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 in Chapter 3, on pages 42-43 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 copayment for each Medicare-covered physical, occupational or speech language therapy visit. You can find this information on page 87 of the Plan's 2021 Evidence of Coverage (EOC).   

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 87 of the Plan's 2021 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 $40 copayment for specialist services. You can find this information in Chapter 4 on page 92 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 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. The Plan contract says that for services obtained Out-of-Network the Plan only pays up to a certain amount. If you choose to see an Out-of-Network dentist, you might be billed for any amount greater than what the Plan pays. You can find this information on page 4-55 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 when billing multiple units of a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code, providers must enter the actual number of units provided on the claim form. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.4.  

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, 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. The contract says for dental services received out of network the plan only pays up to a certain amount. The contract lists the specific dental services that are covered. This benefit includes a 50% coinsurance for extractions. Unspecified preventive service is not listed and therefore is not a covered service. The contract says any services not listed are not covered. You can find this information on pages 4-56 to 4-70 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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. The Plan contract says that the Plan only covers manual manipulation of the spine to correct subluxation. Other services performed by a chiropractor are not covered. You can find this information on page 64 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 $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You can find this information in Chapter 4 on page 94 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 $35 copayment for eye exams to diagnose and treat diseases and conditions of the eye for vision care. You can find this information in Chapter 4 on page 110 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 the Centers for Medicare and Medicaid Service (CMS) has established units of service edits referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most circumstances allowable by the same provider for the same enrollee on the same date of service. Claims submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied.    

MUEs are assigned MUE Adjudication Indicators (MAIs) which give information about the limit. Codes with an MUE with an MAI of 3 are "per day edits based on clinical benchmarks."  MUEs assigned an MAI of "3" are based on criteria (e.g., nature of service, prescribing information) combined with data such that it would be possible but medically highly unlikely that higher values would represent correctly reported medically necessary services. Evidence must be submitted for exceeding an MUE with an MAI of 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.
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 page 44 of the 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 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.  The rules say that a Medicare plan may not pay for services given by a physician or other practitioner who has opted out of Medicare. This rule does not apply to emergency or urgently needed services. A Medicare plan must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a private contract with the enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 6, Section 60.2.  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 covers certain dental services as a supplemental (extra) benefit. The contract says in order to take advantage on this benefit, please confirm your dentist has not opted out of Medicare. You can find this information on page 72 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 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. The contract lists the specific dental services that are covered. Resin based composite for a posterior tooth is not listed and therefore is not a covered service. You can find this information on pages 101 to 106 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 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 2 preventive exams, 2 cleanings (regular or periodontal maintenance), 1 set of bitewing x-rays, 1 brush biopsy, and radiographs once every 2 years. You can find this information on page 78 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 screening digital rectal examinations are covered at a frequency of once every 12 months. You can find this rule in the National Coverage Determination (NCD) - Prostate Cancer Screening Tests (210.1) - Effective June 19, 2006.   

The rules say that screening prostate specific antigen tests are covered at a frequency of once every 12 months for men who have attained age 50 (at least 11 months have passed following the month in which the last Medicare-covered screening prostate specific antigen test was performed). You can find this rule in the National Coverage Determination (NCD) - Prostate Cancer Screening Tests (210.1) - 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. The health plan contract says that for men, age 50 and older, covered services include the following - once every 12 months:  -Digital rectal exam -Prostate Specific Antigen (PSA) test  You can find this rule on page 33 of the plan's 2021 Schedule of Cost Sharing.
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, Publication 100-02, 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 Plan contract also says that covered drugs include drugs that are not usually 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 on page 4-33 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  

The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the 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 a full mouth series, bitewing x-rays, or panoramic x-ray, payable once per calendar year. You can find this information on page of the Dental Plan's 2021 Summary of Dental Plan Benefits.