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 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 that 42 CFR, Section 410.32, indicates that diagnostic tests may only be ordered by the treating 
physician (or other treating practitioner acting within the scope of his or her license and Medicare 
requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses 
the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician 
(or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary 
(see Sec. 411.15(k)(1) of this chapter). You can find this rule in Local Coverage Determination (LCD) 
Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms L37810. 
 
The rules say that for Medicare to consider coverage and payment for an item or service, the information 
submitted by the supplier or provider must corroborate the services so we can confirm Medicare coverage has 
been met. You can find this rule in the Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1. 
 
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.
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 also says that there is a $1,000 out-of-network deductible which applies to certain items and services. 
The Plan deductible applies to the OON specialist services. You can find this information on pages 63-64 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 
 
Nationally Covered Indications 
 
The following indications are covered nationally unless otherwise indicated: 
 
    Computer analysis of EKGs when furnished in a setting and under the circumstances required for coverage 
of other EKG services. 
 
    EKG services rendered by an IDTF, including physician review and interpretation. Separate physician 
services are not covered unless he/she is the patients attending or consulting physician. 
 
    Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed as a 
laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance at the time 
the service is performed or immediately thereafter. 
 
    Home EKG services with documentation of medical necessity. 
 
    Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications 
described below, when performed with equipment meeting the standards described below, subject to the 
limitations and conditions specified below. Coverage is further limited to the amounts payable with respect to 
the physicians service in interpreting the results of such transmissions, including charges for rental of the 
equipment. The device used by the beneficiary is part of a total diagnostic system and is not considered DME 
separately. Covered uses are to: 
        Detect, characterize, and document symptomatic transient arrhythmias; 
        Initiate, revise, or discontinue arrhythmic drug therapy; or, 
        Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); (only if 
24-hour coverage is provided, see C.5. below).  
 
Certain uses other than those specified above may be covered if, in the judgment of the local Medicare 
Administrative Contractor (MAC), such use is medically necessary. You can find this information in 
Medicare's National Coverage Determination (NCD): Electrocardiographic Services (20.15). 
 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 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 health 
plan contract says up to sixty (60) one-way trips are covered each year (limited to ground transportation only). 
Each one-way trip must not exceed seventy-five (75) miles of driving distance. A trip is one-way 
transportation; a round trip is two (2) trips. You can find this information in Chapter 4 on page 4-61 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 that Medicare does not pay for over-the-counter (OTC) items, including non-prescription drugs. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 40.2. 
 
The rules say that Medicare does not pay for gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. 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 Plan 
offers a supplemental (extra) benefit to cover certain health and wellness services that are not covered by 
Original Medicare. This benefit includes up to $150 per calendar year towards your cost for membership in a 
qualified health club or fitness facility, covered instructional fitness classes, participation in certain wellness 
programs, AAA senior driving, memory fitness activities, acupuncture, and/or covered nutritional counseling 
sessions with a licensed nutritional counselor or registered dietician. You pay all charges over $150 per 
calendar year. You can find this information on pages 80-82 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 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 providers that render services or items to a prisoner or patient in a jurisdiction that meets the 
conditions of 42 CFR 411.4(b) should indicate this fact on the claim by billing as follows:  
 For outpatient claims, providers shall append a HCPCS modifier QJ on all lines with a line-item date of 
service during the incarceration period. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 1, Section 10.4.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 specialist visit received from 
an in-network provider. The contract also states that enrollees must pay 30% coinsurance for each Medicare-
covered specialist visit received from an out-of-network provider. You can find this information on pages 87-
89 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 a health plan must pay for a medical service or item if regular Medicare would pay for it in 
this case. This rule can be found at 42 CFR Part 422.101. 
 
The rules state that routine services such as physical checkups, eyeglasses, contact lenses, eye examinations for 
the purpose of prescribing, fitting, or changing eyeglasses, eye refractions, hearing aids and hearing aid 
examinations, and immunizations are not covered. The routine checkup exclusion applies to: 
a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, 
complaint, or injury; and 
b) examinations required by third parties such as insurance companies, business establishments, or government 
agencies. 
 
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 says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that physical exams and other services required by third parties such as obtaining or maintaining 
employment or participation in employee programs, required for insurance or licensing, requested sports 
physicals, or on court order or required for parole or probation are not covered under any condition. You can 
find this information on page 133 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 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 Plan 
contract includes a list of covered supplemental dental services. Problem focused limited oral evaluation 
(D0140) and first intraoral periapical x-ray (D0220) are not included on this list and are not covered 
supplemental benefits. You can find this information on pages 91 and 92 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 for a patient who has had an implant(s) placed for reconstructive or cosmetic purposes, 
Medicare considers treatment of any 1 or more of the following conditions to be medically necessary: 
 
-Broken or failed implant 
-Infection 
-Implant extrusion 
-Siliconoma or granuloma 
-Interference with diagnosis of breast cancer 
-Painful capsular contracture with disfigurement 
 
You can find this rule in the Local Coverage Determination (LCD) - Cosmetic and Reconstructive Surgery 
(L33428) - Effective July 29, 2021. 
 
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 the medical effectiveness of prolotherapy, joint sclerotherapy, and ligamentous injections 
with sclerosing agents have not been verified by scientifically controlled studies. Accordingly, reimbursement 
for these modalities should be denied on the ground that they are not reasonable and necessary as required by 
Section 1862(a)(1) of the Act. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-03, Medicare National Coverage Determination for Prolotherapy, Joint 
Sclerotherapy, and Ligamentous Injections with Sclerosing Agents, 150.7. 
 
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 $45 copayment for each in-network office visit to providers other than 
your POC or primary care provider. You can find this information on page 140 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. 
 
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 contract 
says that the Plan covers routine vision services as a supplemental (extra) benefit. This benefit includes a 
routine eye exam when provided by a participating optometrist or optician. You can find this information on 
pages 112 to 113 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 Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only 
those preferred brands and manufacturers, as long as the following conditions are met (42 CFR 422.100(l)): 
 
The MA plan provides all categories of DME covered under original Medicare Part B; 
The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
The MA plans contracted suppliers provide access to all preferred DME brands; 
During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 90-
day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year; 
Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the EOC and ANOC and on its website; and 
The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by CMS to require full coverage. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-16, Medicare Managed Care Manual, Chapter 4 10.12.2. 
 
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.