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 a contract plan provider is an agent of the plan. Services and referrals obtained from a plan provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service. If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or item is never covered, the plan does not have to hold the enrollee harmless. For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 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 160.
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 all SNF Part A inpatient services are paid under a prospective payment system (PPS). This involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code. Under the new Patient-Driven Payment Model (PDPM), which is effective for services provided on or after 10/1/2019, the HIPPS code is structured differently, as a result of there being five case-mix adjusted rate components under the revised model. The first position represents the Physical and Occupational Therapy case-mix group. The second position represents the Speech-Language Pathology (SLP) case-mix group. The third character represents the nursing case-mix group. The fourth character represents the Non-Therapy Ancillary (NTA) case-mix group. The fifth character represents the assessment indicator code. You can find this information in the Centers for Medicare and Medicaid Service (CMS), Internet-Only Manual, Medicare Claims Processing Manual, Chapter 6, Sections 10, 30, and 120. The rules also say that in order to report "Active Diagnoses" in Section I of the Minimal Data Set (MDS) assessment form, there must be documentation from a physician which confirms the condition within the past 60 days, and also evidence that the diagnosis has a direct relationship to the resident's current functional cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. You can find this information in the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Chapter 4, Section I.
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 the Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations
Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 stipulates that ventilators (E0465, E0466, and
E0467) are covered for the following conditions:
"Neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic
obstructive pulmonary disease."
Each of these disease categories are comprised of conditions that can vary from severe and life-threatening to
less serious forms. These ventilator-related disease groups overlap conditions described in this Respiratory
Assist Devices LCD used to determine coverage for bi-level PAP devices. Each of these disease categories are
conditions where the specific presentation of the disease can vary from beneficiary to beneficiary. For
conditions such as these, the specific treatment plan for any individual beneficiary will vary as well. Choice of
an appropriate treatment plan, including the determination to use a ventilator vs. a bi-level PAP device, is made
based upon the specifics of each individual beneficiary's medical condition. In the event of a claim review,
there must be sufficient detailed information in the medical record to justify the treatment selected.
Ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and payment policy
requirements preclude FSS payment for devices used to deliver continuous and/or intermittent positive airway
pressure, regardless of the illness treated by the device. (Social Security Act 1834(a)(3)(A)) This means that
products currently classified as HCPCS code E0465, E0466, or E0467 when used to provide CPAP or bi-level
PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in
the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions described in
this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP
(E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions
described in this RAD policy will be denied as not reasonable and necessary.
General principles of correct coding require that products assigned to a specific HCPCS code only be billed
using the assigned code. Thus, using the HCPCS codes for CPAP (E0601) or bi-level PAP (E0470, E0471)
devices for a ventilator (E0465, E0466, or E0467) used to provide CPAP or bi-level PAP therapy is incorrect
coding. Claims for ventilators billed using the CPAP or bi-level PAP device HCPCS codes will be denied as
incorrect codingYou can find this information in the Local Coverage Determination (LCD) Respiratory Assist Devices
(L33800).
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 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 Plan contract also includes a list of covered supplemental dental benefits. The surgical implant placements (D6010), prefabricated abutments (D6056), implant supported crowns (D6086) and retainer crown (D6750) are not on this list and are not covered supplemental benefits. You can find this information on pages 98 and 99 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 does not include
2D oral/facial photographic imaging. You can find this information on page 1 of the Plan's 2021 dental
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. Dental services are only
covered under this benefit when provided by providers in the dental plan network. 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 state that a manual wheelchair for use inside the home is covered if 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.
The beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane
or walker.
The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for use of
the manual wheelchair that is provided.
Use of a manual wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and
the beneficiary will use it on a regular basis in the home.
The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
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.
The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
A heavy duty wheelchair (K0006) is covered if the beneficiary weighs more than 250 pounds or the beneficiary
has severe spasticity.You can find this in the Illinois Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788),
effective January 1, 2020.
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 plans may choose the networks of providers available to enrollees and may require enrollees
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare
Managed Care Manual, Chapter 1, Section 20.2.
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, with limited exceptions, members of the Plan must use network providers to get medical care
and services. The only exceptions are emergencies, urgently needed care when the network is not available
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan
authorizes the use of out-of-network providers. You can find this information on page 29 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 20% coinsurance for each durable medical equipment (DME) item. You
can find this information on page 71 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 $300 copayment per one-way trip for ambulance services. You can find
this information on page 53 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 $20 copayment per day for days 1 to 20, $140 copayment per day for days
21 to 44, and $0 copayment per day for days 45 to 100 of a benefit period for Skilled Nursing Facility (SNF)
Care. For services provided in 2020, you can find this information in Chapter 4 on pages 104 to 105 of the
Plan's 2020 Evidence of Coverage. For services provided in 2021, you can find this information in Chapter 4
on pages 110 to 111 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 $275 copayment for Outpatient hospital services. You can find this
information on page 79 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services,
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes exams
and cleanings, bitewing x-rays, some fillings, simple extractions, palliative care, major restorations such as
crowns, inlays and onlays, dentures and bridges, adjustments and repairs of prosthetics, and endodontics. Any
other dental services not listed are not covered. You can find this information on pages 74-76 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 certain data elements are required to submit a claim under home health prospective payment
system (PPS). A required provider-submitted code is code 85 - County Where Service Is Rendered. Where
required by law or regulation, report the Federal Information Processing Standards (FIPS) State and County
code of the place of residence where the home health service is delivered. You can find this rule in Medicare
Claims Processing Manual Chapter 10, Section 40.2.
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 that when billing multiple units of a Healthcare Common Procedure Coding System
(HCPCS)/Current Procedural Terminology (CPT) code, providers must enter the actual number of units
provided on the claim form. You can find this rule in the Centers for Medicare and Medicaid Services, Internet
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.4.
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 Medicare denies coverage for all cardiovascular genetic risk assessment panels. This rule
can be found in the Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services.
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.