, doorway thresholds, and surfaces. There must be a written report of this evaluation availableon request. You can find this information in Local Coverage Determination (LCD): Power Mobility Devices (L33789).If any power operated vehicle or power wheelchair is only for use outside the home, it will be denied as noncovered. You can find this rule in Local Coverage Article: Power Mobility Devices -Policy Article (A52498).If you want to read these Medicare rules, you can go to thisweb site 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 fora 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 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 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 422.2.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contractsays that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $300 copayment for each outpatient surgery service. You can find this information in Chapter 4 on pages 81 -82 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 CFR 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 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 web site 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 whenthe 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 31 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 CFR 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 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 422.2.
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. The Plan contract says that enrollees must pay a $40 copayment for each therapy visit. Covered services include: physical therapy, occupational therapy, and speech language therapy. You can find this information on page 74 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 ifregular Medicare would pay for it in this case. You can find this rule at 42 CFR 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 422.112.The rules say that the plan must pay for emergency and urgently needed services. This rule applies whether the services are obtained in or out of the plan's network. This rule applies whether or not there is priorauthorization for the services. The rules say that 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. The rules say that urgently needed servicesare those needed because of an unforeseen illness or condition and it is not reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside of the service area. You can find this rule at 42 CFR 422.113.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.
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 CFR 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 programgenerally 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 need supervision 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 412.622.If you want to read these Medicare rules, you can go to this web site 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 CFR 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 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 422.2.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. The Plan contract says that enrollees must pay a $120 copayment for emergency care. You can find this information in Chapter 4 on page 78 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 at42 CFR 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 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 web site www.medicareappeal.com.The Plan contract says that the Plancovers 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 31 of the 2019 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 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 web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says 2 non-surgical or surgical extractions per year are covered. You can find this information on page 84 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 CFR 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 web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract lists the specific dental services that are covered by the Plan. Retainer crown is not listed and therefore is not a covered service. Pontic is not listed and therefore is not a covered service either. You can find this information on pages 21 to 26 of the Plan's 2019Customer Handbook. The Plan contract also says that if a dental item or service is not listed in the benefit chart then it is not a covered service. You can find this information on page 27 of the Plan's 2019 Customer Handbook.
Appeal type: unknown
Decision: unknown

The rules say that the PACE benefit package must include the following: (a) All Medicare-covered items and services; (b) All Medicaid-covered items and services, as specified in the State's approved Medicaid plan; and (c) Other services determined necessary by the interdisciplinary team to improve and maintain the enrollee's overall health status. You can find this rule at 42 CFR 460.92.The rules say that PACE (Program of All-inclusive Care for the Elderly) benefits must include all services and items covered by Medicare and Medicaid. The benefits must also include all other services determined necessary by the interdisciplinary team (IDT) to improve and maintain the enrollee's overall health status. You can find this rule at 42 CFR 460.92. The rules also say that enrollees in a PACE program must have a written plan of care. This plan must meet their needs in all care settings 24 hours a day every day of the year. You can find this rule at 42 CFR 460.98.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules. The PACE Enrollment Agreement describes all of the PACE services available and how to get services from the PACE organization. This Agreement also describes how to get emergency and urgently needed services out-of-network
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 CFR 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 422.112(a)(3).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. 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 43-51 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 CFR 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 411.15 and 411.15(o).The rules state that beneficiaries covered for the first three months of an E0470 or an E0471 device must be re-evaluated to establish the medical necessity of continued coverage by Medicare beyond the first three months. While the beneficiary may certainly need to be evaluated at earlier intervals after this therapy is initiated, the re-evaluation upon which Medicare will base a decision to continue coverage beyond this time must occur no sooner than 61 days after initiating therapy by the treating physician. Medicare will not continue coverage for the fourth and succeeding months of therapy until this re-evaluation has been completed. There must be documentation in the beneficiary's medical record about the progress of relevant symptoms and beneficiary usage of the device up to that time. Failure of the beneficiary to be consistently using the E0470 or E0471 device for an average of 4 hours per 24-hour period by the time of the re-evaluation (on or after 61 days after initiation of therapy) would represent non-compliant utilization for the intended purposes and expectations of benefit of this therapy. This would constitute reason for Medicare to deny continued coverage as not reasonable and necessary. A signed and dated statement completed by the treating physician no sooner than 61 days after initiating use of the device, declaring that the beneficiary is compliantly using the device (an average of 4 hours per 24-hour period) and that the beneficiary is benefiting from its use must be obtained by the supplier of the device for continued coverage beyond three months. If the above criteria are not met, continued coverage of an E0470 or an E0471 device and related accessories will be denied as not reasonable and necessary.You can find this rule in Local Coverage Determination (LCD): Respiratory Assist Devices (L33800).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.
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 CFR 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 web site 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 two preventive exams, two cleanings, and 50% of the cost of one set of bitewing x-rays. You can find this information on page 74 of the plan's 2019 Evidence of Coverage.
The Plan contract also says that the plan covers Exam(s) and cleaning(s), bitewing x-rays, fillings and crown repair, root canals, crowns and associates substructures, non-surgical removal of teeth, and relines & repairs to bridges and dentures. You can find this information on page 118 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 CFR 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 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 422.2.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. The Plan contract says that enrollees must pay a $25 copayment for each specialist visit for Medicare-covered benefits. You can find this information on page 47 of the Plan's 2019 Schedule of Cost Sharing.The Plan contract says that enrollees must pay10% of the cost for Medicare Part B prescription drugs. You can find this information on page 35 of the Plan's 2019 Schedule of Cost Sharing.