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 $45 copayment for an exam to diagnose and treat diseases or conditions 
of the eye. You can find this information on page 127 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 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 $65 copayment for an in-network emergency room visit. You can find 
this information on page 79 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. 
 
  
  Since 1999, HHAs have been required by Medicare to assess potential patients, and reassess existing patients, 
incorporating the OASIS (Outcome and Assessment Information Set) tool as part of the assessment process. 
The total case-mix adjusted payment is based on elements of the OASIS data set and other information 
provided on the claim. Payments made for the period are case-mix adjusted based on Grouper run in Medicare 
systems. Pricer software run by the A/B MAC (HHH) processing home health claims performs pricing 
including wage index adjustment and other factors. 
Submission of an OASIS assessment is a condition of payment for HH periods of care. OASIS reporting 
regulations require the OASIS to be transmitted within 30 days of completing the assessment of the 
beneficiary. Under the HH PDGM, matching a claim to the OASIS assessment is more important than ever. 
During claims processing, the quality system, known as the Internet Quality Improvement and Evaluation 
System (iQIES), provides the claims system (FISS), with the OASIS items used for payment grouping under 
the PDGM. The HIPPS code is calculated by Medicare's Grouper program with FISS. Because payment 
grouping cannot occur without the OASIS information, if the OASIS assessment is not found in the quality 
system upon receipt of a claim, Medicare systems will return the HH claim.  
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, Sections 10.1.6 and 10.1.19. 
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.
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 coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of knee. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this information in the Local Coverage Determination (LCD): 
Lower Limb Prostheses (L33787). 
 
In the event of a claim review, information contained directly in the contemporaneous medical record is the 
source required to justify payment except as noted elsewhere for prescriptions and CMNs. The medical record 
is not limited to treating physician/practitioner's office records but may include records from hospitals, nursing 
facilities, home health agencies, are professionals, etc. (not all-inclusive). Records from suppliers or healthcare 
professionals with a financial interest in the claim outcome are not considered sufficient by themselves for 
determining that an item is reasonable and necessary. DMEPOS suppliers are reminded that: 
*Supplier-produced records, even if signed by the prescribing physician/practitioner, and attestation letters (e.g. 
letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes. 
*Templates and forms, including CMS CMNs, are subject to corroboration with information in the medical 
record. 
*A prescription is not considered to be part of the medical record. Medical  information intended to 
demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated 
by information contained in the medical record. You can find this information in the Local Coverage Article: 
Standard Documentation Requirements for All Claims Submitted to DME MACs (A5542). 
 
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 the requested insulin pump to be covered, the patient with diabetes must be 
insulinopenic per the updated fasting C-peptide testing requirement, or, as an alternative, must be beta cell 
autoantibody positive. 
Updated fasting C-peptide testing requirement: 
1. Insulinopenia is defined as a fasting C-peptide level that is less than or equal to 110% of the lower limit 
of normal of the laboratory's measurement method.  
2. For patients with renal insufficiency and creatinine clearance (actual or calculated from age, gender, 
weight, and serum creatinine)  50 ml/minute, insulinopenia is defined as a fasting C-peptide level that 
is less than or equal to 200% of the lower limit of normal of the laboratory's measurement method.  
3. Fasting C-peptide levels will only be considered valid with a concurrently obtained fasting glucose  
225 mg/dL.  
4. Levels only need to be documented once in the medical records.  
Continued coverage of the insulin pump would require that the patient be seen and evaluated by the treating 
physician at least every 3 months. 
You can find more information in Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, National Coverage Determination (NCD): Infusion Pumps (280.14). 
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 gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also say that they provide supplemental coverage for gym membership. The contract says that they 
will reimburse up to $400 each year in total for Fitness services. The contract also says that monthly gym 
membership fees are reimbursable for the current year.
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 3-3 to 3-4 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. 
 
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 says if you choose an EyeMed Vision Care participating provider, you have the benefit of $150 per 
calendar year applied at the time of service and would be responsible to pay for any remaining balance. The 
EyeMed Vision Care provider will process the claim. If you use a non-participating provider, you will need to 
pay out of pocket and submit for reimbursement. You would be reimbursed up to $90 per calendar year. You 
must file a claim with EyeMed Vision Care to get reimbursed. You can find this information on pages 113-117 
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 for services performed on or after January 21, 2020, Medicare will now provide limited 
coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, 
CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, 
such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This 
benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated 
improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may 
be provided by a physician in accordance with state requirements, or by physician assistants, nurse 
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. 
Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, 
physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determinations Manual, Section 30.3.3. 
 
