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 $40 copayment for specialist visits provided in-network and a $60 copayment for specialist visits provided out-of-network. You can find this information in Chapter 4 on page 61 of the Plan's 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 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 $300 deductible before the Plan will pay their share for enrollees
covered medical services and then you will pay your share of copayments or coinsurances amounts for the rest
of the calendar year from an in-network providers. The Plan contract also says that enrollees must pay a $10
copayment for Medicare-covered lab services. You can find this information in Chapter 4 on page 59 and pages
98 to 99 of the Plan's 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 medically necessary services are those that are reasonable and necessary for the diagnosis or
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).
The rules say Ultraviolet Cabinets -Covered for selected patients with generalized intractable psoriasis. Using
appropriate consultation, the Medicare Administrative Contractor (MAC) should determine whether medical
and other factors justify treatment at home rather than at alternative sites, e.g., outpatient department of a
hospital. You can find this information in Medicare's National Coverage Determination (NCD): Durable
Medical Equipment Reference List (280.1).
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 screening tests are excluded from coverage. The only exceptions are for the following services:  1. screening mammography,  2. colorectal cancer screening tests, 3. screening pelvic exams,  4. prostate cancer screening tests,  5. glaucoma screening exams,  6. ultrasound screening for abdominal aortic aneurysms (AAA),  7. cardiovascular disease screening tests,  8. diabetes screening tests, and 9. screening electrocardiograms, and 10. certain other testing recommended by the United States Preventive Services Task Force and approved by the Centers for Medicare and Medicaid Service.  You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64.  The rules say Criteria for Testing:      Individual with breast, ovarian, pancreatic, or prostate cancer from a family with a known deleterious BRCA1 or BRCA2 gene mutation     Individual with a personal history of ovarian cancer     Individual with a breast cancer diagnosis meeting any of the criteria.  Nationally Non-Covered Indications  BRCA1/BRCA2 genetic testing is not reasonable and necessary, thus it is non-covered, for the following indications:      Genetic screening in the general population. Such testing is considered screening and is excluded by Medicare statute. An Advance Beneficiary Notice of Non-coverage (ABN) must be obtained for BRCA1 and BRCA2 testing for individuals without signs and symptoms of breast, ovarian or other hereditary cancer syndromes as indicated in this policy.      Testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer. Such testing is considered screening and is excluded by Medicare statute. An ABN must be obtained for BRCA1 and BRCA2 testing for individuals without signs and symptoms of breast, ovarian or other hereditary cancer syndromes as indicated in this policy.  You can find this information in Medicare's Local Coverage Determination (LCD): MolDX: BRCA1 and BRCA2 Genetic Testing (L36163).  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 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 certain telehealth services including: Urgently Needed Services, Home Health Services,
Primary Care Physician, Occupational Therapy, Specialist, Individual Sessions for Mental Health, Podiatry
Services, Other Health Care Professional, Individual Sessions for Psychiatric, Physical Therapy and
Speech-Language Pathology Services, Individual Sessions for Outpatient Substance Abuse, and Diabetes Self-
Management Training are covered. You have the option of getting these services through an in-person visit or
by telehealth. If you choose to get one of these services by telehealth, you must use a network provider who
offers the service by telehealth. You can find this information on pages 116-117 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 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 a 100%
coinsurance for dental services received out of network. You can find this information on pages 84 to 85 of the
Plan's 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 initial 36 months:  Reimbursement for oxygen equipment is limited to 36 monthly rental payments. Payment for accessories (e.g., cannula, tubing, etc.), delivery, back-up equipment, maintenance, and repairs is included in the rental allowance. Payment for oxygen contents (stationary and/or portable) is included in the allowance for stationary equipment (E0424, E0439, E1390, E1391).  Payment for stationary equipment is increased for beneficiaries requiring greater than 4 liters per minute (LPM) of oxygen flow and decreased for beneficiaries requiring less than 1 LPM. If a beneficiary qualifies for additional payment for greater than 4 LPM of oxygen and also meets the requirements for portable oxygen, the appropriate modifiers (QB or QF) must be used.  The supplier who provides oxygen equipment for the first month must continue to provide any necessary oxygen equipment and all related items and services through the 36-month rental period, unless one of the following exceptions is met:      Beneficiary relocates temporarily or permanently outside of the supplier's service area     Beneficiary elects to obtain oxygen from a different supplier     Individual case exceptions made by CMS or DME MAC     Item becomes subject to competitive bidding  Providing different oxygen equipment/modalities (e.g., concentrator [stationary or portable], gaseous, liquid, trans-filling equipment) is not permitted unless one of the following requirements is met:      Supplier replaces the equipment with the same or equivalent item     Treating practitioner's orders different equipment     Beneficiary chooses to receive an upgrade and signs an Advance Beneficiary Notice of Non-coverage (ABN)     CMS or the DME MAC determines that a change in equipment is warranted  A new 36-month rental period can begin only in the following situations:      Specific incident of damage beyond repair (e.g., dropped and broken, fire, flood, etc.) or the item is stolen or lost     Break-in-need for at least 60 days plus the days remaining in the month of discontinuation and new medical necessity is established (see "BREAK-IN-SERVICE" below)  A new 36-month rental period does not start in the following situations:      Replacing equipment due to malfunction, wear and tear, routine maintenance, repair     Providing different equipment based on a treating practitioner order or beneficiary request for an upgrade     Break-in-need less than 60 days plus the days remaining in the month of discontinuation (see "BREAK-IN-SERVICE" below)     Break-in-billing (see "BREAK-IN-SERVICE" below)     Changing suppliers  You can find this information in Medicare's Local Coverage Article: Oxygen and Oxygen Equipment - Policy Article (A52514).  