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 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, 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 in the plan's 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 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 says that prior authorization (approval in advance) may be required. You can find this information on 
page 80 of the Plan's 2020 Evidence of Coverage. 
 
The contract says that periapical radiographs are required for each tooth involved in the authorization request. 
You can find this information on page 97 of the Plan's 2020 supplemental dental coverage handbook.
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 says services 
must be performed by a participating general dentist. You can find this information on page 64 of the Plan?s 
2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that enrollees must pay $50 copayment for Medicare covered comprehensive dental. You can find
this information on page 61 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 CFR 422.101.
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information
to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances,
Organization/Coverage Determinations, and Appeals Grievance Manual, Section 50.12.1.
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 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 surgery services provided by a specialist. You can
find this information in Chapter 4 on pages 69 - 70 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 Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1.
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 also says that enrollees must pay 50% of the Medicare-allowed amount for each out-of-network Medicare-covered individual or group therapy visit. You can find this information on page 101 of the Plan's 2018 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 state that it is considered not reasonable and necessary to perform more than 2 epidural injections in a single setting (e.g., single level bilaterally or two levels unilaterally). You can find this information in the Local Coverage Determination (LCD): Epidural Injections for Pain Management (L36920).
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 CFR422.101.Medicare rules say that the provider must notify the enrollee in writing before it ends coverage of home health services. A Notice of Medicare Non-Coverage (NOMNC) must be issued no later than two days before the last The Appeal Number is:1-9110371391The Appeal Number is:1-9110371391
covered day. If the span of time between services exceeds two days, the notice should be given no later than the next to last time services are furnished. The notice must include:1. The date that coverage of service ends;2. The date the enrollee becomes responsible to pay for the service; and3. A description of the enrollee's right to a fast-track appeal and other appeal procedures. You can find this rule at 42 CFR 422.624(b). A Health Plan is financially liable for continued services until two days after the enrollee receives valid notice. You can find this rule at 42 CFR 422.624(d).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 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 $20 copayment (per provider, per day) plus a daily specialist copayment of $35 for Radiation Therapy services. You can find this information on pages 92 and 99 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 Appeal Number is:1-9038251081The Appeal Number is:1-9038251081
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). You can find this information inthe Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1.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.
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).
Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. An axial rotation unit (L5982-L5986) is covered for beneficiaries whose functional level is 2 or above.
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 at42 CFR422.101.The rules say that Medicare will not pay for dental services. Dental services are items and services involvingthe 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 contract says that Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. This is covered with a $40 copayment. You can find this on page 104 of the 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 that services must be medically necessary as documented in recent notes by the physician, ordered by the patient's physician who has knowledge of the patient, and verified as delivered to the member by proof of delivery. You can find this information in 42 Code Federal Regulations (CFR) 410.32, Medicare Managed Care Manual, Chapter 4 Benefits and Beneficiary Protections, 20.3 (MAO Responsibility), 110.1 (Access and Availability Rule) and Medicare Benefit Policy Manual, Chapter 15, 20.0-40.4 Physician Services and Physician/Practitioner --Covered Medical and Other Health Services.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 that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1.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 that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Grievance Manual, Section 50.12.1.The rules say to qualify for home health services, the patient must be: 1. Confined to the home; 2. Under the care of a physician; 3. Receiving services under a plan of care established and reviewed by a physician; 4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) continuing occupational therapy. You can find this rule at 42 CFR ?409.42. The rules say that eligibility for the home health benefit will be determined based on the certifying physician's records. If the enrollee was directly admitted to home health from an acute or post-acute care facility, the facility records may be used instead. The medical records for the enrollee must contain information that justifies the referral for home health services. The certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face encounter visit. You can find these rules in the Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1, 30.5.1.1, and 30.5.1.2.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.
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 segmented, calibrated gradient pneumatic compression device (HCPCS code E0652) is only covered when the individual has unique characteristics which prevent them from receiving adequate satisfactory pneumatic compression treatment using a non-segmented device along with a segmented appliance or compression device without manual control of the pressure in each chamber". There is no documentation that this patient has any unique characteristics preventing treatment with a non-segmenteddevice. There is documentation that he tried a non-segmented pump in 2016 and it caused too much pain to continue treatment. However, a trial with a non-segmented device was not repeated with lower pressures.The rules say that a PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone if other unique characteristics are not met, such as lymphedema extending onto the chest, trunk and/or abdomen. Hence, a PCD coded as E0652 used to treat lymphedema not extending onto the chest, trunk and/or abdomen or chronic venous insufficiency is not eligible for reimbursement.The rules say that a pneumatic compression device (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: -The beneficiary has lymphedema of an extremity-The coverage criteria for an E0650 or E0651 are met, and -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 of conservative therapy. You can find these rules in the Local Coverage Determination (LCD) for Pneumatic Compression Devices, L33829. This LCD is effective for services provided on or after 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 the National Correct Coding Initiative (NCCI) was developed to prevent inappropriate
payment of services that should not be reported together. NCCI edits are organized in a Column I/Column 2
table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of an edit
pair, only the Column 1 code is payable. For edits with a modifier indicator of 1, the Column 2 code is payable
only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. If the
modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a modifier is used. You can
find this in the NCCI Manual, Chapter I.
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, 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 networkis 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 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 crowns, bridges, inlay/onlay, and periodontal work may not be provided more often than once per tooth every five (5) years. You can find this information on page 65 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay 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 an electrical bone growth stimulator is covered only for the following indications:1. Nonunion of long bone fractures; 2. Failed fusion, where a minimum of 9 months has elapsed since the last surgery; 3. Congenital pseudarthroses; Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical osteogenic stimulator. Serial radiographs must include a minimum of 2 sets ofradiographs, each including multiple views of the fracture site, separated by a minimum of 90 days. You can find this rule in the Medicare National Coverage Determinations Manual, Section 150.2.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.