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 $100 copayment for diagnostic procedures and tests provided at an
outpatient hospital. You can find this information on pages 70 to 73 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.
The rules say that health 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 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 pages 42 to 47 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.
An implantable infusion pump is covered when used to administer anti-spasmodic drugs intrathecally (e.g.,
baclofen) to treat chronic intractable spasticity in patients who have proven unresponsive to less invasive
medical therapy as determined by the following criteria:
As indicated by at least a 6-week trial, the patient cannot be maintained on non-invasive methods of spasm
control, such as oral anti-spasmodic drugs, either because these methods fail to control adequately the spasticity
or produce intolerable side effects. And prior to pump implantation, the patient must have responded favorably
to a trial intrathecal dose of the anti-spasmodic drug.
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication
100-03, Medicare National Coverage Determinations (NCD) Manual Chapter 1, Section 280.14.
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. The contract says see your
Dental fee schedule for comprehensive dental benefit copayments. You can find this information on page 66 of
the Plan's 2021 Evidence of Coverage (EOC).
The contract says Provider office pre-assignment is not required. However, members must visit a Dental Plan
contracted dental office to utilize covered benefits. Your dental office will initiate a treatment plan or will
initiate the specialty referral process with Dental Plan if the services are dentally necessary and outside the
scope of general dentistry. You can find this information on the Dental Plan's 2021 Plan Schedule of Benefits.
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 group 2 support surface is covered if the beneficiary meets at least one of the following
three Criteria (1, 2 or 3):
1. The beneficiary has multiple stage 2 pressure ulcers located on the trunk or pelvis (refer to the ICD-10
code list section in the LCD-related Policy Article for applicable diagnoses) which have failed to
improve over the past month, during which time the beneficiary has been on a comprehensive ulcer
treatment program including each of the following:
a. Use of an appropriate group 1 support surface, and
b. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and
c. Appropriate turning and positioning, and
d. Appropriate wound care, and
e. Appropriate management of moisture/incontinence, and
f. Nutritional assessment and intervention consistent with the overall plan of care
2. The beneficiary has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis (refer to the
ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses),
3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within
the past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable
diagnoses), and has been on a group 2 or 3 support surface immediately prior to discharge from a
hospital or nursing facility within the past 30 days
If the beneficiary is on a group 2 surface, there should be a care plan established by the treating practitioner or
home care nurse which includes the above elements. The support surface provided for the beneficiary should be
one in which the beneficiary does not "bottom out" (see Appendices section).
When a group 2 surface is covered following a myocutaneous flap or skin graft, coverage generally is limited
to 60 days from the date of surgery.
When the stated coverage criteria for a group 2 mattress or bed are not met, a claim will be denied as not
reasonable and necessary.
You can find this in the Local Coverage Determination (LCD): Pressure Reducing Support Surfaces - Group 2
(L33642).
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 $350 copayment for days 1-5 for inpatient hospital care. You can find
this information in Chapter 4 on pages 73 - 74 of the Plan's 2021 Evidence of Coverage (EOC).
The Plan contract also says that enrollees must pay a $250 copayment for ambulance services. You can find
this information in Chapter 4 on pages 61 - 62 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 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 $10 copayment for primary care provider visits. You can find this
information in Chapter 4 on page 52 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).
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 there is a $1,000 deductible which applies to certain items and services. The Plan deductible applies to inpatient hospital care. You can find this information in Chapter 4 on page 57 of the Plan's 2021 Evidence of Coverage (EOC). The Plan contract also says that after the $1,000 deductible has been met, enrollee's must pay an $850 copayment for inpatient hospital care. You can find this information in Chapter 4 on pages 76 - 77 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 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 $500 deductible which applies to certain items and services. The Plan
deductible applies to the diabetic shoes and inserts. You can find this information on page 61 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% coinsurance for Medicare Part B prescription drugs. You can find
this information in Chapter 4 on page 34 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. The contract lists the dental services that are covered. Sleep apnea appliance is not listed and therefore is not a covered service. You can find this information on pages 75 to 77 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 Medicare coverage for this service is limited to patients who have demonstrated a specific
need for this type of cardiac telemetry service. The ordering physician must have determined and documented
that patients who require this service are at low risk for a life-threatening cardiac event. In addition, the medical
record must clearly demonstrate that the results of this testing will provide diagnostic and/or treatment
information useful in the ongoing management of the patient.
The following uses of real-time, outpatient cardiac telemetry are considered medically reasonable and
necessary:
1. Detection, characterization, and documentation of symptomatic transient or paroxysmal dysrhythmia
when the frequency of the symptoms is limited and the use of a 24-hour ambulatory electrocardiogram (ECG)
is documented in the medical record to be unlikely to capture and record the dysrhythmia, or
2. Other testing and/or monitoring/recording/telemetry has been unrevealing. The ordering physician must
document the prior testing performed and the results. This information must be maintained in the patient's
medical record and be available upon request, or
3. Prolonged monitoring is required specifically to ensure the absence of atrial fibrillation prior to the
discontinuation of anticoagulation therapy.
You can find this rule in Local Coverage Determination (LCD): Real-Time, Outpatient Cardiac Telemetry
(L34997).
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 $345 copayment for days 1-5 for inpatient hospital care. You can find
this information in Chapter 4 on pages 21 - 22 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 2
fillings per calendar year. You can find this information on pages 89 to 91 of the Plan's 2021 Evidence of
Coverage (EOC).
The contract also says non-network dentists have not agreed to provide services at contracted fees. If you see
an out of network dentist, the coinsurance level will apply to the average negotiated in network fee schedule
(INFS) in your area. The member is responsible for the difference between the INFS and dentists' charged fees
when visiting an out of network dentist. You can find this information on page 96 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 medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).
The rules say that procedures and examinations which are not covered under the portable x-ray provision include the following: procedures involving fluoroscopy, procedures involving the use of contrast media, procedures requiring the administration of a substance to the patient or injection of a substance into the patient and/or special manipulation of the patient, procedures which require special medical skill or knowledge possessed by a doctor of medicine or doctor of osteopathy or which require that medical judgment be exercised, procedures requiring special technical competency and/or special equipment or materials, routine screening procedures, and procedures which are not of a diagnostic nature. You can find this information in the Medicare Benefit Policy Manual; Chapter 15 80.4.4 - Exclusions from Coverage as Portable X-Ray 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.