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 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 $35 copayment for each Specialist telemedicine visit. You can find this 
information in Chapter 4 on pages 87 to 90 of the Plan's 2022 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, 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 includes 
complete maxillary denture (D5110) and complete mandibular denture (D5120), and are each limited to once 
per 60 months. You can find this information on pages 98 and 99 of the Plan's 2022 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 $188 copayment each day for Medicare-covered days 21 to 57 for SNF 
care. You can find this information in Chapter 4 on page 4-51 of the Plan's 2022 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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(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 a refraction is only covered when billed as part of the routine eye exam. You can find this 
information on page 86 of the Plan's 2022 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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(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 you are eligible for up to $1,000 per year to be used toward the purchase of eyeglasses (frames 
and lens) and/or contact lens. Maximum benefit amount applies for both in-network and out-of-network. The 
Plan contract says you must pay 10% coinsurance for covered services (covered through reimbursement, based 
on providers contracted rates, less applicable coinsurance). You can find this information on pages 121 to 122 
of the Plan's 2022 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, 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 are 
listed on pages 146-178 in the Plan's 2022 Evidence of Coverage. Any service not listed is not covered.
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, Publication 100-02, 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 includes 
coverage of two crowns per calendar year, but you are responsible for paying 70 percent of the cost when the 
services are received in-network. The benefit does not include any coverage for core buildups. You can find 
this information on pages 85 and 86 of the Plans 2022 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 state that to meet the DME benefit category requirements, the speech generating device must meet all 
of the following requirements: 
 
    Can withstand repeated use; and, 
 
    Has an expected life of at least 3 years; and, 
 
    Is primarily and customarily used to serve a medical purpose; and, 
 
    Generally is not useful to an individual in the absence of an illness or injury; and, 
 
    Is appropriate for use in the home; and, 
 
    Be limited to use by a patient with a severe speech impairment; and, 
 
    Be primarily used for the purpose of generating speech, as defined above. 
 
Upgrades to speech generating devices and/or software programs that are provided within the 5 year useful 
lifetime of the device will be denied as statutorily non-covered. 
 
You can find this information in the Local Coverage Article Speech Generating Devices (SGD) - Policy Article 
A52469. 
 
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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes 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 several Healthcare Common Procedural Coding System (HCPCS) modifiers are used to 
signify a specific line item is either not covered or not payable by Medicare, for many different reasons. The 
chart immediately below lists those modifiers, many more commonly used on professional claims, for services 
not covered or not payable by Medicare. Modifiers not payable on professional claims are also not payable on 
institutional claims and will be denied if submitted on such claims. Providers are liable for these denials, 
UNLESS a specific modifier or indicator on the claim (i.e., occurrence code 32) specifically assigns liability to 
the beneficiary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 60.4.2. 
 
The rules say that at Medicare administrative contractor (MAC) discretion, claims submitted using the GY 
modifier may be auto-denied. If the GZ and GA modifiers are submitted for the same item or service, treat the 
item or service as having an invalid modifier and therefore unprocessable. You can find this rule in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 20.9.1.  
 
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 state that meals may be offered as a supplemental benefit to address the following two types of 
circumstances: 
 
1. Immediately following surgery or an inpatient hospital stay, for a temporary duration - typically a four-week 
period - per enrollee per year, provided they are ordered by a physician or practitioner. 
2. For a chronic condition, for a temporary period  typically two weeks  per enrollee per year provided they 
are ordered by a physician or practitioner and are part of a supervised program designed to transition the 
enrollee to lifestyle modifications. 
 
You can find this rule in Medicare Managed Care Manual Chapter 4, Section 30.2. 
 
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 contract 
says that the Plan allows meals delivered to your home following discharge from a hospital as an inpatient due 
to congestive heart failure, up to two meals per day in a consecutive four-week period, once per calendar year. 
A referral is required. You can find this information on page 70 of the Plan's 2022 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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(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 also says that Original Medicare does not cover routine eye exams (eye refractions) for 
eyeglasses/contacts. You can find this information on page 129 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that high frequency chest wall oscillation devices (HFCWO) (E0483) are covered for 
beneficiaries who meet: 
 
    Criterion 1, 2, or 3, and 
 
    Criterion 4 
 
        There is a diagnosis of cystic fibrosis (refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses). 
 
        There is a diagnosis of bronchiectasis (refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses) which has been confirmed by a high resolution, spiral, or standard CT scan and which is 
characterized by: 
 
                Daily productive cough for at least 6 continuous months; or 
 
                Frequent (i.e., more than 2/year) exacerbations requiring antibiotic therapy. 
 
        Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed 
diagnosis of bronchiectasis do not meet this criterion. 
 
        The beneficiary has one of the following neuromuscular disease diagnoses (refer to the ICD-10 code list in 
the LCD-related Policy Article for applicable diagnoses): 
        Post-polio 
        Acid maltase deficiency 
        Anterior horn cell diseases 
        Multiple sclerosis 
        Quadriplegia 
        Hereditary muscular dystrophy 
        Myotonic disorders 
        Other myopathies 
        Paralysis of the diaphragm 
         There must be well-documented failure of standard treatments to adequately mobilize retained secretions. 
 
If all of the criteria are not met, the claim will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) High Frequency Chest Wall 
Oscillation Devices L33785. 
 
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 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, Publication 100-02, 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. Cone beam computed tomography (CT) scan (D0360) and bone 
replacement graft for ridge preservation are not included on this list and are not covered supplemental benefits. 
You can find this information on pages 69 to 79 of the Plans 2022 Evidence of Coverage (EOC). 
 
The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The Plan 
contract says that an implant is the artificial replacement of the root of a permanent tooth used to replace one or 
various teeth surgically placed in the maxillary or mandibular bone to hold a prosthesis of a complete denture 
in the cover for members who are completely toothless in an arch. The contract also says that a dental implant 
to hold a complete denture is a covered service under the implant category. You can find this information on 
pages 73 and 74 of the Plan's 2022 Evidence of Coverage. 
 
The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract 
says that conscious intravenous sedation services require prior authorization. You can find this information on 
page 77 of the Plan's 2022 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, 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 includes the 
requested item or service but is limited to the dental services maximum benefit of $1,500 every year for non-
Medicare covered preventive dental services and non-Medicare covered comprehensive dental services 
combined. You can find this information in Chapter 4 on pages 71 to 72 of the Plan's 2022 Evidence of 
Coverage (EOC).