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 a custom fabricated mandibular advancement oral appliance (E0486) used to treat
obstructive sleep apnea (OSA) is covered if criteria A - D are met.

The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to
assess the beneficiary for obstructive sleep apnea testing. Refer to the ICD-10 code list in the LCD-related
Policy Article for applicable diagnoses.
The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 - 3):
The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15
events per hour with a minimum of 30 events; or,
The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum
of 10 events and documentation of:
Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,
Hypertension, ischemic heart disease, or history of stroke; or,
If the AHI> 30 or the RDI> 30 and meets either of the following(a or b):
The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or,
The treating practitioner determines that the use of a PAP device is contraindicated.
The device is ordered by the treating practitioner following a review of the report of the sleep test. (The
practitioner who provides the order for the oral appliance could be different from the one who performed the
clinical evaluation in criterion A.)
The device is provided and billed for by a licensed dentist (DDS or DMD).

If all of these criteria (A-D) are not met, the custom fabricated oral appliance (E0486) will be denied as not
reasonable and necessary.

You can find this information in the Local Coverage Determination (LCD) Oral Appliances for Obstructive
Sleep Apnea (L33611).

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 Group 4 power wheelchairs (PWCs) (K0868, K0869, K0870, K0871, K0877, K0878,
K0879, K0880, K0884, K0885, K0886) have added capabilities that are not needed for use in the home.
Therefore, if these wheelchairs are provided, they will be denied as not reasonable and necessary. If the PWC
base is not covered, then related accessories will be denied. You can find this information in the Local
Coverage Determination (LCD) Power Mobility Devices (L33789).
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 1 deep cleaning every 2 years, per quadrant. You can find this information on page 78 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 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 charges for mileage must be based on loaded mileage only, as in from the pickup of a patient
to his/her arrival at destination. You can find this in the Medicare Claims Processing Manual, Chapter 15,
Ambulance, Section 20.2, Payment for Mileage Charges.
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 you are covered by both Medicare and Medicaid:
- Medicare is the Federal health insurance program for people 65 years of age or older, some people under
age 65 with certain disabilities, and people with end-stage renal disease (kidney failure).
- Medicaid is a joint Federal and state government program that helps with medical costs for certain people
with limited incomes and resources. Medicaid coverage varies depending on the state and the type of
Medicaid you have. Some people with Medicaid get help paying for their Medicare premiums and other costs.
Other people also get coverage for additional services and drugs that are not covered by Medicare.
You can see this on page 11 of the Plans 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 is the secondary payer to certain primary plans. When Medicare is the secondary
payer, the provider or enrollee must first submit the claim to the primary payer. If the primary payer does not
pay in full for the services, Medicare secondary benefits may be paid. The enrollee must file a claim with the
primary payer or cooperate fully with the provider so that the provider can file the necessary claim. You can
find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-05,
Medicare Secondary Payer Manual, Chapter 1, Sections 10 and 30.
The rules say that plans must identify payers that are primary to Medicare, identify the amounts payable by the
primary payer, and coordinate benefits to Medicare enrollees with the benefits of the primary payer. You can
find this rule at 42 CFR Section 422.108.
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 when you have other insurance, there are rules set by Medicare that decide whether our plan
or your other insurance pays first. The insurance that pays first is called the "primary payer" and pays up to the
limits of its coverage. The one that pays second, called the "secondary payer," only pays if there are costs left
uncovered by the primary coverage. The secondary payer may not pay all the uncovered costs. You can see this
on page 23 of the Plans 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 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 for submitted claims, providers must enter the appropriate 3-digit numeric type of bill code,
according to the Medicare coding structure. You can find this in the Medicare Claims Processing Manual
Chapter 11.
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 all items and nonphysician services furnished to inpatients must be furnished directly by the
hospital or billed through the hospital under arrangements. This provision applies to all hospitals, regardless of
whether they are subject to PPS. This includes transportation, including transportation by ambulance, to and
from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not
available at the facility where the patient is an inpatient. You can find this rule in the Medicare Claims
Processing Manual Chapter 3, Inpatient Hospital Billing, Section 10.4 for Payment of Nonphysician Services
for Inpatients.
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 there is a $0 copayment for days 1-20 in a skilled nursing facility and a $100 copayment per
day for days 21 to 100 in a skilled nursing facility within a benefit period. The Plan contract also says that there
is a $200 copayment for days 1-6 in an inpatient hospital setting. You can find this information in the Plan's
2021 Medical Benefit Highlights documentation provided separately from the 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 the following interventional treatments are not considered medically reasonable or necessary
