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 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.  
 
From April 4, 2022  May 11, 2023, Original Medicare covered and paid for up to 8 OTC COVID-19 tests for 
people with Medicare Part B, including those enrolled in MA plans under the terms of this demonstration. 
Eligible Medicare patients could get these OTC tests at no cost from eligible participating providers, and their 
annual deductible, coinsurance, and copayment dont apply. After May 11, 2023, you can continue to sell OTC 
COVID-19 tests to patients, including those enrolled in Part B or MA plans. But, starting on May 12, 2023, 
Medicare wont cover or pay for OTC COVID-19 tests for Medicare Part B patients. You can find this 
information in the Centers for Medicare and Medicaid Services, cms.gov online article, COVID-19 Over-the-
Counter Tests. (https://www.cms.gov/files/document/covid-over-counter-test-coverage.pdf). 
 
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 the Plan covers a quarterly $40 credit for over-the counter items. Over-the-counter 
COVID-19 test kits are excluded from this benefit. You can find this information on page 75 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 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 report home health (HH) visits, the home health agency (HHA) reports one of the 
following Healthcare Common Procedure Coding System (HCPCS) codes to represent a visit by each HH care 
discipline: 
 
Occupational Therapy (revenue code 043x)  
G0152 Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 
minutes.  
G0158 Services performed by a qualified occupational therapist assistant in the home health or hospice setting, 
each 15 minutes.  
G0160 Services performed by a qualified occupational therapist, in the home health setting, in the 
establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes.  
G2169 Services performed by an occupational therapist assistant in the home health setting in the delivery of a 
safe and effective occupational therapy maintenance program, each 15 minutes.  
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet Only Manual, Pub 
100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.2. 
 
The rules say that Medicare systems may return to the provider Low Utilization Payment Adjustment (LUPA) 
claims if the claim meets the criteria for a LUPA add-on payment, but it contains no qualifying skilled service. 
In these cases, the HHA may add the skilled visit to the claim if it was omitted in error and re-submit the claim. 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet Only Manual, Pub 
100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.2. 
 
The rules say that to report home health visits, the home health agency reports a G-code to represent a visit by 
each home health care discipline. The location where services were provided must always be reported along 
with the first visit reported on the claim. In addition to reporting a visit line using the G codes, HHAs must 
report an additional line item with the same revenue code and date of service, reporting one of the three Q 
codes (Q5001, Q5002, and Q5009), one unit and a nominal covered charge (e.g., a penny). You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 10, Section 40.2. 
 
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 
unspecified periodontal procedures. You can find this information on pages 87-90 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. 
 
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 for Pick Your Perks reimbursement, members will need to submit a reimbursement claim along 
with required documentation to be considered for reimbursement. Required documentation may include 
receipts for proof of purchase, itemized bill, a prescription or doctors note and other supporting information. 
This documentation must be postmarked within 120 days of the purchase/service date. You can find this 
information on page 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 state that, to repair means to fix or mend and to put the equipment back in good condition after 
damage or wear. Repairs to equipment which a beneficiary owns are covered when necessary to make the 
equipment serviceable. However, do not pay for repair of previously denied equipment or equipment in the 
frequent and substantial servicing or oxygen equipment payment categories. If the expense for repairs exceeds 
the estimated expense of purchasing or renting another item of equipment for the remaining period of medical 
need, no payment can be made for the amount of the excess. You can find this information in the Centers for 
Medicare & Medicaid Services, Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, 
chapter 15 section 110. 
 
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 certain individuals and entities frequently attempt to enroll in Medicare but are not eligible to 
do so. If the Medicare contractor receives an enrollment application from the individual or entity, the contractor 
shall deny the application. Mental Health Counselor is among the provider types that are not eligible to enroll 
in Medicare. You can find this rule in Medicare Program Integrity Manual Chapter 10, Section 10.2.8. 
 
The rules say that to receive payment for covered items or services from either Medicare or a Medicare 
beneficiary, a provider or supplier must be enrolled in the Medicare program. You can find this rule in 42 Code 
of Federal Regulations (CFR) Section 424.505. 
 
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 both percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA) 
will be considered reasonable and necessary for osteoporotic conditions when ALL of the following criteria are 
met: 
 
a. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1  
L5) by recent (within 30 days) advanced imaging (bone marrow edema on magnetic resonance imaging (MRI) 
or bone-scan/Single-Photon Emission Computerized Tomography (SPECT)/computed tomography (CT) 
uptake) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score greater 
than or equal to 8)  
ii. Non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) despite optimal non-
surgical management (NSM) (ONE): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still greater than or equal to 5) (with greater than or equal to 2 of 
the following): 
A. Progression of vertebral body height loss 
B. greater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) greater than 17) 
E. Steroid-induced fracture F. Reinforcement of stabilization of vertebral body prior to surgery 
 
You can find this information in the Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38213). 
 
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 the 
crown but is limited to 3 every calendar year. This benefit also includes the core buildup but is limited to 3 
every year. This benefit also includes a bone graft but is limited to e every calendar year. You can find this 
information on pages 105 to 125 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 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 the 
requested item or service but is limited to 1 procedure code per calendar year. You can find this information in 
Chapter 4 on page 75 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 that only the Progensa PCA3 and ConfirmMDx tests have met Medicare coverage 
criteria. You can find this rule at Local Coverage Article (LCA) A58718: Billing and Coding: MolDX: 
Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (eff. August 
8, 2022, to November 1, 2023).

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 does not pay for over-the-counter (OTC) items, including self-administered 
COVID-19 tests. 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 generally cover or pay for over-the-counter products. The demonstration 
that allowed Medicare to offer coverage for COVID-19 over-the-counter tests at no cost ended on May 11, 
2023. You can find this information in the Coverage for COVID-19 Tests Article at Coverage for COVID-19 
Tests (cms.gov). 
 
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. 
 
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. The Plan 
contract also says that there is coverage for worldwide emergency and urgent care services outside the United 
States under the following circumstances: emergency services, including emergency or urgently needed care 
and emergency ambulance transportation from the scene of an emergency to the nearest medical treatment 
facility. Transportation back to the United States from another country is not covered. Pre-scheduled, pre-
planned treatments (including chronic dialysis) for any ongoing known conditions and/or elective procedures 
are not covered. Any follow-up care including after-care, rehabilitation, physician visits, and skilled nursing 
facility stay are not considered emergent or urgently needed care and are not covered. You can find this 
information on page 46 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 the provider, supplier, or beneficiary, as appropriate, must furnish to the 
intermediary or carrier sufficient information to determine whether payment is due and the amount 
of payment. You can find this rule at 42 CFR 424.5.

The rules say for Medicare to consider coverage and payment for any item or service, the 
information submitted by the supplier or provider must corroborate the documentation in the 
beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You 
can see this in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-08, 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 state that facet joint injections are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL the following criteria: 
 
1) Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale 
2) Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3) Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst) 
4) There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
You can find this information in the Local Coverage Determination: L35936: Facet Joint Interventions for Pain 
Management: 
 
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 70 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 Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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 contract 
says up to one windshield replacement is covered per year. You can find this information on page 174 of the 
Plan's 2023 Evidence of Coverage (EOC).