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 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 39-40 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 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 state that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be 
ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or 
treats a beneficiary for a specific medical problem and who uses the results in the management of the 
beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are 
not reasonable and necessary. You can find this information in the 42 Code of Federal Regulations, Section 
410.32. 
 
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 43 and 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 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 specialist services provided in an outpatient 
department. You can find this information in Chapter 4 on page 87 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 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 
services received from dentists who do not participate in the Plan's network will result in your out of pocket 
costs being higher. If you receive services from a dentist that does not participate in the Plan's network, you 
will be responsible for the difference between the Plan's payment to you and the amount charged by the non-
participating dentist. The Plan contract says that the Plan pays an 80% coinsurance for diagnostic and 
preventive services, including exams, received by an out-of-network dentist. The contract also says that the 
Plan pays a 50% coinsurance for major restorative services including crowns received by an out-of-network 
dentist. You can find this information on pages 2 and 3 of the Plan's 2020 Optional Supplemental Dental 
Program.
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. The contract specifically says that any 
procedure not listed is not covered. Replace broken teeth is not included on this list and is not a covered 
supplemental benefit. You can find this information on pages 93 and 94 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% coinsurance for Medicare-covered Part B drugs. You can find this 
information on page 36 of the Plan's 2020 Medical Benefits Chart.
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 Medicare Part B prescription drugs. You can find 
this information on page 73 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 payment under the fee schedule for ambulance services covers both the transport of the 
beneficiary to the nearest appropriate facility and all items and services associated with such transport; and 
does not include a separate payment for items and services furnished under the ambulance benefit. 
 
Payment for items and services is included in the fee schedule payment. Such items and services include but 
are not limited to oxygen, drugs, extra attendants, and EKG testing but only when such items and services are 
both medically necessary and covered by Medicare under the ambulance benefit. You can find this in the 
Medicare Claim Processing Manual, Chapter 15, Section 20.1.1. 
 
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 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 physician/practitioner services/specialist. You can 
find this information on pages 79-80 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 the clinical effectiveness of arthroscopic lavage and arthroscopic debridement for the severe 
osteoarthritic knee has not been verified by scientifically controlled studies.  After thorough discussions with 
clinical investigators, the orthopedic community, and other interested parties, CMS determines that the 
following procedures are not considered reasonable or necessary in treatment of the osteoarthritic knee and are 
not covered by the Medicare program: 
? Arthroscopic lavage used alone for the osteoarthritic knee; 
? Arthroscopic debridement for osteoarthritic patients presenting with knee pain only; or, 
? Arthroscopic debridement and lavage with or without debridement for patients presenting with severe 
osteoarthritis ((Severe osteoarthritis is defined in the Outerbridge classification scale, grades III and IV. 
Outerbridge is the most commonly used clinical scale that classifies the severity of joint degeneration of 
the knee by compartments and grades. Grade I is defined as softening or blistering of joint 
cartilage. Grade II is defined as fragmentation or fissuring in an area <1 cm.  Grade III presents 
clinically with cartilage fragmentation or fissuring in an area >1 cm.  Grade IV refers to cartilage 
erosion down to the bone. Grades III and IV are characteristic of severe osteoarthritis.) 
You can find this rule in the National Coverage Determination Manual, Section 150.9. 
 
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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and necessary for the following indications:
1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have not responded to non-surgical medical management (e.g., narcotic and/or non- narcotic medication, physical therapy modalities) with and without methods of immobility (e.g., rest, bracing).
o Both PVP and PVA will be considered reasonable and necessary when ALL of the following criteria are met:
&#9642; Acute (<6 wks.) or subacute (6-12 wks.)18,28,42 osteoporotic VCF (T5 - L5) confirmed by recent (within 30 days) advanced imaging demonstrating bone marrow edema on MRI or bone-scan/SPECT/CT uptake1-3,8,26,43 and
&#9642; The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or Visual Analog Scale [VAS] pain score &#8805; 8)4-7 or is non-hospitalized with moderate to severe pain (NRS or VAS &#8805;5) despite optimal non-surgical management (NSM)8 with one of the following:
&#9642; Worsening Pain or
&#9642; Stable to improved pain (but NRS or VAS &#8805;5) when 2 or more of the following are present:
&#9642; Progression of vertebral body height loss
&#9642; > 25% vertebral body height reduction
&#9642; Kyphotic deformity
&#9642; Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) >17)
You can find this rule at Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L34976) (eff. 7/12/20).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $180 copayment for diagnostic radiology services. You can find this information in Chapter 4 on pages 73 - 74 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 a $250 copayment for each one-way Medicare-covered ground trip. You 
can find this information on page 4-6 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 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). 
 
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 program reimbursement for HBO therapy will be limited to that which is administered in a 
chamber (including the one-man unit) and is limited to the following conditions: 
 
1. Acute carbon monoxide intoxication, 
2. Decompression illness, 
3. Gas embolism, 
4. Gas gangrene, 
5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in 
combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened. 
6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an 
adjunctive treatment when loss of function, limb, or life is threatened. 
7. Progressive necrotizing infections (necrotizing fasciitis), 
8. Acute peripheral arterial insufficiency, 
9. Preparation and preservation of compromised skin grafts (not for primary management of wounds), 
10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, 
11. Osteoradionecrosis as an adjunct to conventional treatment, 
12. Soft tissue radionecrosis as an adjunct to conventional treatment, 
13. Cyanide poisoning, 
14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to 
antibiotics and surgical treatment 
15. Diabetic wounds of the lower extremities in patients who meet the following three criteria: 
-Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; 
-Patient has a wound classified as Wagner grade III or higher; and 
-Patient has failed an adequate course of standard wound therapy. 
 
You can find this rule in National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29) - 
Effective June 19, 2006. 
 
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
1. The services are specific and effective treatment for the patient's condition, 
2. The services require the skills or direct supervision of a therapist,  
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, 
and   
4. The services are needed to address recovery of or improvement in function OR to establish, design, 
deliver, or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 220.2. 
 
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.