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 a 30% coinsurance for provider and professional services rendered by an 
out-of-network inpatient hospital. You can find this information on page 69 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 $30 copayment for each urgent care visit at a "preferred facility". You 
can find this information on page 99 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 a power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a 
solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or 
swingaway detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without 
variable speed programmability; a switch control which is independent of the power wheelchair drive control 
interface. 
 
A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are 
not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or 
E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will 
be denied as non-covered. 
 
You can find this information in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article 
(A52504). 
 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a power tilt seating system (E1002) includes: a solid seat platform and a solid back; any 
frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway 
detachable legrests; fixed or flip-up footplates; a motor and related electronics with  or without variable speed 
programmability; a switch control which is independent of the power wheelchair drive control interface. You 
can find this information in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article 
(A52504). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that an expandable Controller - An electronic system that is capable of accommodating one or 
more of the following additional functions 
a. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head 
control, etc.) other than a standard proportional joystick. 
b. Non-proportional input devices (e.g., sip and puff, head array, etc.) 
c. 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: 
d. A separate display (i.e., for alternate control devices) 
e. Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's 
drive control) 
f. An attendant control 
 
A power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a solid back; any 
frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway 
detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable 
speed programmability; a switch control which is independent of the power wheelchair drive control interface. 
 
A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or 
without variable speed programmability which allows the legrest to be raised and lowered independently of the 
recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with 
the power tilt and/or recline control(s). 
 
You can find this information in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article 
(A52504) 
 
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 $225 copayment for each outpatient surgery and/or services at an 
ambulatory surgical center or outpatient hospital facility. 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 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 Medicare pays for home health care services under a prospective payment system (HH PPS). 
Home health services under a plan of care are paid based on a 60-day episode of care. Payment for home health 
care episodes is usually made in two parts. To receive the first part of the HH PPS split payment, the home 
health agency must submit a Request for Anticipated Payment (RAP). Specific data elements are required to 
submit a RAP. The home health agency must enter the claim - Outcome and Assessment Information Set 
(OASIS) matching key output by the Grouper software. This is known as the Treatment Authorization Code. 
You can find this rule, a list of the data elements, and instructions for the Treatment Authorization Code in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 10, Section 40.1. 
 
The rules say that after a RAP has been paid and a 60-day episode has been completed or the enrollee has been 
discharged, the home health agency must submit a claim to receive the rest of payment due for the episode. 
You can find this rule and detailed instructions for the claim in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 
40.2. 
 
The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid 
information for all of these elements may be returned as unprocessable. You can find this rule in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 1, 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. 
 
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 $275 copayment for each one-way Medicare-covered ambulance 
transport. You can find this information in Chapter 4 on page 65 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 Plan 
contract includes a list of covered supplemental dental services. Mandibular partial denture (D5214) is not 
included on this list and is not a covered supplemental benefit. You can find this information on pages 80 and 
81 of the Plans 2022 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 oral 
exams, cleanings, x-rays, fluoride treatments, restorations, extractions and prosthodontics. You can find this 
information on pages 63 through 64 of the Plans 2022 Evidence of Coverage (EOC). 
 
The contract with the dental Plan includes a list of covered dental services. You can find this information on 
pages 149, through 183 of the dental Plan's Benefits for 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 MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the 
following conditions are met (42 CFR 422.100(l)): 
 
1. The MA plan provides all categories of DME covered under original Medicare Part B; 
2. The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
3. The MA plans contracted suppliers provide access to all preferred DME brands; 
4. During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 
90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year; 
5. Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
6. The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
7. The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a nonpreferred 
DME product or brand with the EOC and ANOC and on its website; and 
8. The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by CMS to require full coverage. 
 
You can find this rule at the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 10.12.2. 
 
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 preferred diabetic testing supplies covered under Part B are Contour and Lifescan OneTouch 
products. All other products are covered only with prior authorization. You can find this information on pages 
79-80 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 that Medicare will cover a manual wheelchair for use inside the home (E1037, E1038, E1039, 
E1161, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009) if: 
 
    Criteria A, B, C, D, and E are met; and 
    Criterion F or G is met. 
 
    A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. A mobility limitation is one that: 
 
      1.  Prevents the beneficiary from accomplishing an MRADL entirely, or 
 
      2.  Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to 
the attempts to perform an MRADL; or 
 
      3.  Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
 
    B. The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted 
cane or walker. 
 
    C. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for 
use of the manual wheelchair that is provided. 
 
   D.  Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in MRADLs 
and the beneficiary will use it on a regular basis in the home. 
 
    E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the 
home. 
 
    F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed 
to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of 
strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both 
upper extremities are relevant to the assessment of upper extremity function.  
    G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the 
wheelchair. 
 
You can find this information in the Local Coverage Determination (LCD): Manual Wheelchair Bases 
(L33788). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a seat lift mechanism is covered if all of the following are met: 
 
1. The enrollee must have severe arthritis of the hip or knee or have a severe neuromuscular disease.  
2. The seat lift mechanism must be a part of the treating practitioner's course of treatment and be prescribed to 
improve, or stop deterioration of, the enrollee's condition. 
3. The enrollee must be completely unable to stand up from a regular armchair or any chair in the home.  
4. Once standing, the enrollee must have the ability to walk. 
You can find this information in the Local Coverage Determination (LCD): Seat Lift Mechanisms (L33801). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the POS code 
is generally used to reflect the actual setting where the beneficiary receives the face-to-face service. For 
example, if the physicians 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. In these cases, the correct POS code -- regardless of where the face-to-face service occurs is that of 
the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital 
POS code (at a minimum POS code 19 or 22, for outpatient services performed off campus or on campus) as 
discussed in section 10.5 of this chapter. You can find this information in the Medicare Claims Processing 
Manual, Chapter 26, Section 10.6. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.