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 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 $130 copayment for in-network Medicare-covered radiological 
diagnostic services, including ultrasounds.  You can find this information on page(s) 79 and 80 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 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 $350 copayment for outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical.  You can find this information on page(s) 81 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 Centers for Medicare & Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied.  
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. Codes with an MAI of 2 have been rigorously reviewed and vetted within 
CMS and obtain this MAI designation because units of service on the same date of service (DOS) in excess of 
the MUE value would be considered impossible because it was contrary to statute, regulation, or subregulatory 
guidance. You can find this rule in the Centers for Medicare & Medicaid Service, Medicare National Correct 
Coding Initiative Policy Manual for Medicare Services, Chapter I(V). 
 
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(s) 25-26 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 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 $40 copayment for physician/practitioner services, including doctors 
office visits.  You can find this information on page(s) 97 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 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% coinsurance for Dental Services. You can find this information in Chapter 4 on pages 41-42 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 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 $40 copayment for vision care.  You can find this information on 
page(s) 91 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 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 $350 copayment for Outpatient surgery, including services provided at
hospital outpatient facility and a 20% cost-sharing for Medicare Part B prescription drugs. You can find this
information on pages 88 and 97 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that a kyphoplasty (PKP) is covered in patients with osteoporotic Vertebral Compression Fracture 
(VCF) when BOTH the following: 
1. Inclusion criteria (ALL are required): 
  
  a. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic Vertebral Compression 
Fracture (VCF) (T1  L5), based on symptom onset, and documented by advanced imaging. 
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 
c. Continuum of care (Both are required)  
i. All patients presenting with VCF should be referred for evaluation of bone mineral 
density (BMD) and osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program. 
2. Exclusion criteria (Can have NONE of the following): 
a. Absolute contraindication  
1. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
2. Osteomyelitis, discitis or active systemic or surgical site infection 
3. Pregnancy 
b. Relative contraindication  
1. Greater than three vertebral fractures per procedure 
2. Allergy to bone cement or opacification agents 
3. Uncorrected coagulopathy 
4. Spinal instability 
5. Myelopathy from the fracture 
6. Neurologic deficit 
7. Neural impingement 
8. Fracture retropulsion/canal compromise 
Vertebral augmentation and Kyphoplasty for vertebral compression fractures with intractable spinal pain 
secondary not relieved with medical therapy will be covered for osteolytic vertebral metastatic disease or 
myeloma involving a vertebral body. 
You can find this information in the Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA for Vertebral Compression Fracture (VCF) (L38201).
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 cervical traction devices (E0840, E0849, E0850, E0855 and E0860) are covered only if both 
of the following criteria are met: 
 
1. The beneficiary has a musculoskeletal or neurologic impairment requiring traction equipment; and 
2. The appropriate use of a home cervical traction device has been demonstrated to the beneficiary and the 
beneficiary tolerated the selected device. 
 
You can find this rule in the Local Coverage Determination (LCD) - Cervical Traction Devices (L33823). 
 
The rules say that cervical traction devices described by code E0849 or E0855 are covered only when criteria 1 
and 2 above and either criterion A, B or C below has been met: 
 
A. The beneficiary has a diagnosis of temporomandibular joint (TMJ) dysfunction; and has received treatment 
for the TMJ condition; or, 
B. The beneficiary has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that a 
chin halter is unable to be utilized; or, 
C. The treating practitioner orders and/or documents the medical necessity for greater than 20 pounds of 
cervical traction in the home setting. 
 
You can find this rule in the Local Coverage Determination (LCD) - Cervical Traction Devices (L33823). 
 
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 Medicare grants contractors the authority to request any information necessary to determine 
the amounts due. This includes proof of delivery in order to verify that the beneficiary received the Durable 
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) item billed and thus to determine the 
amount due to the provider. For any items that do not have proof of delivery from the supplier, such claimed 
items shall be denied. The signature of the designee (defined as any person who can sign and accept the 
delivery on behalf of the beneficiary) should be legible. If the signature of the designee is not legible, the 
supplier/shipping service should note the name of the designee on the delivery slip. You can find these rules in 
Medicare Program Integrity Manual Chapter 4, Sections 4.7.3.1 and 4.7.3.1.1. 
 
The rules say that if the supplier utilizes a shipping service or mail order, the proof of delivery (POD) 
documentation must be a complete record tracking the item(s) from the DMEPOS supplier to the beneficiary. 
An example  of acceptable POD would include both the suppliers own detailed shipping invoice and the 
delivery services tracking information. The suppliers record must be linked to the delivery service record by 
some clear method like the delivery services package identification number or suppliers invoice number for 
the package sent to the beneficiary. The POD document must include: 
 
1. Beneficiarys name 
2. Delivery address 
3. Delivery services package identification number, supplier invoice number, or alternative method that  
            links the suppliers delivery documents with the delivery services records 
4. A description of the item(s) being delivered. The description can be either a narrative description (e.g.,  
            lightweight wheelchair base), a code, the long description of a code, or a brand name/model number 
5. Quantity delivered 
6. Date delivered 
7. Evidence of delivery 
 All items that do not have appropriate proof of delivery from the supplier will be denied. You can find this rule 
in Local Coverage Article (LCA) Standard Documentation Requirements for All Claims Submitted to DME 
MACs (A55426). 
 
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 & 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 
coverage for the requested items or services, but only when they are received from an in-network provider. You 
can find this information on pages 7 and 61 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 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 $120 copayment for emergency care.  You can find this information on 
page(s) 57 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 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 & 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. The Plan contract says you 
are allowed one set (up to 4) of bitewing x-rays (codes D0270-D0274) every 2 calendar years or one set (up to 
6) of periapical films (codes D0220, D0230) every 2 calendar years. You can find this information on page 61 
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 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 47% coinsurance for physician/practitioner services, including doctors 
office visits.  You can find this information on page(s) 93 to 95 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 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 $95 copayment for emergency care, a $250 copayment for each 
Medicare-covered computed tomography (CT) scan performed by a provider other than your primary-care 
physician, and a $40 copayment Medicare-covered physician specialist services. You can find this information 
respectively on page 58, pages 69 to 71, and pages 76 to 78 of the Plan's 2023 Evidence of Coverage (EOC).