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 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 when a patient is admitted for observation care and then is discharged on a different calendar 
date, the physician shall report Initial Observation Care, from CPT code range 99218 - 99220, and CPT 
observation care discharge CPT code 99217. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 12, Section 
30.6.8. 
 
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 Healthcare Common procedure Coding System (HCPCS) codes E0655, E0656, E0657, E0660, 
E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673 must not be used when billing for 
appliances used with E0676 devices. You can find this rule in the Local Coverage Article: Pneumatic 
Compression Devices - Policy Article (A52488). 
 
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 Botox is covered for migraine without aura when the following indications have been met: 
A. At least five attacks fulfilling the following criteria  
1. Headache attacks lasting 4-72 hours (when untreated or unsuccessfully treated) 
2. Headache has at least two of the following:  
I. unilateral location 
II. pulsating quality 
III. moderate or severe pain intensity 
IV. aggravation by or causing avoidance of routine physical activity (e.g. walking or 
climbing stairs) 
3. During headache at least one of the following:  
I. nausea and/or vomiting 
II. photophobia and phonophobia 
You can find more information in Local Coverage Determination (LCD): Botulinum Toxin Type A & Type B 
(L34635). 
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 there are certain individuals and entities that frequently attempt to enroll in Medicare but are 
not eligible to do so. This list is not an all-inclusive list. If the contractor receives an enrollment application 
from any of these individuals or entities, the contractor shall deny the application. A Mental Health Counselor 
is on the list of individuals who are not eligible to enroll in Medicare. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program 
Integrity Manual, Chapter 1, 10.2.8 
 
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 contract 
says that eye refractions outside of the annual supplemental routine eye exam are not covered. You can find 
this information on page 61 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 state that all laboratory services furnished to individuals for the treatment of ESRD are included in 
the ESRD PPS as Part B services and are not paid separately as of January 1, 2011. The laboratory services 
include but are not limited to: 
 
 Laboratory tests included under the composite rate as of December 31, 2010 (discussed below); and 
 Former separately billable Part B laboratory tests that were billed by ESRD facilities and  
independent laboratories for ESRD patients. 
 
You can find this information in the Medicare Benefit Policy Manual Chapter 11 Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for
a person who meets the following criteria:
1. The person must have a personal mobility deficit;
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such
as toileting, feeding, grooming and bathing in customary locations within the home;
3. The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and
4. The person must be capable of safely operating the PMD.
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B).
The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility
limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
The rules state that the beneficiary must have had a specialty evaluation that was performed by a
licensed/certified medical professional, such as a PT or OT, or practitioner who has specific training and
experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the
wheelchair and its special features (see Documentation Requirements section). 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. 
 
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 you have a $200 vision allowance for routine contact lenses or eyewear every year. This 
benefit is administered on a rolling calendar year since your last date of service. You can find this information 
on page 115 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 
coverage only for those dental services explicitly listed in your dental benefits chart. You can find this 
information on pages 4-59 to 4-67 of the Plans 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and 
payment policy requirements preclude FSS payment for devices used to delivery continuous and/or intermittent 
positive airway pressure, regardless of the illness treated by the device. This means that products currently 
classified as code E0466 when used to provide continuous or bi-level positive airway pressure (CPAP or 
BiPAP) therapy, regardless of the underlying medical condition, shall not be paid in the FSS payment category. 
Requests for ventilators used to provide positive airway pressure (PAP) therapy for conditions such as chronic 
obstructive pulmonary disease (COPD) will be denied as not reasonable and necessary. You can find this rule 
in Local Coverage Determination (LCD) Respiratory Assist Devices (L33800). 
 
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 In certain instances, MAC provided by anesthesia personnel may be reasonable and 
necessary for procedures that are generally provided by the attending surgeon if certain conditions or situations 
are present. In these situations, MAC may be necessary for these active and serious accompanying situations or 
conditions to ensure smooth anesthesia (and surgery) by the prevention of adverse physiologic complications. 
Special conditions or criteria must be supported by documentation in the medical record. For procedures that 
do not usually require anesthesia services, MAC could be covered when the patients condition requires the 
presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician 
performing the procedure and is so documented in the patients medical record. The presence of an underlying 
condition alone may not be sufficient evidence that MAC is necessary. The medical condition must be 
significant enough to impact on the need to provide MAC such as the patient being on medication or being 
symptomatic, etc. The presence of a stable, treated condition, of itself, is not necessarily sufficient. You can 
find this rule in the Local Coverage Determination for Monitored Anesthesia Care, L35049.  
 
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. 
 
Per Medicare guidelines, as of April 4, 2022, Medicare covers up to 8 over-the-counter COVID-19 tests each 
calendar month, at no cost to you. This coverage continues until the COVID-19 public health emergency (PHE) 
ends. Medicare Part B (Medical Insurance) will cover these tests if you have Part B. If you are in a Medicare 
Advantage Plan, you wont get this benefit through your plan, but will get it like you would if you werent 
enrolled in the plan. You might need to show your red, white, and blue Medicare card to get your free over-the-
counter COVID-19 tests (even if you have another card for a Medicare Advantage Plan or Medicare Part D 
plan). 
 
Additionally, Medicare will not provide payment for over-the-counter COVID-19 tests obtained prior to April 
4, 2022; and Medicare cannot process a claim submitted by a 
beneficiary for a COVID-19 over-the-counter test. You should check whether your 
pharmacy or health care provider is participating in the initiative, in which case they will bill Medicare for the 
over-the-counter test on your behalf. You can find this information at https://www.medicare.gov/medicare-
coronavirus. 
 
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 pages A1-40 to A1-41
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 Interpret the phrase "new patient" to mean a patient who has not received any professional 
services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or 
physician group practice (same physician specialty) within the previous 3 years. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 12, Section 30.6.7. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $1300 deductible out of pocket before the Plan will pay their share for 
their covered services. You can find this information on page 55 of the Plan's 2022 Evidence of Coverage 
(EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
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 services included in the global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, 
physicians' offices. The services include follow-up visits during the postoperative period of the surgery that are 
related to recovery from the surgery. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40. 
 
The rules say that In those cases where a critical care visit is unrelated to the procedure with a global surgical 
period, critical care visits may be paid separately in addition to the procedure. When the critical care service is 
unrelated to the procedure, append the modifier -FT ((unrelated evaluation and management (E/M) visit on the 
same day as another E/M visit or during a global procedure (preoperative, postoperative period, or on the same 
day as the procedure, as applicable). (Report when an E/M visit is furnished within the global period but is 
unrelated, or when one or more additional E/M visits furnished on the same day are unrelated.)) to the critical 
care CPT code(s). You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.12.7. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.