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

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare 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.

The rules say that the following are utilization guidelines for drug testing: 

1. The contractor will consider presumptive urine drug testing (UDT) testing in excess of 12 per Calendar year not reasonable and necessary.

NOTE: An exception to the above limitation will be made when patients have documented diagnoses consistent with a substance abuse disorder (SUD), for which patients presumptive UDT shall not occur more than 3 times within a seven-day period, based upon the following guidelines for monitoring abstinence.
a) For patients with 0 to 30 consecutive days of abstinence, presumptive UDT is expected at a frequency of 1 to 3 presumptive UDT per week. More than 3 presumptive panels in one week is not reasonable and necessary and is not covered by Medicare.
b) For patients with 31 to 90 consecutive days of abstinence, presumptive UDT is expected at a frequency of 1 to 3 UDT per week. More than 3 presumptive UDT in one week is not reasonable and necessary and is not covered by Medicare.
c) For patients with more than 90 consecutive days of abstinence, presumptive UDT is expected at a frequency of 1 to 3 UDT in one month. More than 3 physician-directed UDT in one month is not reasonable and necessary and is not covered by Medicare.
2. The contractor will only pay for one presumptive UDT test per patient per date of service regardless of the number of billing providers. 3. For chronic opioid therapy (COT), the contractor will consider up to 12 definitive tests (i.e., definitive UDT) per Calendar year reasonable and necessary. This would correspond to random testing performed 1-3 times every 3 months for prescribed medications, non-prescribed medications that may pose a safety risk if mixed with prescribed and illicit substances based on patient history, clinical presentation or community usage.

You can find these rules in the Local Coverage Determination (LCD) for Controlled Substance Monitoring and Drugs of Abuse Testing, L35006.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your home may be a dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, an institution may not be considered your home if it is an acute hospital or a skilled nursing facility (SNF). 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(D). 

The rules say that when DME is furnished for use in a SNF during a covered Part A stay, the DME Regional Carriers (DMERCs) shall not make separate payment for DME, since the DME is already included in the payment that the SNF receives for the covered stay itself. You can find this information in the Centers for Medicare and Medicaid Services Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 20, 211.1.

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 that providers 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 critical care is a time-based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided. You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.12(e).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services,
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the
services listed in the Plan's benefit chart; any service not listed is not covered. You can find this information on
page 4-56 to 4-70 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 effective for dates of service specified below, the Centers for Medicare & Medicaid
Services (CMS) has determined that PILD will be covered by Medicare when provided in a clinical study under
section 1862(a)(1)(E)of the Social Security Act (the Act) through Coverage with Evidence Development
(CED) for beneficiaries with LSS who are enrolled in an approved clinical study. You can find this information
in the National Coverage Determination (NCD): Percutaneous Image-Guided Lumbar Decompression for
Lumbar Spinal Stenosis (150.13).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes a maximum allowance of $500 per year. After the annual maximum is exhausted, any remaining charges are your responsibility. You can find this information on page 4-55 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 $25 copayment for x-rays. You can find this information in Chapter 4
on page 78 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).
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 the Plan will cover only manual manipulation of the spine to correct subluxation. You can find this information on page 61 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 definitive urine drug testing (UDT) is reasonable and necessary in order to: 

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 patient's 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) - Controlled Substance Monitoring and Drugs of Abuse Testing (L35006) - Effective October 17, 2019.

The rules say that definitive urine drug testing may be reasonable and necessary based on patient specific indications, including historical use, medication response, and clinical assessment, when accurate results are necessary to make clinical decisions. The clinician's rationale for the definitive urine drug testing and the tests ordered must be documented in the patient's medical record. You can find this rule in the Local Coverage Determination (LCD) - Controlled Substance Monitoring and Drugs of Abuse Testing (L35006) - Effective October 17, 2019. 

The rules say that the frequency of testing beyond the baseline presumptive urine drug testing must be based on individual patient needs substantiated by documentation in the patient's medical record. The patient's medical record must include an appropriate testing frequency based on the stage of screening, treatment, or recovery; the rationale for the drugs/drug classes ordered; and the results must be documented in the medical record and used to direct care.

The frequency of testing must be based on a complete clinical assessment of the individual's risk potential for abuse and diversion using a validated risk assessment interview or questionnaire and should include the patient's response to prescribed medications and the side effects of medications. You can find this rule in the Local Coverage Determination (LCD) - Controlled Substance Monitoring and Drugs of Abuse Testing (L35006) - Effective October 17, 2019.

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 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 contract
says that you have $100 plan coverage limit for supplemental eyewear every year. You can find this
information on page 96 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 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 a $741
copayment for a porcelain crown, and a $172 copayment for core build up. You can find this information on
pages 104 to 105 of the Plan's 2021 Evidence of Coverage (EOC).
The contract also says when you receive any of the listed procedures from a participating dental provider, you
will pay the fee listed for that service. The participating dental providers have agreed to accept that fee as
payment in full for that procedure. Neither the Health Plan nor Dental Plan is liable for payment of these fees
or for any fees incurred as the result of receipt of a noncovered dental service. You can find this information on
page 101 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 definitive urine drug testing (UDT) is reasonable and necessary in order to:
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 patient's 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) - Controlled Substance Monitoring and
Drugs of Abuse Testing (L35006) - Effective October 17, 2019.
The rules say that definitive urine drug testing may be reasonable and necessary based on patient specific
indications, including historical use, medication response, and clinical assessment, when accurate results are
necessary to make clinical decisions. The clinician's rationale for the definitive urine drug testing and the tests
ordered must be documented in the patient's medical record. You can find this rule in the Local Coverage
Determination (LCD) - Controlled Substance Monitoring and Drugs of Abuse Testing (L35006) - Effective
October 17, 2019.
The rules say that the frequency of testing beyond the baseline presumptive urine drug testing must be based on
individual patient needs substantiated by documentation in the patient's medical record. The patient's medical
record must include an appropriate testing frequency based on the stage of screening, treatment, or recovery;
the rationale for the drugs/drug classes ordered; and the results must be documented in the medical record and
used to direct care. The frequency of testing must be based on a complete clinical assessment of the individual's risk potential for abuse and diversion using a validated risk assessment interview or questionnaire
and should include the patient's response to prescribed medications and the side effects of medications. You
can find this rule in the Local Coverage Determination (LCD) - Controlled Substance Monitoring and Drugs of
Abuse Testing (L35006) - Effective October 17, 2019.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 1 limited oral evaluation per plan year. You can find this information on page 4-57 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 one upper and lower complete denture every five years, including routine post-delivery care. This benefit also states that you have a $1,000 annual maximum. You can find this information on pages 85-87 of the Plan's 2021 Evidence of Coverage (EOC).