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. 
 
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 covered services include the following when performed by an EyeQuest routine vision care 
provider: Eye refractions during a routine exam. You can find this information on pages 84 to 85 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 does not pay for over-the-counter (OTC) items, including non-prescription drugs. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, 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 The OTC COVID-
19 test demonstration ended on May 11, 2023. Starting on May 12, 2023, Medicare no longer covers or pays 
for OTC COVID-19 tests for those with Medicare Part B benefits. You can find this information at CMS.gov.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
requested item or service but is limited to once per 24 months. You can find this information in the 2023 Dental 
Benefits Chart.
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 
coverage for one complete denture (D5110) and associated dentures every 60 floating months. You can find 
this information in the 2023 Medicare quick reference guide.
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 $45 copayment and a 20% coinsurance for physician/practitioner 
services, including doctor's office visits and durable medical equipment (DME) and related supplies. You can 
find this information on pages 55, 74, and 75 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 state that treatment for lower urinary tract symptoms attributable to benign prostatic hyperplasia 
(LUTS/BPH) treatment will be considered reasonable and necessary when performed ONCE in patients with 
the following: 
 
1. Indications including ALL of the following: 
a. Age less than or equal to 80 
b. Prostate volume of 30-150 cubic centimeters by transrectal ultrasound 
c. Persistent moderate to severe symptoms despite maximal medical management including ALL of the 
following: 
i. International Prostate Symptom Score greater than or equal to 12 
ii. Maximum urinary flow rate of less than or equal to 15 milliliters (voided volume greater than 125 cubic 
centimeters) 
iii. Failure, contraindication or intolerance to at least three months of conventional medical therapy for 
LUTS/BPH 
 
2. Only treatment using a Food and Drug Administration (FDA) approved/cleared device will be considered 
reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Fluid Jet System in the Treatment 
of Benign Prostatic Hyperplasia (BPH) (L38378). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes only 
those items and services specifically listed in your Plan contract. Surgical placement of implant body: endosteal 
implant (D6010) is not covered under the Plans dental benefits. You can find this information on page 84 of 
the Plans 2023 Dental benefit limitations and exclusions guide.
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 
bone replacement grafts. You can find this information in the Plans 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 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 
periodontal scaling and root planing when meeting certain criteria. You can find this information in the 2023 
Dental Benefits Chart.
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 custodial care is not covered. Custodial care is personal care for a person who does not need 
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of 
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, 
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also 
custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
The rules also say that for home health aide services to be covered the services provided must be part-time or 
intermittent. The term part time or intermittent means skilled nursing and home health aide services 
furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day 
and 28 or fewer hours each week. Coverage for less than 8 hours each day and 35 or fewer hours per week is 
subject to review on a case-by-case basis. You can find this information in the Centers for Medicare and 
Medicaid Service, Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, 
Sections 40 and 50.2. 
 
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 Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 to be covered; all hearing aids must be purchased through NationsHearing. You can find this 
information on pages 60 to 61 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 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 life-
saving 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 
doctors 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 10 one-way trips per Plan year. You can find this information on page 54 of the Plans 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 that Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. 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 coverage for blood glucose monitors, and blood glucose test strips is limited to the 
OneTouch products manufactured by LifeScan, Inc. You can find this information on pages 69 to 70 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 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 
coverage for specific dental items/services stated in the Plans contract, but only when they are received from 
an in-network provider. You can find this information on pages 61-63 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). 
 
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 $150 copayment for surgery services at an outpatient hospital. You can 
find this information on pages 63 to 65 of the Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $15 copayment provider and professional services at a 
specialist's office visit. You can find this information on pages 66 to 68 of the Plans 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 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 
coverage for the requested items or services, but only when they are received from an in-network provider. You 
can find this information on page 98 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 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 the Plan has a Point-of-Service (POS) option to use either network providers or out-of-
network providers for certain covered services. Certain covered services may only be received from network 
providers. You can find this information on pages 32-33 of the Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract also says that out-of-network outpatient surgery, including facet joint injections is not 
covered. You can find this information on pages 100-102 of the Plan's 2023 EOC.