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 Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 custom programmed, open-fit design digital hearing aids are covered. Enrollees are 
limited to 2 hearing aids/devices per year. Hearing aids must be ordered from the Plans network provider. You 
can find this information on page 4-18 of the Plans 2017 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 $55 copayment for Physician/Practitioner services, including doctors 
office visits. You can find this information on page 60 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 state that colonoscopies are covered for the following indications: 
1. For evaluation of an abnormality discovered on barium enema and/or other imaging technique that is likely 
to be clinically significant, such as a filling defect or stricture or an inadequate examination; 
 
2. For evaluation of unexplained gastrointestinal (GI) bleeding;   
 
3. For unexplained iron deficiency anemia; 
 
4. For surveillance of colonic neoplasia; 
 
5. For chronic inflammatory bowel disease (IBD) of the colon (if a more precise diagnosis or if a determination 
of the extent of activity of disease will influence immediate management); 
 
6. For clinically significant diarrhea of unexplained origin with additional findings (e.g., weight loss or 
negative stool cultures persisting for more than 3 weeks); 
 
7. For intraoperative identification of the site of a lesion that cannot be detected by palpation or gross 
inspection at surgery (e.g., polypectomy site or location of a bleeding source); 
 
8. For evaluation of acute colonic ischemia/ischemic bowel disease; 
 
9. For evaluation of a patient with Streptococcus bovis (S. bovis) endocarditis or bacteremia; 
 
10 For treatment of bleeding from such lesions as vascular anomalies, ulceration and neoplasia; 
 
11. For removal of a foreign body; 
 
12. For excision of colonic polyps; 
 
13. For decompression of pseudo-obstruction of the colon (Olgilvies Syndrome) following a trial of 
neostigmine or cathartics or a documented reason that this would be either unsafe or inappropriate for the 
beneficiary; 
 
14. For treatment of colonic volvulus or stricture;  
15. For evaluation of an unexplained, new onset constipation, refractory to medical therapy; 
 
16. For evaluation of an anorectal polyp (adenomatous polyp only); or, 
 
17. For palliative treatment of stenosing, bleeding neoplasms (e.g., laser, electrocoagulation, stenting). 
 
You can find this information in Local Coverage Determination (LCD): 
Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy (L34454). 
 
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 pay for an inpatient rehabilitation facility (IRF) admission when the services 
are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary 
approach to providing rehabilitation.  
  
  The patient must need active and ongoing treatment by more than one therapy discipline. One of the therapies 
must be physical therapy or occupational therapy. The patient must need and be expected to actively participate 
in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy 
program generally consists of at least three hours of therapy per day at least five days per week. The patient 
does not need to be expected to achieve complete independence in self-care nor be expected to return to his or 
her prior level of functioning. The patient must need supervision by a rehabilitation physician. The physician 
must see the patient at least three days per week throughout the stay. You can find these rules in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, 
Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622. 
 
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 state that all skilled nursing facility (SNF) Part A inpatient services are paid under a prospective 
payment system (PPS). This involves payment based on a Health Insurance Prospective Payment System 
(HIPPS) rate code. Under the new Patient-Driven Payment Model (PDPM), which is effective for services 
provided on or after 10/1/2019, the HIPPS code is structured differently, as a result of there being five case-mix 
adjusted rate components under the revised model. The first position represents the Physical and Occupational 
Therapy case-mix group. The second position represents the Speech-Language Pathology (SLP) case-mix 
group. The third character represents the nursing case-mix group. The fourth character represents the Non-
Therapy Ancillary (NTA) case- mix group. The fifth character represents the assessment indicator code. You 
can find this information in the Centers for Medicare and Medicaid Service (CMS), Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Sections 10, 30, and 120. 
 
The rules also say that active diagnoses are intended to code diseases that have a direct relationship to the 
residents current functional status, cognitive status, mood or behavior status, medical treatments, nursing 
monitoring, or risk of death. One of the important functions of the Minimum Data Set (MDS) assessment is to 
generate an updated, accurate picture of the residents current health status. You can find this rule in the 
Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 
Manual, Chapter 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.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that immunizations are not covered unless they are directly related to the treatment of an injury or 
direct exposure to a disease or condition. In the absence of injury or direct exposure, vaccination or inoculation 
is not covered. However, pneumococcal, hepatitis B, influenza virus vaccines, and any FDA-approved COVID-
19 vaccines are exceptions to this rule. You can find this rule at 42 CFR Section 411.15(e) and Section 3713 of 
the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). 
 
