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 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 usually arent 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 pages 77 to 78 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 state that if an independent lab bills for services, the place where the sample was taken is reported as 
the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of 
service. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.6. 
 
The rules say that in the case of a molecular pathology test performed by a laboratory other than a blood bank 
or center, a test designated by CMS as an ADLT under paragraph (1) of the definition of an advanced 
diagnostic laboratory test in Section 414.502, a test that is a cancer-related protein-based Multianalyte Assays 
with Algorithmic Analyses, or the test described by CPT code 81490, the date of service of the test must be the 
date the test was performed only if - 
(i) The test was performed following a hospital outpatient's discharge from the hospital outpatient department; 
(ii) The specimen was collected from a hospital outpatient during an encounter (as both are defined in  410.2 
of this chapter); 
(iii) It was medically appropriate to have collected the sample from the hospital outpatient during the hospital 
outpatient encounter; 
(iv) The results of the test do not guide treatment provided during the hospital outpatient encounter; and 
(v) The test was reasonable and medically necessary for the treatment of an illness. 
 
You can find this rule in CFR 42, Section 414.510(b)(5). 
 
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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 15, Section 15.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that ou can get your care from an out-of-network provider, however, in most cases that 
provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who 
has opted out of or been excluded or precluded from the Medicare Program. If you receive care from a provider 
who is not eligible in Medicare, you will be responsible for the full cost of the services you receive. You can 
find this information on page 3-2 to 3-3 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 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 42 to 43 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 state that if an independent lab bills for services, the place where the sample was taken is reported as 
the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of 
service. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.6. 
 
The rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other 
supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two 
exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or 
outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You 
can find this information in the MLN Matters article number MM7631, Revised and Clarified Place of Service 
(POS) Coding Instructions. 
 
The rules say if one laboratory procedure evaluates multiple genes utilizing a next generation sequencing 
procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis current 
procedural terminology (CPT) code. If no CPT code accurately describes the procedure performed, the 
laboratory shall report CPT code 81479 (unlisted molecular pathology procedure) with one unit of service. The 
laboratory shall not report multiple individual CPT codes describing the component test results. If a single 
procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the 
procedure. You can find this rule in the Centers for Medicare and Medicaid Services, National Correct Coding 
Initiative Policy Manual Chapter X. 
 
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 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 for laboratories performing single gene technologies, a sequential genetic testing approach is 
expected. Once a positive result is obtained and the appropriate diagnosis is established, further testing should 
stop. Reflex testing to the next gene will be considered reasonable and necessary if the following sequence of 
genetic tests produce a negative result: 
1. BCR-ABL negative test results, progress to #2 
2. JAK 2, cv negative test results, progress to #3 or #4 
3. JAK, exon 12 (JAK2 exon 12 is only done when PV is suspected) 
4. Calreticulin (CALR)/MPL (CALR/MPL is only done when either ET or PMF is suspected; testing for 
CALR/MPL does NOT require a negative JAK2 exon 12, just a negative JAK2 V617F result) 
Genetic testing of the JAK2 V617F mutation is medically necessary when the following criteria are met: 
 Genetic testing impacts medical management; and  
 Patient would meet World Health Organizations (WHO) diagnostic criteria for myeloproliferative 
disease (i.e., PV, ET, PMF) if JAK2 V617F were identified. 
Genetic testing of the CALR gene (only found in ET and PMF) is medically necessary when the following 
criteria are met: 
 Genetic testing impacts medical management; and 
 JAK2 V617F mutation analysis was previously completed and negative; and 
 Patient would meet WHOs diagnostic criteria for MPD (i.e., ET, PMF) if a clonal marker were 
identified. 
 
You can find this rule in the Local Coverage Determination for Molecular Diagnostics Service Program 
(MolDX): Genetic Testing for BCR-ABL Negative Myeloproliferative Disease, L36815.  
 
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 2 oral 
exams per calendar year. You can find this information on pages 68 to 69 of the Plans 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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that when a non-plan provider provides care to a beneficiary enrolled in a Medicare health plan, 
the provider must accept, as payment in full, the amount collectable if the beneficiary were enrolled in fee for 
service Medicare. You can find this rule at 42 CFR, Section 422.214. 
 
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 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.
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 repeat ESIs may be considered medically reasonable and necessary when the first injection 
directly and significantly provided improvement of the condition being treated and when the medical record 
documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from 
baseline using the same scale for at least three months. If a patient fails to respond well to the initial ESI, a 
repeat ESI after 14 days can be performed using a different approach, level and/or medication, if appropriate, 
with the rationale and medical necessity for the second ESI documented in the medical record. 
 
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 13 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 $65 copayment for each Medicare-covered urgent care facility visit. 
You can find this information in Chapter 4 on page 102 of the Plan's 2021 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $45 copayment for physician specialist services. You can find 
this information in Chapter 4 on pages 91 to 94 of the Plan's 2021 Evidence of Coverage (EOC). 
 
The Plan contract says that enrollees must pay a $350 copayment for CT scans. You can find this information 
in Chapter 4 on pages 84 to 85 of the Plan's 2021 Evidence of Coverage (EOC). 
 
The Plan contract says that enrollees must pay a $350 copayment for diagnostic radiology other than CT scans. 
You can find this information in Chapter 4 on pages 84 to 85 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 all Home Health Agencies (HHAs) must submit a request for anticipated payment (RAP) 
within 5 calendar days after the start of care date for initial 30-day periods and within 5 calendar days after the 
from date for each subsequent 30-day period of care, which is set at 0 percent at the beginning of every 30-
day period. HHAs receive a single payment for a 30-day period of care after the final claim is submitted. You 
can find this information in 42 CFR 484.205 (g)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract lists the dental 
services that are covered. Bone replacement graft is not listed and therefore is not a covered service. Guided 
tissue regeneration is not listed and therefore is not a covered service either. You can find this information on 
pages 5 to 86 of the Plans 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 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. 
 
The rules say that the plan must pay for emergency and urgently needed services. This rule applies whether the 
services are obtained in or out of the plans network. This rule applies whether or not there is prior 
authorization for the services. The rules say that an emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules 
say that urgently needed services are those needed because of an unforeseen illness or condition, and it is not 
reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside 
of the service area. You can find this rule at 42 CFR Section 422.113. 
 
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.