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 immunizations are not covered unless they are directly related to the treatment of an injury or 
direct exposure to a disease or condition. In the absence of injury or direct exposure, vaccination or inoculation 
is not covered. However, pneumococcal, hepatitis B, influenza virus vaccines, and any FDA-approved COVID-
19 vaccines are exceptions to this rule. You can find this rule at 42 CFR Section 411.15(e) and Section 3713 of 
the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). 
 
The rules say that for Medicare Advantage Patients you vaccinate on or after January 1, 2022, submit COVID-
19 vaccine administration claims to the Medicare Advantage Plan. Original Medicare won't pay these claims 
beginning in January 2022. For patients enrolled in a Medicare Advantage Plan in 2021, submit COVID-19 
vaccine administration claims to Original Medicare through your Medicare Administrative Contractor (MAC). 
Use your patients' Medicare Beneficiary Identifiers (MBls) (not their Medicare Advantage Plan Member IDs) 
to bill Original Medicare. You can find this in the Medicare Billing for COVID-19 Vaccine Shot 
Administration guide page. 
 
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. 
 
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). 
  
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 Mandatory Supplemental Vision Benefit with a Frames and Lens 
Package. You have a choice of $50 Benefit toward the purchase and fitting of eyeglasses and pair of 
lenses or contact lenses at a network optical provider (1 per calendar year). Contact lenses will include 
conventional or disposable. You can find this information on page 87 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, contingent upon the patient's consent, the clinical psychologist (CP) will attempt to consult 
with the patient's attending or primary care physician in accordance with accepted professional ethical norms, 
taking into consideration patient confidentiality. If the patient assents to the consultation, the CP must attempt 
to consult with the patient's physician within a reasonable time after receiving the consent. If the CP's attempts 
to consult directly with the physician are not successful, the CP must notify the physician within a reasonable 
time that he or she is furnishing services to the patient. Additionally, the CP must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement for CPs is in cases where the patient's primary care or attending physician refers 
the patient to the CP. 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, Section 160(e). 
 
The rules say that a clinical social worker must comply with the same consultation requirements as a clinical 
psychologist. You can find this rule at 42 CFR Section 410.73. 
 
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 modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. Modifier -XS was developed to provide greater reporting specificity where 
modifier -59 was previously reported. Modifier -XS identifies a service that is distinct because it was 
performed on a separate organ/structure. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(d). 
 
The rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be 
ordered by the physician who is treating the beneficiary, that is, the physician 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 who is treating the beneficiary are 
not reasonable and necessary. You can find this rule in 42 CFR, Section 410.32. 
 
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. 
 
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 "Urgently needed services" are non-emergency, unforeseen medical illness, injury, 
or condition that requires immediate medical care. Urgently needed services may be furnished by network 
providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. 
The contract says that when you are outside the service area and cannot get care from a network provider, our 
plan will cover urgently needed services that you get from any provider at the lower in-network cost-sharing 
amount. You can find this information on page 47 of the Plan's 2021 Evidence of Coverage (EOC). 
 
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 $90 copayment for both in and out of network emergency services. You 
can find this information on page 65 of the Plan's 2021 EOC.  
 
The Plan contract does not clearly disclose how much enrollees should expect to pay for outpatient hospital 
clinic visits.  
 
The Plan contract says that enrollees must pay a $400 copayment for outpatient surgery at an in-network 
outpatient hospital. You can find this information on page 81 of the Plans 20201 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 supplier of a covered item of durable medical equipment (DME) may not contact an 
individual by telephone regarding the furnishing of a covered item to the individual unless: the individual has 
given written permission to the supplier to make contact by telephone regarding the furnishing of a covered 
item; or, the supplier has furnished a covered item to the individual and the supplier is contacting the individual 
only regarding the furnishing of such covered item, or another covered item to this same individual within 15 
months. If a supplier knowingly contacts an individual in violation of this prohibition, no payment may be 
made for any item subsequently furnished to the individual by the supplier. You can find this information in the 
Social Security Act, Section 1834(a)(17). 
 
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. 
 
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 Plan 
contract also says that in addition to Medicare-covered services, our Plan also covers routine eye exams: one 
exam every year. Non-Medicare covered eye wear: $125 maximum benefit every year. You can find this 
information on page 101 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the Plan 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)): 
 
1. The Plan provides all categories of DME covered under original Medicare Part B; 
2. The Plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
3. The Plans contracted suppliers provide access to all preferred DME brands; 
4. During an enrollees first year of enrollment in a 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; 
5. Although the Plan may add brands to its preferred formulary during the year, it may not remove any brands 
mid-year; 
6. The Plan treats denials of non-preferred DME products or brands as organization determinations; 
7. The Plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the Evidence of Coverage (EOC) and Annual Notice of Change (ANOC) and on 
its website; and 
8. The Plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by Centers for Medicare & Medicaid Services (CMS) to require full 
coverage. 
 
You can find this information at Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 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.
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. 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, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 74 of the 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). 
  
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 other eyewear: We provide an allowance (shown at right) every calendar 
year that you can use to pay for eyewear to correct vision. The allowance can be used to pay for the following 
items: Eyeglasses (lenses and frames). Eyeglass lenses. Eyeglass frames when a provider puts two lenses 
(at least one of which must have refractive value) into the frame.  Contact lenses, fitting, and dispensing.  
$250 allowance. You can find this information on page 93 of the Plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
Please note, the Local Coverage Determination, L39082, the Plan used in their decision to deny services is not 
binding in this case. The rule was not in effect at the time the services at issue were provided. 
 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be 
ordered by the physician who is treating the beneficiary, that is, the physician 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 who is treating the beneficiary are 
not reasonable and necessary. You can find this rule in 42 CFR, Section 410.32. 
 
The rules say that 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 find this rule 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 for a beneficiary who is not currently being treated with insulin administrations, more than 
100 test strips and more than 100 lancets every 3 months are covered if criteria (a)  (c) below are met. 
For a beneficiary who is currently being treated with insulin administrations, more than 300 test strips and 
more than 300 lancets every 3 months are covered if criteria (a)  (c) below are met. 
a. Basic coverage criteria for home glucose monitors and related accessories and supplies are met; and, 
b. Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization 
guidelines, the treating practitioner has had an in-person visit with the beneficiary to evaluate their 
diabetes control and their need for the specific quantity of supplies that exceeds the usual utilization 
amounts described above; and, 
c. Every six (6) months, for continued dispensing of quantities of testing supplies that exceed the usual 
utilization amounts, the treating practitioner must verify adherence to the high utilization testing 
regimen. 
You can find this rule in Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
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 $395 copayment per day for days 1-5 for inpatient hospital care. You 
can find this information on page 70 of the Plan's 2021 Evidence of Coverage (EOC).