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 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 up to 24 one-way routine transportation trips per year. Each one-way trip must not exceed 50 miles of 
driving distance. You can find this information on page 4-53 of the Plans 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 your in-network maximum out-of-pocket amount is $6,700. This is the most you pay during 
the calendar year for covered Medicare Part A and Part B services received from network providers. The 
amounts you pay for copayments and coinsurance for covered services from network providers count toward 
this in-network maximum out-of-pocket amount. Once you have paid $6,700 for covered Part A and Part B 
services from network providers, you will not have any out-of-pocket costs for the rest of the year when you 
see our network providers. You can find this information on page 4-2 of the Plan's 2021 Evidence of Coverage 
(EOC). 
 
The Plan contract also says that enrollees must pay 20% coinsurance for each Medicare-covered Part B drug. 
Additionally, for the administration of that drug, you will pay the cost-sharing that applies to primary care 
provider services, specialist services, or outpatient hospital services. You can find this information on page 4-
34 of the Plan's 2021 EOC.  
 
The Plan contract also says that enrollees must pay $395 copayment for Medicare-covered surgery or other 
services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility 
charges and physician or surgical charges. You can find this information on page 4-50 of the Plan's 2021 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 the plan of care, for a 90 day episode of care, is based on the treating physicians 
assessment. The minimum evaluation that must be documented includes the history, physical examination, 
CEAP clinical classification, VCSS, and a venous duplex scan documenting the venous flow. 
 
Supplemental plethysmography, contrast venography, venous pressure measurements, intravascular ultrasound 
(IVUS), computed tomography (CT) venography, or magnetic resonance (MR) venography may be relevant to 
the plan of care in patients with severe or unusual presentations of venous disease in which there is possible 
concurrent involvement of pelvic veins or arterial-venous malformations or fistulae. Indications for these more 
extensive procedures should be documented in the plan of care. 
 
You can find this information in the Local Coverage Determination (LCD) Treatment of Chronic Venous 
Insufficiency of the Lower Extremities L34924. 
 
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 MRIs are covered when medically necessary and reasonable for the diagnosis or treatment of 
the specific patient involved. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 220.2(B). 
 
Lumbar MRI may be indicated for a patient with a red-flag condition, such as a suspected tumor, infection, 
herniated intervertebral disc with nerve compression, or a major neurological problem. The MRI test result may 
be needed to evaluate these conditions to determine the need for surgery or other aggressive therapy, such as a 
work- up for metastatic cancer. 
 
"Red flags" are identified through an appropriate history plus a physical examination that typically includes 
evaluating muscle strength, limb circumference, reflexes, sensation, straight leg raise, and sitting knee 
extension tests. 
 
Eighty (80) to ninety (90) percent of patients with low back pain improve one month after symptom onset even 
without treatment. Therefore, spinal imaging tests are not generally necessary during the first month of 
symptoms except when a "red flag" (suggesting a medically emergent condition) is noted on the medical 
history and physical examination. For a "non-red flag" condition, the MRI may be appropriate after 1 month of 
symptoms. 
 
For example, for a patient with low back pain syndrome where there is no known injury, history of cancer, or 
septic disorder and there are no symptoms or signs suggesting nerve root disorder or spinal cord dysfunction 
(i.e. no "red flags"), MRI will be covered only if the patient has not responded to a reasonable trial of 
conservative management lasting at least four weeks.  
 
You can find this information in the Local Coverage Determination (LCD): Lumbar MRI (L37281). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a stress echocardiogram is reasonable and necessary in additional to an electrical stress test 
in the following instances: 
 
1. An electrical stress test alone is not useful or effective, and a stress echocardiogram is needed. Such 
circumstances may include: 
 
-An abnormal resting electocardiogram (ECG) due to digitalis, left ventricular hypertrophy, bundle branch 
block, preexcitation syndrome (Wolff-Parkinson-White), electronically paced ventricular rhythm, or greater 
than 1 mm of resting ST depression; 
-A prior equivocal stress ECG; or 
-A history of posterior wall myocardial infarction. 
 