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 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 copayment for urgently needed services provided in a specialist office. You can find this information on pages 82-83 of the Plan's 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 Medicare rules say that for the services of a Clinical Psychologist (CP), if the patient consents, you must attempt to consult their attending or primary care physician about provided services and either document consent or declination date to consultations and date of consultations in patient's medical record. If consultations are unsuccessful, document the patient's medical chart with the date and physician notification method. This does not apply if the physician referred the patient to the CP. You can find this information in the Centers for Medicare and Medicaid Services MLN Booklet: Medicare Mental Health.  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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. You can find this rule at 42 CFR 424.5.  The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare Program Integrity Manual Chapter 3  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 say that a Medicare plan may restrict members to a network of providers as long as medically
necessary covered care is accessible and available through this network. The rules say that the Plan must
arrange for specialty care outside of the Plan provider network when network providers are unavailable or
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 pages 43-49 of the Plan's 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 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 Plan contract includes a list of covered supplemental dental services. Add tooth to existing partial denture (D5650) is not included on this list and is not a covered supplemental benefit. This benefit includes intraoral x-rays and are limited to one procedure code per calendar year. You can find this information on pages 85 and 86 of the Plan's 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
Coverage Indications, Limitations, and/or Medical Necessity
This LCD addresses use of water vapor thermal therapy for the treatment of lower urinary tract symptoms
attributable to benign prostatic hyperplasia (LUTS/BPH).
ONE treatment for LUTS/BPH treatment is covered ONCE in patients with BOTH the following:
1. Indications including ALL of the following:
a. Age greater than or equal to 50
b. Symptomatic despite maximal medical management including ALL of the following:
i. International Prostate Symptom Score (IPSS) greater than or equal to 13
ii. Maximum urinary flow rate (Qmax) of less than or equal to 15 mL/s (voided volume greater than 125
cc)
iii. Failure, contraindication or intolerance to at least three months of conventional medical therapy for
BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride)
c. Prostate volume of 30-80 cc,
d. Poor candidate for other surgical interventions for BPH due to underlying disease (e.g., cardiac disease,
pulmonary disease, etc.), or at high risk of bleeding
2. No contraindications including ALL of the following:
a. Known or suspected prostate cancer (based on NCCN Prostate Cancer Early Detection guidelines) or a
prostate specific antigen (PSA) greater than 10 ng/mL
b. Active urinary tract infection
c. History of bacterial prostatitis in the past three months
d. Prior prostate surgery
e. Neurogenic bladder
f. Active urethral stricture (i.e., the source of the current LUTS
You can find this information in Medicare's Local Coverage Determination (LCD): Water Vapor Thermal
Therapy for LUTS/BPH (L37808).
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 effective for dates of service specified below, the Centers for Medicare & Medicaid Services
(CMS) has determined that PILD will be covered by Medicare when provided in a clinical study under section
1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED) for
beneficiaries with LSS who are enrolled in an approved clinical study that meets the criteria. You can find this
information in Medicare's National Coverage Determination (NCD) Percutaneous Image-Guided Lumbar
Decompression for Lumbar Spinal Stenosis (150.13).
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 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. The Plan contract says that
for services obtained Out-of-Network the Plan only pays up to a certain amount. If you choose to see an Outof-
Network dentist you might be billed for any amount greater than what the Plan pays. This benefit also
includes an annual maximum benefit of $1,500 every year. The contract says that after the annual maximum is
exhausted, any remaining charges are your responsibility. You can find this information on page 4-77 of the
Plan's 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 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. The contract lists the specific dental services that are covered. Scaling in presence of generalized moderate or severe gingival inflammation is not listed and therefore is not a covered service. Gingival irrigation is not listed and therefore is not a covered service. Take home drugs are not listed and therefore are not covered services either. The contract also says any service not listed is not covered. You can find this information on pages 4-76 to 4-86 of the Plan's 2021 Evidence of Coverage (EOC).