Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 once per 60 months. This benefit also says that replacement of lost or 
broken dentures is limited to less than five (5) years of age. You can find this information on pages 107 and  
109 of the Plan's 2023 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). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says supplemental benefits are only offered to high-risk, chronically ill members who also meet 
additional criteria for eligibility. 
 Members must meet and maintain all three eligibility criteria below to qualify: 
1. The member must require intensive care management. 
 Based on physician assessment of patient having had 2 or more inpatient admissions in the 
last 60 days OR having had 3 or more emergency room visits in the last 60 days. 
2. The member must be at high risk for hospitalization. 
 Based on physician assessment of patient being at high-risk for unplanned hospitalization in 
the next 60 days. 
3. The member must have a documented and active diagnosis for one or more of the qualifying 
comorbid and medically complex conditions. The condition must be life threatening or 
significantly limit the overall health or function of the member. 
 After required office visit, physician to submit claim showing diagnosis code(s) for 
qualifying eligible condition(s). 
 Eligibility is determined at the discretion of your plan through processes that review claims history, 
risk classification, and other information. Members who cannot be automatically qualified will be 
required to schedule a visit with their physician to ensure sufficient documentation (e.g. claims, 
qualifying assessment) are available to validate eligibility. Copays or other costs not covered by 
your plan may apply. 
 Confirmation that all criteria has been met is required prior to receiving access to these benefits. 
 All benefits end on 12/31/2023 and members will be required to re-qualify each plan year. 
 For more information, please contact Member Services at the number on the back of your ID card.  Please go to the "Special Supplemental Benefits for the Chronically Ill" row in the below Medical 
Benefits Chart for further detail. 
 
You can find this information in the Chapter 4 Medical Benefits Chart of the 2023 Evidence of Coverage for 
Wellcare Dual Liberty (HMO D-SNP).
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 provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules state that special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The Plan must have written policies for determining enrollee eligibility and 
must document its determination that an enrollee is a chronically ill enrollee. You can find this information in 
42 CFR 422.102. 
 
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 if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. You can find this information on pages 55 to 
57 of the Plan's 2023 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). 
  
  The rules state that for parenteral nutrition to be considered reasonable and necessary, the treating practitioner 
must document that enteral nutrition has been considered and ruled out, tried and been found ineffective, or that 
EN exacerbates gastrointestinal tract dysfunction. The beneficiary must have (a) a condition involving the 
small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients or (b) disease 
of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to be transported 
through and absorbed by the gastrointestinal (GI) system. The beneficiary must have a permanent impairment.  
 
The treating practitioner is required to evaluate the beneficiary within 30 days prior to initiation of parenteral 
nutrition. If the treating practitioner does not see the beneficiary within this timeframe, they must document the 
reason why and describe what other monitoring methods were used to evaluate the beneficiary's parenteral 
nutrition needs. There must be documentation in the medical record supporting the clinical diagnosis. 
 
You can find this information in the Local Coverage Determination (LCD) Parenteral Nutrition (L38953). 
 
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 WCE is indicated for the diagnosis of occult gastrointestinal bleeding (i.e., likely involving 
the small intestine), the site of which has not previously been identified by any of the following: upper 
gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging or radiological procedures. 
  
  WCE is limited to those patients who have undergone upper GI endoscopy and colonoscopy and these tests 
have failed to reveal a source of bleeding. Medicare would not expect to see a WCE provided if upper and 
lower endoscopy has not previously been performed. Documentation in the medical record must indicate that 
the beneficiary has suspected GI blood loss with or without anemia. Appropriate differential diagnoses for the 
evaluation of such bleeding include: 
 Angiodysplasia 
 Neoplasm 
 Iron deficiency anemia, which is unexplained after upper and lower endoscopy 
 Zollinger-Ellison syndrome 
 Tuberculosis 
 Vasculitis 
 Radiation enteritis 
 Meckels diverticulum 
 Jejunal diverticula 
 Chronic mesenteric ischemia 
Other indications include the management of celiac disease (e.g., surveillance for small-intestinal cancer) and 
of Crohns disease (that is, either Crohns disease is suspected, but not diagnosed, or colonic involvement of 
Crohns disease is known, but it is necessary to determine whether there is also involvement of the small 
bowel). In addition, WCE is indicated where an indeterminate type of colitis exists, but where a more specific 
diagnosis is being sought via small bowel evaluation. 
Esophageal capsule endoscopy may be used in the evaluation of esophageal varices in patients with portal 
hypertension, as an alternative to upper GI endoscopy. You can find this rule at Local Coverage Determination 
(LCD) L35089: Wireless Capsule Endoscopy (eff. 11/21/19). 
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 traction equipment is covered if the patient has orthopedic impairment requiring traction 
equipment which prevents ambulation during the period of use (Consider covering devices usable during 
ambulation; e.g., cervical traction collar, under the brace provision). You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, National Coverage Determination 
(NCD) - Durable Medical Equipment (DME) Reference List (280.1). 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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 page 10 of the 2023 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 only the 
items and services listed in the dental services benefit category. An endosteal implant (D6010, a prefabricated 
abutment (D6056), an abutment supported crown (D6058), and a pontic (D6245) may be covered by the Plans 
dental benefits. The contract says that prior authorization may be required. You can find this information on 
pages 54-55 of the Plans 2023 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 push-rim activated power assist device (E0986) for a manual wheelchair is covered if all of 
the following criteria are met: 
  
   
A. All of the criteria for a power mobility device listed in the Basic Coverage Criteria section are met; and 
B. The beneficiary has been self-propelling in a manual wheelchair for at least one year; and 
C. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical 
professional, such as a PT or OT, or practitioner who has specific training and experience in rehabilitation 
wheelchair evaluations and that documents the need for the device in the beneficiarys home. The PT, OT, or 
practitioner may have no financial relationship with the supplier; and 
D. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology 
Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the 
wheelchair selection for the beneficiary. 
 
You can find this rule in the Local Coverage Determination (LCD) - Power Mobility Devices (L33789) - 
Effective January 1, 2020. 
 
The rules say that Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as 
toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(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 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.
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 $100 copayment per day for a Medicare-covered ultrasound. You can 
find this information on page 99 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). 
 
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 there is a $1000 deductible which applies to certain items and services. The Plan contract 
says that until enrollees have paid the deductible amount, they must pay the full cost for most covered services.  
You can find this information on page 4-2 of the Plan's 2022 Evidence of Coverage (EOC). The Plan contract 
also says that the deductible applies to in and out-of-network outpatient diagnostic x-rays and in and out-of-
network outpatient diagnostic radiology services. You can find this information on page 4-3 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 enrollees must pay a $75 copayment for Medicare-covered emergency room visits. You can 
find this information on page 74 of the Plan's 2022 Evidence of Coverage (EOC).