The rules say that given the significant cost determination, Medicare payment for COVID vaccinations 
administered during calendar years 2020 and 2021 to MA beneficiaries will be made through the Medicare FFS 
program. Medicare beneficiaries enrolled in MA plans will be able to access the COVID-19 vaccine, without 
cost sharing, at any FFS provider or supplier that participates in Medicare and is eligible to bill under Part B for 
vaccine administration, including those enrolled in Medicare as a mass immunizer or a physician, non-
physician practitioner, hospital, clinic, or group practice. MA organizations should inform their contracted 
providers about this coverage policy and direct them to submit claims for administration of the COVID-19 
vaccine to the CMS Medicare Administrative Contractor (MAC) for payment. You can find this information in 
the Centers for Medicare and Medicaid Services COVID-19 Vaccine Significant Cost Determination. 
 
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 certain conditions have both an underlying etiology and multiple body system manifestations 
due to the underlying etiology. For such conditions, the ICD10-CM has a coding convention that requires the 
underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a 
combination exists, there is a use additional code note at the etiology code, and a code first note at the 
manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology 
followed by manifestation. You can find this information in ICD-10-CM Official Guidelines for Coding and 
Reporting, FY 2020. 
 
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 $120 copayment per stay for each emergency room visit for emergency 
room services. You can find this information in Chapter 4 on page 80 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 $250 coinsurance for an endoscopy. You can find this information in 
Chapter 4, on page 101, 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 state that facet joint procedures in patients for the indication of generalized pain conditions (such as 
fibromyalgia) or chronic centralized pain syndromes are considered not reasonable and necessary. Individual 
consideration may be considered under unique circumstances and with sufficient documentation of medical 
necessity on appeal. You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD) L33930, Facet Joint Interventions for Pain Management. 
 
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 program reimbursement for hyperbaric oxygen (HBO) therapy will be limited to that which 
is administered in a chamber (including the one man unit) and is limited to the following conditions: 
 
1. Acute carbon monoxide intoxication, 
2. Decompression illness, 
3. Gas embolism, 
4. Gas gangrene, 
5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in 
combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened. 
6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an 
adjunctive treatment when loss of function, limb, or life is threatened. 
7. Progressive necrotizing infections (necrotizing fasciitis), 
8. Acute peripheral arterial insufficiency, 
9. Preparation and preservation of compromised skin grafts (not for primary management of wounds), 
10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, 
11. Osteoradionecrosis as an adjunct to conventional treatment, 
12. Soft tissue radionecrosis as an adjunct to conventional treatment, 
13. Cyanide poisoning, 
14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to 
antibiotics and surgical treatment, 
15. Diabetic wounds of the lower extremities in patients who meet the following three criteria: 
      a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; 
      b. Patient has a wound classified as Wagner grade III or higher; and 
      c. Patient has failed an adequate course of standard wound therapy. 
 
All other indications not specified are not covered under the Medicare program. No program payment may be 
made for any conditions other than those listed. You can find this in the National Coverage Determination 
(NCD): Hyperbaric Oxygen Therapy (20.29). 
 
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 the 
requested item or service but is limited to one procedure every five plan years. You can find this information 
on pages 4-66 to 4-79 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. 
 
The rules say that Medicare will cover a one-time initial preventive physical examination (IPPE) for new 
Medicare beneficiaries that meet certain eligibility requirements. Medicare will pay for only one IPPE per 
beneficiary per lifetime. You can find this rule at the Medicare Claims Processing Manual, Chapter 18, Section 
80. 
 
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 $350 copayment for an outpatient hospital facility visit per date of 
service. You can find this information on page 96 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 immunizations are not covered unless they are directly related to the treatment of an injury or 
direct exposure to a disease or condition. In the absence of injury or direct exposure, vaccination or inoculation 
is not covered. However, pneumococcal, hepatitis B, influenza virus vaccines, and any FDA-approved COVID-
19 vaccines are exceptions to this rule. You can find this rule at 42 CFR Section 411.15(e) and Section 3713 of 
the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). 
 
The rules say that for calendar years 2020 and 2021, Medicare payment for the COVID-19 vaccine (if 
providers do not receive it for free) and its administration for beneficiaries enrolled in Medicare Advantage 
plans will be made through the Original Medicare program. You can find this rule in the Toolkit on COVID-19 
Vaccine: Health Insurance Issuers and Medicare Advantage Plans (Updated December 17, 2021). 
 
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 cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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). 
 
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 $250 copayment per one-way trip by ground ambulance. You can find 
this information in Chapter 4, on page 62, of the Plan's 2021 Evidence of Coverage (EOC).