2. The patient has significant valvular heart disease, and measuring the physiologic changes with exercise is 
necessary to determine the need for a valve intervention, 
3. When needed to determine the significance or the extent of myocardial ischemia (or scar), or to assess 
myocardial viability (e.g., risk stratification following acute myocardial infarction), 
4. When information from the clinical assessment and an electrical stress test does not adequately assess 
functional capacity, and such information is needed to manage the patient (e.g., for a patient with angina and 
left bundle branch block to assess the level of exercise tolerance for treatment planning), 
5. When needed to aid in diagnosis of hypertrophic or dilated cardiomyopathy, 
6. When needed to differentiate ischemic from non-ischemic cardiomyopathy, 
7. As part of a preoperative evaluation of a patient who is at intermediate or high risk for CAD when the 
surgery is likely to induce significant cardiac stress. 
 
You can find this rule in the Local Coverage Determination (LCD) - Cardiovascular Stress Testing, Including 
Exercise and/or Pharmacological Stress and Stress Echocardiography (L36889) - Effective October 1, 2019. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 pages 14-17 of the Plan's 2022 
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 dentures once every five plan years. You can find this information on pages 4-72 nd 4-73 of the 
Plans 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $180 copayment for a mammography. You can find this information in 
Chapter 4 on pages 82-83 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). 
 
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. 
 
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. 
 
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 $10 copayment for each Medicare-covered primary care provider visit. 
You can find this information on page 100 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 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. 
 
Medically Unlikely Edits (MUEs) for HCPCS codes with an MUE Adjudication Indicator (MAI) of 3 are 
per day edits based on clinical benchmarks. MUEs assigned an MAI of 3 are based on criteria (e.g., nature 
of service, prescribing information) combined with data such that it would be possible but medically highly 
unlikely that higher values would represent correctly reported medically necessary services. If contractors have 
evidence (e.g., medical review) that units of service (UOS) in excess of the MUE value were actually provided, 
were correctly coded and were medically necessary, the contractor may bypass the MUE for a HCPCS code 
with an MAI of 3 during claim processing, reopening, or redetermination, or in response to effectuation 
instructions from a reconsideration or higher-level appeal. 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(V). 
 
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 if medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG) 
Positron Emission Tomography (PET) scan to determine the initial level of cancer treatment needed for an 
enrollee. After the completion of the initial anti-cancer therapy, additional FDG PET scans may be covered at 
the discretion of Medicare.  
 
Initial Anti-Tumor Treatment Strategy Nationally Non-Covered Indications 
 
CMS continues to nationally non-cover initial anti-tumor treatment strategy in Medicare beneficiaries who 
have adenocarcinoma of the prostate. 
CMS continues to nationally non-cover FDG PET imaging for diagnosis of breast cancer and initial staging of 
axillary nodes. 
CMS continues to nationally non-cover FDG PET imaging for initial anti-tumor treatment strategy for the 
evaluation of regional lymph nodes in melanoma. 
CMS continues to nationally non-cover FDG PET imaging for the diagnosis of cervical cancer related to initial 
anti-tumor treatment strategy. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, National Coverage Determinations Manual, Section 220.6.17. 
 
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 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 also says you have a $500 combined in and out of network maximum benefit coverage amount for 
both hearing aid(s) (all types) up to 2 every 3 years. You can find this information on page 93 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 20% coinsurance for Part B chemotherapy drugs. You can find this 
information on pages 95-96 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. 
 
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). 
 
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 
offers a supplemental (extra) benefit to cover routine vision services that are not covered by Original Medicare. 
This benefit includes a $0 copayment for up to 1 pair of eyeglass lenses (standard, plastic single, bifocal, 
trifocal or lenticular lenses) once every two calendar years. The Plan will also pay up to $200 every two calendar years for eyeglass frames or contact lenses.  
 
For upgrades to eyeglass lenses and contact lenses: a $15 copay applies to UV treatment, tint, or standard 
plastic scratch coating. A $65 copay applies to standard and premium progressive lenses and standard anti-
reflective coating. You can find this information on page 92 of the Plan's 2022 Evidence of Coverage.