Effective for services performed on and after October 24, 2006, the Centers for Medicare & Medicaid Services 
has determined that there is sufficient evidence to conclude the use of infrared therapy devices and any related 
accessories is not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act (the Act). 
The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-
covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic 
and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous 
tissues. You can find this information in the National Coverage Determination (NCD) 
Infrared Therapy Devices 270.6. 
 
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 Auxiliary personnel furnishing acupuncture must be under the appropriate level of 
supervision of a physician, PA, or NP/CNS required by our regulations at 42 CFR  410.26 and 410.27. You can find this information on pages 64 to 66 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 state that there is no laboratory or imaging test for establishing the diagnosis of trigger points; it 
depends therefore, upon the detailed history and thorough directed examination. The following clinical features 
are present most consistently and are helpful in making the diagnosis: 
1. history of onset and its cause (injury, sprain, etc.); 
2. distribution of pain; 
3. restriction of movement; 
4. mild muscle specific weakness; 
5. focal tenderness of a trigger point; 
6. palpable taut band of muscle in which trigger point is located; 
7. local taut response to snapping palpitation; and 
8. reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point. 
The goal is to identify and treat the cause of the pain and not just the symptom of pain. 
After making the diagnosis of myofascial pain syndrome and identifying the trigger point responsible for it, the 
treatment options are: 
1. medical management, including the use of anti-inflammatory agents, tricyclics, etc.; 
2. stretch and use of coolant spray followed by hot packs and/or aerobic exercises; 
3. application of low intensity ultrasound directed at the trigger point (this approach is used when the 
trigger point is otherwise inaccessible); 
4. deep muscle massage; 
5. injection of local anesthetic into the muscle trigger points: 
a. as the initial or the only therapy when a joint movement is mechanically blocked, as is the case 
of coccygeus muscle, or when a muscle cannot be stretched fully, as is the case of the lateral 
pterygoid muscle; 
b. as treatment of trigger points that are unresponsive to non-invasive methods of treatment, e.g., 
use of medications, spray and stretch. 
You can find these rules in the Local Coverage Determination (LCD) for Trigger Points, Local Injections, 
L34588. 
 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 an 
annual maximum benefit of $500. After the annual maximum is exhausted, any remaining charges are your 
responsibility. You can find this information on page 4-56 of the Plans 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 enrollees may receive care from in-network providers. Enrollees may also receive care from 
an out-of-network provider for most covered services using the Plans Point-of-Service (POS) option. Out-of-
network providers must be Medicare-certified. You can find this information in Chapter 3 on pages 43 to 44 of 
the Plan's 2022 Evidence of Coverage (EOC). 
 
The Plan contract says that if an enrollee uses an out-of-network provider, the enrollee will be using the Point-
of-Service (POS) benefits. You dont need to get a referral when you get care from out-of-network providers. 
Prior authorization rules may still apply for services received using your POS option. Your costs may be higher 
if you use out-of-network providers or see an in-network specialist without a referral. You can find this 
information in Chapter 3 on pages 43 to 44 of the Plans 2022 EOC. 
 
The Plan contract says that enrollees must pay $150 copayment for each in-network outpatient surgery services 
or 20% coinsurance for each out-of-network outpatient surgery when using the POS benefit. You can find this 
information in Chapter 4 on pages 114 to 115 of the Plans 2022 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 for patients enrolled in a Medicare Advantage (MA) Plan in 2020 and 2021, submit COVID-
19 vaccine administration claims to Original Medicare through your Medicare Administrative Contractor 
(MAC). Use your patients Medicare Beneficiary Identifiers (MBIs) (not their Medicare Advantage Plan 
Member IDs) to bill Original Medicare. You can find this information on 
https://www.cms.gov/medicare/covid-19/medicare-billing-covid-19-vaccineshot-administration. 
 
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 20% coinsurance for Medicare covered durable medical equipment and 
related supplies. You can find this information in Chapter 4 on page 71 of the Plan's 2022 Evidence of 
Coverage (EOC).