and are denied as such:
-Surgery, endovenous ablation, or sclerotherapy are typically not performed for varicose veins that develop
or worsen during pregnancy because most will spontaneously resolve or improve after delivery.
-Reinjection following recanalization or failure of vein closure without recurrent signs or symptoms.
-Sclerotherapy of the saphenous vein at its junction with the deep system.
-Non-compressive sclerotherapy.
-Compressive sclerotherapy for large, extensive or truncal varicosities.
-Sclerotherapy, ligation and/or stripping of varicose veins, or endovenous ablation therapy are generally not
covered for patients with severe distal arterial occlusive disease; obliteration of deep venous system; an allergy
to the sclerosant; or a hypercoagulable state.
-Any interventional treatment that uses equipment or sclerosants not approved for such purposes by the
FDA.
You can find this in the Local Coverage Determination (LCD): Varicose Veins of the Lower Extremity,
Treatment of (L33575).
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 you are covered by both Medicare and Medicaid. Medicare is the Federal health
insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and
people with end-stage renal disease (kidney failure). Medicaid is a joint Federal and state government program
that helps with medical costs for certain people with limited incomes and resources. Medicaid coverage varies
depending on the state and the type of Medicaid you have. Some people with Medicaid get help paying for
their Medicare premiums and other costs. Other people also get coverage for additional services and drugs that
are not covered by Medicare. You can see this on page 11 of the Plans 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).
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 you are covered by both Medicare and Medicaid:
- Medicare is the Federal health insurance program for people 65 years of age or older, some people under
age 65 with certain disabilities, and people with end-stage renal disease (kidney failure).
- Medicaid is a joint Federal and state government program that helps with medical costs for certain people
with limited incomes and resources. Medicaid coverage varies depending on the state and the type of
Medicaid you have. Some people with Medicaid get help paying for their Medicare premiums and other costs.
Other people also get coverage for additional services and drugs that are not covered by Medicare.
You can see this on page 11 of the Plans 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 that a KX modifier must be added to the claim line(s) for the immunosuppressive drug(s) only if all
of the following four requirements are met: The supplier has obtained from the treating practitioner the specific
date of the organ transplant, and The supplier is retaining this documentation of the transplant in its files, and
The beneficiary was enrolled in Medicare Part A, at the time of the organ transplant (whether or not Medicare
paid for the transplant), and The transplant date precedes the date of service on the claim. If these four
requirements are not met, the KX modifier must not be added to the claim. If any of criteria I - V listed above
have not been met, the GY modifier must be added to the claim line(s). The diagnosis code(s) that justify the
need for these items must be included on the claim. See the below list for covered transplant diagnosis codes. A
new order is required if a new drug(s) is added to the beneficiary's immunosuppressive regimen or if there is a
change in dose or frequency of administration of an already allowed drug. You can find this in the Local
Coverage Article (LCA) Immunosuppressive Drugs - Policy Article A52474.
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. 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 contract says that if you receive dental services out of network, you will be responsible for the full cost of
those services. You can find this in the Plans Summary of Dental Benefits on page 2 of the Dental Plan's 2020
Certificate of Coverage and on page 2 of the 2021 Certificate 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 patients with end stage renal disease (ESRD) receiving administrations of ESA for the
treatment of anemia may receive intravenous administration or subcutaneous administrations of the ESA.
Effective for claims with dates of services on or after January 1, 2012, all facilities billing for injections of ESA
for ESRD beneficiaries must include the modifier JA on the claim to indicate an intravenous administration or
modifier JB to indicate a subcutaneous administration. ESRD claims containing ESA administrations that are
submitted without the route of administration modifiers will be returned to the provider for correction. Renal
dialysis facility claims including charges for administrations of the ESA by both methods must report separate
lines to identify the number of administrations provided using each method. You can find this in the Medicare
Claims Processing Manual Chapter 8 for Outpatient ESRD Hospital, Independent Facility, and Physician or
Supplier Claims, Section 50.9.
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 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 selfinjection.
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. In addition to
your coverage for Part D drugs, (HMO) also covers some drugs under the plan's medical benefits. Through its coverage of Medicare Part A benefits, the Plan generally covers drugs you are given during covered stays in the hospital or in a skilled nursing facility. Through its coverage of Medicare Part B benefits, our plan covers drugs including certain chemotherapy drugs, certain drug injections you are given during an office visit, and drugs you are given at a dialysis facility. You can see this on page 107 of the Plans 2021 Evidence of Coverage.
The Plan contrast says that drugs covered under Medicare Part B typically only include those drugs that are not
self-administered. You can see this on page 71 of the Plans 2021 Evidence of Coverage.