Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles, and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).

The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that enrollees must pay 30% coinsurance for each Medicare-covered hospital stay for inpatient
care when provided out-of-network. You can find this information on pages 53-54 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 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 Medical Necessity of Services Performed: There are many different relationships that exist in providing the provision of pathology services in the United States. Some physicians, groups, laboratories and hospitals submit global claims for the services described in this LCD. In other instances, there are separate individuals or entities providing the professional and the technical services. It is the obligation of each billing party to recognize that they are responsible for the medical necessity of the charges submitted. For example, when a physician or physician group bills for the professional component of services described in this LCD and another entity bills for the technical services, it is the obligation of each entity to independently assure the medical necessity of the services rendered and billed. And this from A57708: 

Documentation Requirements 

1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request. 
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. 
3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. 
4. The medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed.
The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition (ICD-10-CM code) that warrants the test(s). 
5. Examples of documentation requirements of the ordering physician/non-physician practitioner (NPP) include, but are not limited to, history and physical or exam findings that support the decision making, problems/diagnoses, relevant data (e.g., lab testing, imaging results). 
6. The medical necessity for the special stain or IHC studies, and the results of the stain or IHC, must be documented in the surgical pathology report. 

You can find this information in Medicare's Local Coverage Determination (LCD) Special Histochemical Stains & Immunohistochemical Stains (L36234).

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 $450 copayment for an in-network outpatient hospital. You can find this
information on page 77 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).
The rules say subluxation may be shown by x-ray or physical exam. 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, Section 240.1.2.
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 health
plan contract says that they only cover manual manipulation of the spine to correct subluxation. You can find
this information on page 12 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 state that when a patient is hospitalized for a dental procedure and the dentist's service is covered under Part B, the inpatient hospital services furnished are covered under Part A. For example, both the professional services of the dentist and the inpatient hospital expenses are covered when the dentist reduces a jaw fracture of an inpatient at a participating hospital. In addition, hospital inpatient services which are necessary because of the patient's underlying medical condition and clinical status or the severity of a non-covered dental procedure, are covered. You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 70.

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 covered, non-routine dental care is limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. You can find this information on page 68 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 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 any physician seeing a patient registered in the emergency department may use emergency
department visit codes (for services matching the code description). The POS code is generally used to reflect
the actual setting where the beneficiary receives the face [1]to-face service. For example, if the physician's
face-to-face encounter with a patient occurs in the office, the correct POS code on the claim, in general, reflects
the 2-digit POS code 11 for office. In these instances, the 2-digit POS code (Item 24B on the claim Form CMS-
1500) will match the address and ZIP entered in the service location (Item 32 on the 1500 Form) - the physical/
geographical location of the physician. However, there are two exceptions to this general rule - these are for a
service rendered to a patient who is a registered inpatient or an outpatient of a hospital. You can find this
information in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.11.
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 $25 copayment for urgently needed services received from providers
other than your PCP. You can find this information on page 111 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 $45 copayment for each covered visit or consultation in an outpatient
location with a specialist. Covered services include consultation, diagnosis, and treatment by a specialist. You
can find this information on pages 103 to 106 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.

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 offers a supplemental (extra) benefit to cover routine vision services that are not covered by Original Medicare. This benefit includes routine eye exams (eye refraction exams) to determine the need for vision correction and to provide a prescription for eyeglass lenses and up to a $100 allowance toward the purchase of prescription eyewear (eyeglass lenses, eyeglass frames and contact lenses) from a network optical provider. Professional services for evaluation, fitting and follow-up care for contact lenses (other than Medicare-covered, medically necessary contact lenses) are excluded from coverage. You can find this information on pages 33-34 of the Plan's 2021 Medical Benefits Chart and in the Plan's 2021 Prescription Eyewear Rider packet.
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.
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 contract
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes some
preventative and comprehensive services which are listed in the Plan's contract. When received out-of-network,
you must pay 0% coinsurance for dental cleanings, 0% coinsurance for periodic oral exams, and 55%
coinsurance for restorations (fillings). Network dentists have agreed to provide services at a negotiated rate. If
you see a network dentist, you cannot be billed more than that rate for covered services. Benefits received out-
of-network are subject to any in-network benefit maximums, limitations and/or exclusions. You may be billed
by an out-of-network provider for any amount greater than the payment made by the Plan to the provider. You
can find this information on pages 78-79 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. This benefit includes
cleanings, oral exams, fluoride treatments, a dental x-ray, minor restorations (fillings) simple extractions,
dentures, and denture repair. Oral hygiene instructions (D1330), periodontal scaling and root planing (D4341),
and palliative (emergency) treatment of dental pain (D9110) are not included on this list and are not covered
benefits. The Plan contract also says that periodontics, endodontics, oral/maxillofacial surgery, and other
prosthodontics are not covered services. You can find this information on page 57 of the Plan's 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 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 page 8 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.
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).
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 routine eye exams and supplemental eyewear must be obtained from a provider in
the Plan's vision vendor network. Services obtained from vendors outside this network are not covered. You
can find this information on page 62 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 Medicare approved amount for these procedures includes payment for the following services related to the
surgery when furnished by the physician who performs the surgery. The services included in the global surgical
package may be furnished in any setting, e.g., in hospitals, ASCs, physicians' offices. Visits to a patient in an
intensive care or critical care unit are also included if made by the surgeon. However, critical care services
(99291 and 99292) are payable separately in some situations.
- Complications Following Surgery - All additional medical or surgical services required of the surgeon
during the postoperative period of the surgery because of complications which do not require additional trips to
the operating room;
- Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to
recovery from the surgery and
- Postsurgical Pain Management - By the surgeon.
You can find this information in the Medicare Claims Processing Manual, Chapter 12, 40.1.
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.