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 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; and 
4. 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 16, Section 110.

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 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; and 4. The person must be capable of safely operating the PMD. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Section 280.3(B). The rules also say that a Power Operated Vehicle (POV) is covered if all of the basic coverage criteria for a PMD have been met and if the criteria below are also met. 4. The beneficiary is able to: a. Safely transfer to and from a POV, and b. Operate the tiller steering system, and c. Maintain postural stability and position while operating the POV in the home. 5. The beneficiary's mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home. 6. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided. 7. The beneficiary's weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV - i.e., a Heavy Duty POV is covered for a beneficiary weighing 285 - 450 pounds; a Very Heavy Duty POV is covered for a beneficiary weighing 428 - 600 pounds. 8. Use of a POV will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it in the home. 9. The beneficiary has not expressed an unwillingness to use a POV in the home. If a POV will be used inside the home and the coverage criteria are not met, it will be denied as not reasonable and necessary. You can find this information in the Local Coverage Determination (LCD): Power Mobility Devices (L33789).
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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services,
Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit does not include
an extraction, or drugs or medicaments dispensed in the office for home use. You can find this information on
pages 4-56 to 4-61 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Section 240.2(E). To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Section 240.2(D)(3). Only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered. You can find this rule in Local Coverage Article: Oxygen and Oxygen Equipment - Policy Article (A52514). The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your home may be a dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D).
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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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. Covered dental services must be performed by a participating general dentist. You can find this information on page 68 of the Plan's 2021 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 a 20% coinsurance for outpatient diagnostic tests/medical supply. You
can find this information on pages 3-3 to 3-4 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that providers must report services correctly. Procedures should be reported with the Current
Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes that
describe the services performed. You can find this rule in the Centers for Medicare and Medicaid Services,
Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).
The rules say that beginning in July 2015, claims for compounded drugs shall be submitted using a
compounded drug, not otherwise classified (NOC) HCPCS code. You can find this information in the Centers
for Medicare and Medicaid Service, Internet-Only Manual, Medicare Claims Processing Manual, Chapter 17,
Section 20.1.2.
The rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by,
or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a
nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy
services under State law. You can find this information in Title 42 CFR Section 410.60.
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 may cover a drug or biological if it is safe and effective and otherwise reasonable
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only
Manual, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1.
An oral antiemetic drug (J8650, J8670, Q0161, Q0162, Q0163, Q0164, Q0166, Q0167, Q0169, Q0173, Q0174,
Q0175, Q0177, Q0180, Q0181) is covered if all of the following criteria (1-4) are met:
1. The drug has been approved by the Food and Drug Administration (FDA) for use as an antiemetic, and
2. The drug has been ordered by the treating practitioner as part of a cancer chemotherapy regimen, and
3. The drug is used as a full therapeutic replacement for an intravenous antiemetic drug that would otherwise
have been administered at the time of the chemotherapy treatment, and
4. ORAL ANTI-EMETIC drugs administered with a particular chemotherapy treatment must be initiated
within two hours of the administration of the chemotherapeutic agent and may be continued for a period not to
exceed 48 hours from that time.
Criterion 3 is not met when the chemotherapy drug is an oral drug or when the chemotherapy drug is
administered intravenously in the home setting because the type and dosage of chemotherapy drugs
administered in these situations do not require intravenous antiemetic drugs. If all of the criteria are not met,
the oral antiemetic drug will be denied as non-covered.
You can find this information in Local Coverage Article: Oral Antiemetic Drugs (Replacement for Intravenous
Antiemetics) - Policy Article (A52480).
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 to qualify for home health services, the patient must be: 1. Confined to the home; 2. Under the care of a physician or allowed practitioner; 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 Section 409.42. The rules say that eligibility for the home health benefit will be determined based on the certifying physician or allowed practitioner'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 or allowed practitioner must document that there was 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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 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 say that plans can restrict members to using contract providers except for emergency care (including ambulance services), out-of-area urgently needed care, post-stabilization care, and pre-approved care. You can find this rule at 42 CFR Section 422.112(a)(9). The rules say that a Medicare plan must pay for emergency care regardless of whether the care is provided by a contract provider or a non-contract provider. Emergency care ends when the patient is stabilized. Post-stabilization care is care that is administered to maintain, improve, or resolve the enrollee's stabilized condition. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required from the plan. However, the requirement for pre-approval does not apply if: 1. The Plan does not respond to a request for pre-approval within one hour, 2. The Plan cannot be contacted, or 3. The Plan representative and the treating physician cannot reach an agreement concerning the enrollee's care and a plan physician is not available for consultation. You can find this rule at 42 CFR Section 422.113(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 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 3-3 to 3-7 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 Part B generally does not pay for drugs that are usually self-administered by the
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection.
The only exceptions are:

1. blood-clotting factors;
2. drugs used in immunosuppressive therapy;
3. erythropoietin for dialysis patients;
4. osteoporosis drugs for certain homebound patients;
5. certain oral cancer drugs;
6. oral anti-emetics used in certain situations;
7. drugs treated as supplies during an outpatient hospital procedure; and
8. drugs required for the effective use of durable medical equipment.
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare
Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health
plan contract says that covered drugs include: Drugs that usually aren't self-administered by the patient and are
injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services.
You can find this information in Chapter 4 on page 4-35 of the plan's 2021 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 $250 copayment for Ambulance Services. You can find this information on page 69 of the Plan's 2021 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 a $110 copayment for each Medicare-covered radiological diagnostic service and a $30 copayment for each Medicare-covered non-radiological diagnostic service. Additionally, enrollees pay a 20% coinsurance for each Medicare-covered medical supply and Medicare-covered Part B drug. Supplies for which an appropriate separate charge is made by providers (such as, chemical agents used in certain diagnostic procedures) are subject to cost-sharing. You can find this information on pages 4-34, 4-40, 4-41, and 4-42 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. This information must be retained in the treating practitioner's or prosthetist's files. A fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is covered for beneficiaries whose functional level is 3 or above. No more than two of the same socket inserts (L5654, L5655, L5656, L5658, L5661, L5665, L5673, L5679, L5681, L5683) are allowed per individual prosthesis at the same time. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Local Coverage Determination (LCD) L33787.
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).
The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).
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