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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, 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 52-53 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 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 Centers for Medicare and 
  
  Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Grievance Manual, Section 50.12.1. 
 
The rules state that therapeutic continuous glucose monitors (CGMs) and related supplies are covered by 
Medicare when all of the following coverage criteria are met: 
  1. The beneficiary has diabetes mellitus, 
  2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a 
Medicare-covered continuous subcutaneous insulin infusion (CSII) pump, 
  3. The beneficiarys insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results, 
  4. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the 
beneficiary to evaluate their diabetes control and determined that criteria (1-3) above are met; and, 
  5. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
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% coinsurance for Medicare Part B prescription drugs. You can find 
this information in Chapter 4 on page 85 to 86 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 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 an annual wellness visit does not include lab tests, radiological diagnostic tests or non-
radiological diagnostic tests and that additional cost share may apply to any lab or diagnostic testing performed 
during your visit. You can find this information on page 4-10 of the Plan's 2022 Evidence of Coverage (EOC). 
 
The Plan contract also says that enrollees must pay a $40 copayment for outpatient diagnostic tests. You can 
find this information on page 4-45 of the Plan's 2022 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 immunizations are not covered unless they are directly related to the treatment of an injury or 
direct exposure to a disease or condition. In the absence of injury or direct exposure, vaccination or inoculation 
is not covered. However, pneumococcal, hepatitis B, influenza virus vaccines, and any FDA-approved COVID-
19 vaccines are exceptions to this rule. You can find this rule at 42 CFR Section 411.15(e) and Section 3713 of 
the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). 
 
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 immunizations covered under Medicare Part B include pneumonia, influenza, Hepatitis 
B, and COVID-19 vaccines. You can find this information on page 68 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 a $30 copayment for each physical therapy visit. You can find this 
information on page 83 of the Plan's 2021 Evidence of Coverage (EOC) and page 80 of the Plans 2022 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 there are currently four botulinum toxin products commercially available in the United 
States: onabotulinumtoxinA, rimabotulinumtoxinB, abobotulinumtoxinA, and incobotulinumtoxinA. Each 
preparation has distinct pharmacological and clinical profiles specified on the product insert. Dosing patterns 
are specific to the preparation of neurotoxin and varies between different serotypes. Failure to recognize the 
unique characteristics of each formulation of botulinum toxin can lead to undesired patient outcomes. It is 
expected that physicians will be familiar with and experienced in the use of these agents and utilize evidence-
based medicine to select the appropriate drug and dose regimen for each patient condition. A patient who is not 
responsive or who ceases to respond to one serotype may respond to the other. You can find these rules in 
Local Coverage Determination (LCD) Botulinum Toxin Type A & B (L34635). 
 
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 20% coinsurance for Medicare-covered durable medical equipment and 
related supplies. You can find this information on page 46 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 state that when an enrollee begins coverage in a new Medicare health plan during an inpatient 
hospital stay, payment for the stay is 
made by the plan the enrollee was in on the date of admission to the hospital. This rule is found in 42 CFR, 
Section 422.318(b). 
 
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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers 24 trips every year. You can find this information on page 113 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 also say that certain data elements are required. Any claim with incomplete, missing, or invalid 
information for all of these elements may be returned as 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 1, Section 80.3.1. 
 
The rules say that home health agencies (HHAs) shall no longer submit Requests for Anticipated Payment 
(RAPS -TOB 0322) for any home health period of care with a from date on or after January 1, 2022. Instead, 
for each admission to home health, the home health agency (HHA) notifies Medicare systems via submission 
of a notice of admission (NOA). HHAs shall send the NOA to the A/B MAC (HHH) by mail, electronic data 
interchange (EDI), or direct data entry (DDE). EDI submissions require additional data not required by the 
NOA itself, to satisfy transaction standards. This data is described in a companion guide available on the CMS 
website. HHAs may voluntarily agree to adopt the companion guide and use it to submit EDI NOAs at any 
time. For all beneficiaries receiving HH services in 2021 whose services will continue in 2022, the HHA shall 
submit an NOA with a one-time, artificial 'admission' date corresponding to the "From" date of the first period 
of continuing care in 2022. For example, if a period of care begins in 2021 and ends on January 10, 2022, the 
HHA submits and NOA with an admission date of January 11, 2022 and then submits a claim when the 30-day 
period of care is over. 
 
You can find this rule in the Medicare Claims Processing Manual, Chapter 10, Section 10.1.10.3 - Submission 
of the Notice of Admission (NOA). 
 
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 $25 copayment for podiatry services. You can find this information on 
page(s) 65 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 1 of D5110-D5226 per arch every 5 calendar years. You can find this 
information in the enhanced dental benefit chart on pages 124-125 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 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 
beneficiarys specific medical problem. Tests not ordered by the physician who is treating the beneficiary are 
not reasonable and necessary. This rule is found in  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 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 page 55 of the Plans 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 20% coinsurance for Medicare-covered durable medical equipment and 
related supplies. You can find this information on page 80 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 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 on pages 30 and 32-33 of the 
Plan's 2022 Evidence of Coverage (EOC).