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 also says that there is a $295 copayment, after your $750 plan deductible, for each Medicare-covered 
outpatient surgery at an ambulatory surgical center or outpatient hospital facility. The Plan deductible applies 
to outpatient surgery services. You can find this information on page 115 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 $298 copayment per day for days 1-7, and a $0 copayment per day for 
days 8-90 for inpatient hospital care. You can find this information on page 68 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 
preventive and comprehensive dental services. The contract also says that the preventive and comprehensive 
dental services are only covered when provided by a contracted dental provider. You can find this information 
on pages 67 to 68 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 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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
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 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 56 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 $50 copayment for each Medicare-covered exam to diagnose and treat 
diseases and conditions of the eye. You can find this information in Chapter 4 on pages 96 to 97 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 to be eligible for coverage of home blood glucose monitors and related accessories and 
supplies, the beneficiary must meet both of the following basic criteria (1)  (2): 
1. The beneficiary has diabetes; and 
2. The beneficiarys treating practitioner has concluded that the beneficiary (or the beneficiarys caregiver) 
has sufficient training using the particular device prescribed as evidenced by providing a prescription for 
the appropriate supplies and frequency of blood glucose testing. 
 
Lancets (code A4259), blood glucose test reagent strips (code A4253), glucose control solutions (code A4256) 
and spring powered devices for lancets (code A4258) are covered for beneficiaries for whom the glucose 
monitor is covered. 
 
For a beneficiary who is not currently being treated with insulin administrations, up to 100 test strips and up to 
100 lancets every 3 months are covered if the basic coverage criteria (1)-(2) (above) are met. 
 
You can find these rules in the Local Coverage Determination (LCD) for 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 $160 copayment for Medicare-covered radiological diagnostic services, 
not including X-rays, performed in a physicians office or at a free-standing facility (such as a radiology center 
or medical clinic). You can find this information in Chapter 4 on pages 4-30 to 4-33 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 Reimbursement for oxygen equipment is limited to 36 monthly rental payments. Payment 
for accessories (e.g., cannula, tubing, etc.), delivery, back-up equipment, maintenance, and repairs is included 
in the rental allowance. Payment for oxygen contents (stationary and/or portable) is included in the allowance 
for stationary equipment. 
 
The rules say that There is no further payment for oxygen equipment during the 5-year reasonable useful 
lifetime (RUL) of the equipment after 36 rental payments have been made. If use of portable equipment begins 
after the use of stationary equipment begins, payment for the portable equipment can continue after payment 
for the stationary equipment ends until 36 rental payments have been made for the portable equipment. 
 
You can find these rules in the Local Coverage Article for Oxygen and Oxygen Equipment - Policy Article, 
A52514. 
 
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 effective for services performed on and after October 24, 2006, the Centers for Medicare & 
Medicaid Services has determined that there is sufficient evidence to conclude the use of infrared therapy 
devices and any related accessories is not reasonable and necessary under section 1862(a)(1)(A) of the Social 
Security Act (the Act). The use of infrared and/or near-infrared light and/or heat, including monochromatic 
infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these 
conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin 
and/or subcutaneous tissues. You can find this information in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 270.6 
(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.
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 $95 copayment for an MRI. You can find this information in Chapter 4 
on page 52 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. 
 
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 routine eye exams have an allowance of $75 when received from a Vision Plan provider. 
When you receive this service out-of-network, any amount over $75 is your responsibility. You can find this 
information on page 92 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 $50 copayment for outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information in Chapter 4 on page 89 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 general use seat cushion (E2601, E2602) and a general use wheelchair back cushion 
(E2611, E2612) are covered for a beneficiary who has a manual wheelchair or a power wheelchair with a 
sling/solid seat/back which meets Medicare coverage criteria. If the beneficiary does not have a covered 
wheelchair, then the cushion will be denied as not reasonable and necessary. If the beneficiary has a POV or a 
power wheelchair with a captain's chair seat, the cushion will be denied as not reasonable and necessary. 
 
For beneficiaries who meet coverage criteria for a power wheelchair and who do not have special skin 
protection or positioning needs, a power wheelchair with Captains Chair provides appropriate support. 
Therefore, if a general use cushion is provided with a power wheelchair with a sling/solid seat/back instead of 
Captains Chair, the wheelchair and the cushion(s) will be covered if either criterion 1 or criterion 2 is met: 
 
      1. The cushion is provided with a covered power wheelchair base that is not available in a Captains Chair 
model  i.e., codes K0839, K0840, K0843, K0860, K0861, K0862, K0863, K0864, K0890, K0891; or 
 
      2. A skin protection and/or positioning seat or back cushion that meets coverage criteria is provided. 
 
If one of these criteria is not met, both the power wheelchair with a sling/solid seat and the general use cushion 
will be denied as not reasonable and necessary. 
 
If the beneficiary has a POV or a power wheelchair with a captain's chair seat, a separate seat and/or back 
cushion will be denied as not reasonable and necessary. 
 
A skin protection seat cushion (E2603, E2604, E2622, E2623) is covered for a beneficiary who meets both of 
the following criteria: 
 
      1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the 
beneficiary meets Medicare coverage criteria for it; and 
 
       
      2. The beneficiary has either of the following (a or b): 
 
          a. Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface 
as reflected in a diagnosis code listed in Group 1 of the ICD-10 code list in the LCD-related Policy Article; or           b. Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a 
functional weight shift as reflected in a diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-
related Policy Article. 
 
You can find this information in the Local Coverage Determination: Wheelchair Seating: L33312. 
 
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. This benefit includes oral 
exams, cleanings, x-rays, and a brush biopsy. You can find this information on pages 77-78 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 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 
$2,000 combined allowance for supplemental preventive and comprehensive services every year. The Plan 
contract also says that the member is responsible for any amount over and above the allowance amount. You 
can find this information on page 42 of the Plan's 2020 Evidence of Coverage (EOC).