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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers 10 one-way trips. You can find this information on pages 56-57 in 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 an expandable controller is capable of accommodating one or more of the following 
additional functions: 
 
- Other types of proportional input devices (such as, mini-proportional or compact joysticks, touchpads, chin 
control, head control, and so on) 
- Non-proportional input devices (such as, sip and puff, head array, and so on) 
- Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating 
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) 
 
 An expandable controller may also be able to operate one or more of the following: 
 
- A separate display (for example, for alternate control devices) 
- Other electronic devices (such as, control of an augmentative speech device or computer through the chair's 
drive control) 
- An attendant control 
 
You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective 
January 1, 2020. 
 
The rules say that elevating leg rests (E0990, K0046, K0047, K0053, K0195) are covered if: 
1. The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90-
degree flexion at the knee; or 
2. The beneficiary has significant edema of the lower extremities that requires an elevating leg rest; or 
3. The beneficiary meets the criteria for and has a reclining back on the wheelchair. 
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. 
You can find this information in the Local Coverage Determination (LCD) for Wheelchair Options/Accessories 
(L33792). 
 
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 state that effective for claims with dates of service on and after December 23, 2009, the Centers for 
Medicare and Medicaid Services (CMS) determines that the evidence is adequate to conclude that OIVIT does 
not improve health outcomes in Medicare beneficiaries. Therefore, CMS determines that OIVIT is not 
reasonable and necessary for any indication under section 1862(a)(1)(A) of the Social Security Act. Services 
comprising of an OIVIT regimen are nationally non-covered under Medicare when furnished pursuant to an 
OIVIT regimen. You can find this rule in the Centers for Medicare and Medicaid Service, Internet-Only 
Manual, Publication 100-03, National Coverage Determination (NCD) - Outpatient Intravenous Insulin 
Treatment (40.7). 
 
The rules also say that drug and chemotherapy administration Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) codes 96360-96375, 96377 and 96401-96425 have been 
valued to include the work and practice expenses of CPT code 99211, defined as evaluation and management 
(E&M) service, office or other outpatient visit, established patient, level I. Although CPT code 99211 is not 
reportable with chemotherapy and non-chemotherapy drug/substance administration HCPCS/CPT codes, other 
non-facility-based E&M CPT codes (for example 99202- 99205, 99212-99215) are separately reportable with 
modifier -25 if the physician provides a significant and separately identifiable E&M service. You can find this  
 
information in the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative 
Policy Manual for Medicare Services, Chapter 9(N). 
 
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 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 the Physician Fee Schedule Status Indicator p means that there are no payment amounts for 
these services. No separate payment should be made for them under the fee schedule. If the item or service is 
covered as incident to a physician service and is provided on the same day as a physician service, payment for 
it is bundled into the payment for the physician service to which it is incident. You can find this information in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 23, Section 30.2.2. 
 
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.
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 show that procedure codes 81410 and 81411 are listed under Group 3 paragraph, Tier 1 Non-covered 
codes for which genetic testing is unlikely to impact therapeutic decision-making in the clinical management of 
the patient and denied automatically as not medically necessary. You can find this information in Local 
Coverage Article (LCA): Billing and Coding: Molecular Pathology Procedures (A56199). 
 
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 15 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 a safety belt/pelvic strap (E0978) is covered if the beneficiary has weak upper body muscles,
upper body instability or muscle spasticity which requires use of this item for proper positioning. You can find
this rule in the Local Coverage Determination (LCD) Wheelchair Options/Accessories (L33792).

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 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 Healthcare Common Procedural Coding System  (HCPCS) Modifiers HA through HZ are 
not covered or not payable by Medicare by HCPCS Definition (HCPCS Administrative Instruction). You can 
find this rule in the Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 1, Section 60.4.2. 
 
