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 $15 copayment for x-rays performed at a specialist office. You can find 
this information on page(s) 86 of the Plan's 2023 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 $1180 copayment for inpatient hospital care. You can find this 
information on page(s) 43 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 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 $35 copayment for physician/practitioner services, including doctors 
office visits. You can find this information on page(s) 80 to 81 of the Plan's 2023 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 $25 copayment for physician/practitoner services, including doctors 
office visits. You can find this information on page(s) 77 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 current available body of evidence demonstrates that  cardiac CT angiography (CCTA) can 
reliably rule out the presence of significant coronary artery disease (CAD) in patients with a low to 
intermediate probability of having CAD and can reliably achieve a high degree of diagnostic accuracy and 
technical performance necessary to replace conventional angiography. 
 
You can find this rule in the Local Coverage Determination (LCD): Cardiac Computed Tomography (CCT) 
and Coronary Computed Tomography Angiography (CCTA) (L33559). 
 
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 $25 copayment for physician/practitioner services/specialist. You can 
find this information on page(s) 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 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 per day, for days 1 to 4 for Medicare-covered hospital 
care each time you are admitted. You can find this information on page 4-23 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 Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars.  
 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1.  
 
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 all End-Stage Renal Disease (ESRD) claims with dates of service on or after July 1, 2010 must 
indicate the applicable Kt/V reading for the dialysis patient. The reading result and the date of the reading must 
be reported on the claim using the following claim codes: 
 
Value Code D5 - Result of last Kt/V reading. For in-center hemodialysis patients this is the last reading taken 
during the billing period. For peritoneal dialysis patients and home hemodialysis this may be before the current 
billing period but should be within 4 months of the claim date of service. 
 
This code is effective and required on all ESRD claims with dates of service on or after July 1, 2010. In the 
event that no Kt/V reading was performed providers must report the D5 with a value of 9.99. 
 
Occurrence Code 51 - Date of last Kt/V reading. For in-center hemodialysis patients, this is the date of the last 
reading taken during the billing period. For peritoneal dialysis patients and home hemodialysis patients, this 
date may be before the current billing period but should be within 4 months of the claim date of service. This 
code is effective for ESRD claims with dates of service on or after July 1, 2010. This code not required when 
reporting value code D5 with a value of 9.99 indicating no Kt/V reading is available for reporting or value 8.88 
to indicate the patient is prescribed and receiving greater than 3 hemodialysis treatments per week for a medically justified and documented clinical need. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 8, Section 50.9. 
 
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).  
 
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 there is a $650 deductible which applies to certain items and services. The Plan 
deductible applies to out-of-network physician/practitioner services. You can find this information on pages 
45-46 of the Plan's 2023 Evidence of Coverage (EOC).   
 
The Plan contract also says that enrollees must pay 30% coinsurance after meeting the deductible for out-of-
network primary care office visits. You can find this information on pages 74-75 of the Plans 2023 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 all items and nonphysician services furnished to inpatients must be furnished directly by the 
hospital or billed through the hospital under arrangements. You can find this information in the Centers for 
Medicare and Medicaid Service, Internet-Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 3, Section 10.4. 
 
Ambulance services are separately reimbursable only under Part B. Once a beneficiary is admitted to a hospital 
it may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care 
while the beneficiary maintains inpatient status with the original provider. This movement of the patient is 
considered "patient transportation" and is covered as an inpatient hospital and payment is made under Part A 
for that service. Because the service is covered and payable as a beneficiary transportation service under Part 
A, the service cannot be classified and paid for as an ambulance service under Part B. You can find this 
information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 15, Section 10.4 
 
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).  
 
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 there is a $1000 deductible which applies to certain items and services. The Plan 
deductible applies to an in-network injection. You can find this information on pages 60 and 94 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 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).  
 
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 there is a $750 deductible which applies to certain items and services. The Plan 
deductible applies to the echocardiogram. You can find this information on page 54 of the Plan's 2023 
Evidence of Coverage (EOC).   
 
The Plan contract also says that enrollees must pay a $20 copayment after the deductible is met for each basic 
imaging service. You can find this information on page 88 of the Plan's 2023 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).  
 
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 there is a $400 deductible which applies to certain items and services. The Plan 
deductible applies to outpatient diagnostic service. You can find this information on pages 66 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 state that Medicare covers pneumatic devices when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. You can find 
this in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare 
National Coverage Determinations Manual, Chapter 1, Section 280.6. 
 
A PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with 
chronic and severe lymphedema when all of the following three requirements are met: 
 
    The beneficiary has a diagnosis of lymphedema as defined above, and 
    The beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence 
of at least one of the following clinical findings: 
        Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
        Papillomatosis cutis lymphostatica, 
        Deformity of elephantiasis, 
        Skin breakdown with persisting lymphorrhea, 
        Detailed measurements over time confirming the persistence of the lymphedema with a history evidencing 
a likely etiology, and 
    In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other 
clinical treatment over the course of a required four-week trial. (See below for trial guidelines.) 
 
A PCD coded as E0650 or E0651 used to treat lymphedema that does not meet all of the requirements above is 
not eligible for reimbursement. Claims will be denied as not reasonable and necessary. 
 
A PCD coded as E0650 or E0651 used to treat edema from causes other than lymphedema is not eligible for 
reimbursement. Claims will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Pneumatic Compression Devices 
L33829 
 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 Plan 
contract says they offer a supplemental benefit of anti-glare lens coating, once per year, photochromic 
("transition") lens tinting, once per year, progressive (no-line) lenses, once per year. Note: The plan does not cover an extra pair of glasses, protective coating for plastic lenses, and contact lens supplies. You can find this 
information on pages 123 to 124 of the Plan's 2023 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 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules state that Medicare Part B coverage is available for outpatient Opioid Treatment Program (OTP) 
services provided by hospitals, critical access hospitals (CAHs), and Free-Standing Opioid Treatment Program 
facilities. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 39, section 50. 
 
The rules state that beginning January 1, 2020, claims for OTP services are submitted using the 837P 
transaction to transmit health care claims electronically, or using the CMS-1500 (the paper version of the 
837P). Beginning January 1, 2021, OTPs may apply on the Medicare Enrollment Application for Institutional 
Providers (CMS-855A) or through the Internet-based Provider Enrollment, Chain and Ownership System 
(PECOS) (837I) when they enroll in the Medicare Program. These providers will submit claims using the 
CMS-1450. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 39, section 40. 
 
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.