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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that the services listed in the benefit chart are covered when a Plan provider is used to obtain 
the service. You can find this information on page 93 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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2. 
 
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 also says that you can get your care from an out-of-network provider; however, in most cases that 
provider must be eligible to participate 
in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to participate in 
Medicare. If you receive care from a provider who is not eligible to participate in Medicare, you will be 
responsible for the full cost of the services you receive. Check with your providers before receiving services to 
confirm that they are eligible to participate in Medicare. You can find this information on page 3-4 to 3-5 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 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 in-network physical therapy visits. You can find this 
information 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 removal of benign skin lesions is not considered cosmetic when symptoms or signs which 
warrant medical intervention are present, including but not limited to: 
1. Bleeding 
2. Intense itching 
 3. Pain 
 4. Change in physical appearance 
5. Physical evidence of inflammation or infection, e.g., purulence, oozing, edema, erythema, etc. 
 6. Lesion obstructs an orifice 
 7. Lesion clinically restricts eye function 
8. Clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration 
based on lesion appearance 
You can find this information in the Local Coverage Article: Billing and Coding: Removal of Benign Skin 
Lesions (A54602). 
 
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Medicare does not reimburse separately for sales tax. You can find this the Centers for Medicare and Medicaid 
Services, Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 23, 
Section 80.3.1. 
 
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. 
 
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. The Plan 
contract says that enrollees must pay a $20 copayment for each physical therapy visits. You can find this 
information on page 21 of the Plan's schedule of cost sharing included in the 2019 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 all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patients medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patients 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
The rules state that therapeutic continuous glucose monitors (CGMs) and related supplies are covered by 
Medicare when all of the following coverage criteria are met: 
  1. The beneficiary has diabetes mellitus, 
  2. The beneficiary has been using a blood glucose monitor (BGM) and performing frequent (four or more 
times a day) testing, 
  3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump, 
  4. The beneficiarys insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results. 
  5. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
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 $0 copayment for days 1-20 for a skilled nursing facility stay. The Plan 
contract also says there is a $184 copayment for days 21-100. There is no charge for the day of discharge. You 
can find this information on pages 111-112 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 (a) Ordering diagnostic tests. Except as otherwise provided in this section, all diagnostic x-
ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating 
the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical 
problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not 
ordered by the physician who is treating the beneficiary are not reasonable and necessary (see Section 
411.15(k)(1) of this chapter). 
 
(1) Mammography exception. A physician who meets the qualification requirements for an interpreting 
physician under section 354 of the Public Health Service Act as provided in  410.34(a)(7) may order a 
diagnostic mammogram based on the findings of a screening mammogram even though the physician does not 
treat the beneficiary. 
 
(2) Application to nonphysician practitioners. Nonphysician practitioners (that is, clinical nurse specialists, 
clinical psychologists, clinical social workers, nurse-midwives, nurse practitioners, and physician assistants) 
who furnish services that would be physician services if furnished by a physician, and who are operating within 
the scope of their authority under State law and within the scope of their Medicare statutory benefit, may be 
treated the same as physicians treating beneficiaries for the purpose of this paragraph. You can find this 
information in Medicare's 42 CFR Chapter IV Section 410.32 Diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests: Conditions. 
 
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 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 of the Plan's 2022 
Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say Covered Indications 
 
    1. Invasive procedures will be considered medically reasonable and necessary if the patient meets the criteria 
as outlined in this LCD, and the intervention is addressed and supported in the plan of care, for a 90-day 
episode of care, that includes a specific treatment plan determined by the assessment and evaluation of the 
lower extremity venous incompetence. 
    2. Invasive procedures for the treatment of varicose veins are considered medically reasonable and necessary 
when ALL of the following criteria have been met: 
        An evaluation of the patient has been performed including a history and physical examination, the CEAP 
clinical classification and the revised Venous Clinical Severity Score (VCSS), AND 
        A duplex scan of the deep and superficial venous systems supports the examination findings,3 AND 
        A duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers in the 
saphenous, or perforator veins is 500 milliseconds or greater3 and absence of deep venous obstruction, AND 
        The documentation supports signs and/or symptoms that interfere with activities of daily living and/or 
quality of life, AND 
        The CEAP clinical classification is C1 to C6 with the following criteria: 
            Treatment of C1 disease (telangiectasia and their feeding reticular veins) is considered medically 
reasonable and necessary for patients with spontaneous and/or traumatic venous hemorrhage. 
            For patients with C2 or C3 disease and VCSS less than 6, the plan of care shall include documentation 
of a period of conservative therapy (2 to 4 weeks) including graduated compression 20-30 mmHg or greater, 
ambulation, elevation, and avoiding prolonged sitting and standing. 
            For patients who meet any one of the following criteria, the mandatory conservative therapy prior to the 
invasive procedure may be waived. 
                VCSS equals 6 
                C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, and active 
venous leg ulceration) 
                Hemorrhage 
                Recurrent superficial thrombophlebitis 
  You can find this information in Medicare's Local Coverage Determination (LCD): Treatment of Chronic 
Venous Insufficiency of the Lower Extremities (L38720). 
 
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. 
 
Medicare Guidance says Respiratory virus laboratory detection (eg. adenovirus, influenza virus, coronavirus, 
metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse 
transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes; is not 
covered. Respiratory infectious agent detection, CPT code 87633 (12-25 targets) is non-covered by Medicare 
and excluded from coverage. Use is restricted to when more limited panels would not be medically appropriate 
(e.g. patient critically ill, etc.). You can find this Medicare guidance in the Medicare Local 
Coverage Article (Palmetto) A54769 - Influenza Diagnostic Tests; Medicare Local Coverage Article A57579: 
Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels; Medicare 
Local Coverage Determination for MolDX Multiplex Nucleic Acid Amplified Tests for Respiratory Viral 
Panels L37713; Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services; Code of 
Federal Regulation 42 CFR 410, Subpart B - Medical and Other Health Services (screening tests) and Code of 
Federal Regulation 42 CFR Chapter IV Section 410.32. 
 
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. 
 
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 states that routine vision benefits are provider through the Plan's third-party vision vendor. The 
enrollee has a $300 benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses at 
a network optical provider (1 per calendar year). Any benefits received at a non-network optical provider are 
excluded from coverage. Even if the enrollee receives the services at an emergency facility, the excluded 
services are still not covered. You can find this information on page 83 and 86 of the Plan's 2021 Evidence of 
Coverage.