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 treatment for temporomandibular joint (TMJ) syndrome may be covered when the actual condition or symptom is medical in nature and the services provided are reasonable and necessary for the diagnosis and/or treatment of a medical illness or injury. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.1.
The rules say that physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are covered only when they are medically reasonable and necessary. Therapy services are considered reasonable and necessary when: 1. The services are specific and effective treatment for the patient's condition, 2. The services require the skills or direct supervision of a therapist, 3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and 4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, or carry out a maintenance program. Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2
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.
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 $370 copayment for outpatient surgery/for other outpatient procedures 
and services. You can find this information on page(s) 98 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that ultraviolet cabinets are covered for selected patients with generalized intractable psoriasis. 
You can find this rule in 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. 
 
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 The rules state that the following is a list of suppliers who frequently attempt to enroll in 
Medicare but are not eligible to do so. (This list is not all-inclusive, however.). If the contractor receives an 
enrollment application from any of these individuals or entities, the contractor shall deny the application with 
the exception of entities eligible to enroll using the Form CMS-20134, which is specific to the furnishing of 
MDPP services. 
     Marriage Family Therapist 
You can find this rule in the Medicare Program Integrity Manual Chapter 10.2.8 - Providers/Suppliers Not 
Eligible to Enroll. 
 
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 definitive urine drug testing (UDT) is reasonable and necessary for the following 
circumstances: 
 
1. Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT; 
2. Definitively identify specific drugs in a large family of drugs; 
3. Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, 
meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
4. Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., 
discontinuation of THC use according to a treatment plan); 
5. Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients self-
report, presentation, medical history, or current prescribed pain medication plan; 
6. Rule out an error as the cause of a presumptive UDT result; 
7. Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 
8. Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
 
You can find this rule in the Local Coverage Determination (LCD) - Lab: Controlled Substance Monitoring 
and Drugs of Abuse Testing (L36707). 
 
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 the Centers for Medicare and Medicaid Services (CMS) policy prohibits separate payment 
for duplicate testing or testing for the same analyte by more than one methodology. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter X. 
 
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 $105 copayment for emergency care. You can find this information on 
page(s) 74 of the Plan's 2023 Schedule of Cost Sharing.
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are covered only when they are medically reasonable and necessary. Therapy services are considered reasonable and necessary when: 1. The services are specific and effective treatment for the patient's condition, 2. The services require the skills or direct supervision of a therapist, 3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and 4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, or carry out a maintenance program. Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2.
The rules say that treatment for temporomandibular joint (TMJ) syndrome may be covered when the actual condition or symptom is medical in nature and the services provided are reasonable and necessary for the diagnosis and/or treatment of a medical illness or injury. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.1.
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 effective for claims with dates of service on and after December 23, 2009, the Centers for 
Medicare and Medicaid Services (CMS) determines that the evidence is adequate to conclude that Outpatient 
Intravenous Insulin Treatment (OIVIT) does not improve health outcomes in Medicare beneficiaries. 
Therefore, CMS determines that OIVIT is not reasonable and necessary for any indication under section 
1862(a)(1)(A) of the Social Security Act. This rule is found in National Coverage Determination (NCD): 
Outpatient Intravenous Insulin Treatment (40.7). 
 
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 $48 copayment for physician/practitioner services, including doctors 
office visits. You can find this information on page(s) 95 to 96 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 diagnostic evaluation of the head and neck (head/neck scans) performed by computerized 
tomography (CT) scanners is covered when the documentation supports that the scan is reasonable and 
necessary. Accurate coding information must be provided with claims to differentiate CT and/or Magnetic 
resonance imaging (MRI) scans from other radiology services and to make coverage determinations. Sufficient 
documentation such as, history and physical notes, laboratory results, signs and symptoms of the disease to 
warrant the diagnostic test and to support the claim of reasonable and necessary must be included in the 
medical records. There is a list of diagnoses which support medical necessity. You can find this rule in the 
Local Coverage Determination (LCD): MRI and CT scans of the Head and Neck (L35175) and the Local 
Coverage Article (A57215). 
 
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 not pay for services given by a physician or other practitioner who has 
opted out of Medicare. This rule does not apply to emergency or urgently needed services. A Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 6, Section 60.2. 
 
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 Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 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 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 $125 copayment for emergency care. You can find this information on 
page(s) 54-55 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a 20% coinsurance for molecular or predisposition genetic testing. You 
can find this information on pages 89 to 91 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a 20% coinsurance for Medicare Part B covered drugs at primary care 
providers office, specialists office and pharmacy. You can find this information on pages 59 to 60 of the 
Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $260 copayment for advanced imaging services. You can find 
this information pages 63 to 64 of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $100 copayment for other outpatient procedures and services, including, 
but not limited to, diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient 
hospital or ambulatory surgical center. You can find this information on page(s) 95 and 96 of the Plan's 2023 
Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $40 copayment for medical care or surgery services in a specialty 
physicians office. You can find this information on page(s) 97 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles, and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $350 copayment for each in-network Medicare-covered hospital stay 
each time they are admitted. You can find this information on page 4-32 of the Plan's 2022 Evidence of 
Coverage (EOC).