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 plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 1, Section 20.2.  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information in Chapter 3 on pages 45 to 46 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 Part B generally does not pay for drugs that are usually self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are:  1. blood-clotting factors;  2. drugs used in immunosuppressive therapy; 3. erythropoietin for dialysis patients;  4. osteoporosis drugs for certain homebound patients; 5. certain oral cancer drugs;  6. oral anti-emetics used in certain situations;  7. drugs treated as supplies during an outpatient hospital procedure; and  8. drugs required for the effective use of durable medical equipment.  You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.  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 pays for care in a skilled nursing facility (SNF) when all of the following four factors are met:  1. The patient requires skilled nursing or skilled rehabilitation services; 2. The patient requires these services on a daily basis; 3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and 4. The services are reasonable and necessary for the treatment of the patient's illness or injury, or the services must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from getting worse.   You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30.    The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110.  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 whole gland HIFU is considered medically necessary as a local treatment for recurrent PCa following radiation therapy (RT) when ALL of the following criteria are met (1,2):  1. Biochemical recurrence (BCR) according to the Phoenix definition (PSA nadir + 2 ng/mL) 2. Positive post-RT transrectal ultrasound guided (TRUS) biopsy 3. Candidate for local curative therapy as evidenced by favorable clinical and pathologic factors (BOTH of the following)  a. Original (pre-RT)- clinical stage T1-T2, NX or N0 b. Current (ALL are required)  i. PSA less than 10 ng/mL ii. absence of distant metastases per National Comprehensive Cancer Network (NCCN) imaging guidelines iii. no lymph node involvement iv. interval to biochemical failure greater than 18 months v. International Society of Urological Pathology (ISUP) grade less than 4 vi. local recurrence amenable to entire destruction 4. Multi-disciplinary consensus (surgeon, oncologist, radiologist) 5. Hi comorbidity (i.e., not a candidate for radical prostatectomy (RP)) (3) Exclusion Criteria (NONE of the below are allowed) 1. Life expectancy less than 10 years (1,2) 2. PCa subtype other than adenocarcinoma (4) 3. Post-RT ADT (5,6) 4. Post-RT anal/rectal stenosis or rectal wall thickness greater than 6 mm by TRUS or MRI (6) You can find this rule in the Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD): Salvage High-Intensity Focused Ultrasound (HIFU) Treatment in Prostate Cancer (PCa) (L38262).  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. The contract lists the specific dental services that are covered. Gingival irrigation is not listed and therefore is not a covered service. The contract also says Procedures and/or appliances not listed on this Patient Charge Schedule are not covered. Any services performed that are not covered are the patient's responsibility at the dentist's usual fees. You can find this information on pages 5 to 22 of the Plan's 2021 Comprehensive dental plan information guide.
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).

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 you have an allowance of up to $220 per calendar year for a combination of routine prescription contacts, routine prescription lenses, routine vision frames, and/or upgrades, such as tinting. You can get your routine vision hardware from any qualified provider. Your routine vision hardware allowance is the same for all providers. You can find this information on page 131 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 an expandable controller is capable of accommodating one or more of the following additional functions:

-Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) -Non-proportional input devices (e.g., sip and puff, head array, etc.) 
-Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)

An expandable controller may also be able to operate one or more of the following:

-A separate display (i.e., for alternate control devices) 
-Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control) 
-An attendant control

You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective January 1, 2020.

The rules say that a power seating system - tilt only, recline only, or combination tilt and recline - with or without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: 
1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; and 
2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary's seating and positioning needs. The PT, OT, or practitioner may have no financial relationship with the supplier; and 
3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary. 
4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or 
6. The power seating system is needed to manage increased tone or spasticity.

You can find this rule in Local Coverage Determination (LCD):Wheelchair Options/Accessories (L33792) - Effective January 1, 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 $40 copayment for each in-person specialist visit. You can find this information on pages 96-97 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 $90 copayment for Emergency care. You can find this information on page 73 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 pay for durable medical equipment that is mainly used to serve a medical
purpose. Items such as hospital beds, respirators, wheelchairs, and crutches are examples of equipment that are
clearly used for medical purposes. Medicare will not pay for:

1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air
conditioners, humidifiers, dehumidifiers, and electric air cleaners;
2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. 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 110.1.

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.
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 E2311 describes electronic components that allow the patient to control two or more of the following motors from a single interface, e.g., proportional joystick, touchpad, or nonproportional interface:

1. Power tilt 
2. Power recline, with or without shear reduction 
3. Combination power tilt and recline, with or without shear reduction 
4. Power leg elevation with or without articulation, power center mount elevating foot platform with or without articulating properties.

You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective January 1, 2020. 

The rules say that an expandable controller is capable of accommodating one or more of the following additional functions:

-Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) 
-Non-proportional input devices (e.g., sip and puff, head array, etc.) 
-Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)

An expandable controller may also be able to operate one or more of the following: 

-A separate display (i.e., for alternate control devices) 
-Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control) 
-An attendant control 

You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective January 1, 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 $40 copayment for Physician/Practitioner services, including doctor's office visits. You can find this information on page 103 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 dental services that are covered. The contract also says the listed services are subject to the Dental Plan's Processing Policies, limitations, and exclusions. You can find this information on page 62 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 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 radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. You can find this information in the Local Coverage Determination (LCD): Pain Management (L33622).   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 $30 copayment for specialist visits. You can find this information in Chapter 4 on page 56 of the Plan's 2021 Evidence of Coverage (EOC).