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.
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 does not include 
D2950 or D5226. You can find this information in the Plans 2023 Dental Benefit Schedule (DEN 101). 
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 $300 copayment for outpatient surgery, including services provided at 
hospital outpatient facilities.  You can find this information on page(s) 83 of the Plan's 2023 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 routine physical checkups, eyeglasses, contact lenses, eye examinations for the purposes of 
prescribing, fitting, or changing eyeglasses, eye refractions, hearing aids and hearing aid examinations, and 
immunizations are not covered. The routine physical checkup exclusion applies to 
a. Examinations performed without relationship to treatment or diagnosis for a specific illness, symptoms, 
complaint, or injury 
b. Examinations required by third parties such as insurance companies, business establishments, or 
government agencies 
 
The routine physical checkup exclusion does not apply to the following services (as noted in section 42 CFR 
411.15(a)(1)): 
- Screening mammography, 
- Colorectal cancer screening tests, 
- Screening pelvic exams, 
- Prostate cancer screening tests, 
- Glaucoma screening exams, 
- Ultrasound screening for abdominal aortic aneurysms (AAA), 
- cardiovascular disease screening tests, 
- diabetes screening tests, 
- screening electrocardiogram, 
- Initial preventive physical examinations, 
- Annual wellness visits providing personalized prevention plan services, and 
- Additional preventive services that meet the criteria specified in 42 CFR 410.64. 
 
You can find these rules in Medicare Benefit Policy Manual Chapter 16, Section 90. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 The Plan contract states that the Plan covers one annual physical exam per year. You can find this in Chapter 4 
on page 49 of the Plans Evidence of Coverage (EOC). 
 
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 $298 copayment per day, for days 1 to 5 and a $0 copayment per day, 
for days 6 to 90. You can find this information on pages 68 to 69 of the Plan's 2022 Evidence of Coverage 
(EOC).  
 
The Plan contract says that enrollees must pay a $100 copayment for diagnostic procedures and tests at an 
outpatient hospital. You can find this information pages 72 to 75 of the Plans 2022 Evidence of Coverage 
(EOC). 
 
The Plan contract says that enrollees must pay a $275 copayment advanced imaging services at an outpatient 
hospital. You can find this information pages 72 to 75 of the Plans 2022 Evidence of Coverage (EOC). 
 
The Plan contract says that enrollees must pay a $30 copayment for provider and professional services at a 
specialist's office. You can find this information pages 79 to 80 of the Plans 2022 Evidence of Coverage 
(EOC). 
 
The Plan contract says that enrollees must pay a $180 copayment advanced imaging services at a specialist's 
office. You can find this information pages 60 to 62 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 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 also say that beginning in 2006, E&M services provided to patients residing in a Skilled Nursing 
Facility (SNF) or a Nursing Facility (NF) must be reported using the appropriate CPT level of service code 
within the range identified for Initial Nursing Facility Care (CPT codes 99304 - 99306) and Subsequent 
Nursing Facility Care (CPT codes 99307 - 99310). Use CPT codes 99315 - 99316 for SNF/NF discharge 
services. You can find this information in the Centers for Medicare & Medicaid Services, Internet-Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 6.14. 
 
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 $4,900 out-of-pocket. This is the most you pay during the calendar year 
for covered Medicare Part A and Part B services received from network providers. The amounts you pay for 
copayments and coinsurance for covered services from network providers count toward this in-network 
maximum out-of-pocket amount. You can find this information on page 52 of the Plan's 2023 Evidence of 
Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $275 copayment per day for days 1-6 per Medicare-covered 
stay and after the 6th day the plan pays 100% of the covered expenses. You can find this information pages 77 
to 78 of the Plans 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 that it is very important to get a written referral (approval in advance) from your primary care 
physician (PCP) before you see a plan specialist or certain other providers (there are a few exceptions, listed in 
Section 2.2 above). If you dont have a written referral (approval in advance) before you get services from a 
specialist, you may have to pay for these services yourself. For some types of referrals, your PCP may need to 
get approval in advance from SCAN Health Plan (this is called getting prior authorization). You can find this 
information on page 41 in the Plan's 2023 Evidence of Coverage.