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 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 says covered
dental services are subject to the limitations and exclusions described in this section. Dental Services described
in this section are covered dental services when such services are provided by a participating provider in the
Dental Plan's PPO Network. You can find this information on page 119 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 an inpatient rehabilitation facility (IRF) admission when the services
are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary
approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one
therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must
need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program.
This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at
least five days per week. The patient does not need to be expected to achieve complete independence in selfcare nor be expected to return to his or her prior level of functioning. The patient must need supervision by a
rehabilitation physician. The physician must see the patient at least three days per week throughout the stay.
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication
100-02, Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section
412.622.
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 state that effective for services performed on or after March 16, 2018, the Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements are met: a. Patient has: i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and ii. not been previously tested with the same test using NGS for the same cancer genetic content, and iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). b. The diagnostic laboratory test using NGS must have: i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, ii. an FDA-approved or -cleared indication for use in that patient's cancer; and, iii. results provided to the treating physician for management of the patient using a report template to specify treatment options. You can find this rule in the National Coverage Determination (NCD) for Next Generation Sequencing (NGS) (90.2).
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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $0 copayment for Medicare-covered diabetic supplies. Additionally, enrollees must pay a 20% coinsurance for Medicare-covered durable medical equipment with a total rental or purchase price of $500 or more of the Medicare allowable rate per item per month. You can find this information on pages 69-70 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 say that Medicare allows payment for one annual wellness visit (AWV) for enrollees who have not
had an AWV within the past 12 months. You can find this information in the Centers for Medicare and
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter
18, Section 140.
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 an annual wellness visit is covered once every 12 months. You can find this information on
pages 59-60 of the 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 20% coinsurance for Part B drugs. You can find this information on pages
4-33 to 4-35 of the Plan's 2020 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 pays only for ambulance transport. Ambulance vehicles must be designed and
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens,
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other lifesaving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You
can find this rule at 42 CFR Section 410.41(a).
The rules say that plans may offer a supplemental benefit to provide transport not covered by original
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the
doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3.
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 contract
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit
covers up to 24 one-way trips to Plan-approved locations every year. You can find this information on page 89
of the Plan's 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 with the implementation of the ESRD PPS, effective for claims with dates of service on or after January 1, 2011, all ESRD-related laboratory services are included in the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, Section 40.6.
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 we only cover one COVID-19 test per day. You can find this information in the Plan's Coronavirus/COVID-19 Rider (eff. 1/14/22).
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 $290 copayment for outpatient hospital services. 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 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 $400 copayment for outpatient surgery in an outpatient hospital facility.
You can find this information on page 102 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 A non-expandable controller has the following features:
- May have the ability to control up to 2 power seating actuators through the drive control (for example,
seat elevator and single actuator power elevating leg rests). (Note: Control of the power seating
actuators though the Control Input Device would require the use of an additional component, E2310 or
E2311.)
- Can accommodate only an integral joystick or a standard proportional remote joystick
- May allow for the incorporation of an attendant control
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 that Medicare does not pay for gym benefits. Gym benefits include exercise classes, such as Tai
Chi, yoga, and dance classes. You can find this rule in the Centers for Medicare and Medicaid Services,
Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3.
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 also says the Plan covers a health and wellness education programs through the Plan's fitness provider
that offers three fitness programs: the Plan's fitness provider's participating fitness centers provide access to
standard services and amenities. The Plan's fitness provider provides an annual reimbursement allowance
towards paid memberships at non-participating fitness clubs and exercise centers. Payment requests should be
submitted after that month has passed, but within 90 days of the end of the calendar year. Future months of
membership cannot be processed (for example, submit receipts for January on or after February 1st). To be
reimbursed, submit an out-of-network reimbursement form, a fitness facility member verification form, and
paid receipts directly to the Plan's fitness provider's customer service. A non-refundable annual fitness
membership fee of $25 is payable directly to the Plan's fitness provider's customer service over the phone or
online using a debit or credit card. An annual non-refundable fee of $10 is payable directly to the plan's
customer service over the phone or online using a debit or credit card. Members can choose BOTH
membership at a participating fitness center AND 1 Home Fitness Kit. You will be reimbursed up to an annual
allowance of $150. You cannot simultaneously enroll in an in-network and an out-of-network fitness facility.
You can change facilities each month. You can find this information on page 67 of the Plan's 2021 Evidence of
Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $65 copayment for urgent care services. You can find this information on page 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 total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. You can find this information in Medicare's Local Coverage Determination (LCD): Hospital Beds and Accessories (L33820).
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 no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 15, Section 15.1.
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).
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 you can receive your care from either a network provider or an out of network provider. While you can get your care form an out of network provider, the provider must be eligible to participate in Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. You can find this information on page 43 of the plans 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 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
The Appeal Number is:
1-10949780096
The Appeal Number is:
1-10949780096
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Grievance Manual, Section 50.12.1.
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable
and necessary. 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 50.4.1.
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must
show that the step therapy drugs have been ineffective in treating the enrollee; or are likely to be ineffective or
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or
other harm to the enrollee.
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42
CFR Sections 422.2 and 422.136.
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.