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. 
 
The rules say that when services or supplies are rendered by a non-contracting, original Medicare, participating 
provider, there is no balance billing paid by either the Plan or the enrollee. 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, 170.2. 
 
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 35% coinsurance for out-of-network inpatient hospital care. You can find 
this information in Chapter 4 on pages 76 to 77 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 to qualify for home health services, the patient must be: 
 
1. Confined to the home;  
2. Under the care of a physician or allowed practitioner;  
3. Receiving services under a plan of care established and reviewed by a physician;  
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) 
continuing occupational therapy.  
You can find this rule at 42 CFR Section 409.42. 
 
The rules say that eligibility for the home health benefit will be determined based on the certifying physician or 
allowed practitioners records. If the enrollee was directly admitted to home health from an acute or post-acute 
care facility, the facility records may be used instead. The medical records for the enrollee must contain 
information that justifies the referral for home health services. 
  
The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the 
enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face 
encounter visit. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and 
30.5.1.2. 
 
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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. 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(A). 
 
The rules also say that the phrase "new patient" is interpreted to mean a patient who has not received any 
professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the 
physician or physician group practice (same physician specialty) within the previous 3 years. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing 
Manual, Chapter 12, Section 30.6.7. 
 
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 $550 copayment for outpatient hospital facility visits. You can find this 
information on page(s) 81-82 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). 
 
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 $1000 deductible which applies to certain items and services. The Plan 
deductible applies to outpatient mental health services. You can find this information on page 56 of the Plan's 
2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that for a Blepharoplasty to be covered, documentation must include relevant medical history, 
physical examination, and results of pertinent diagnostic tests or procedures. Visual fields must be recorded 
using either a tangent screen visual field, Goldmann Perimeter (III 4-E test object), or a programmable 
automated perimeter, equivalent to a screening field with a single intensity strategy using a 10dB stimulus, to 
test a superior (vertical) extent of 50-60 degrees above fixation with targets presented at a minimum four-
degree vertical separation starting at zero (0) degrees above fixation while using no wider than a 10-degree 
horizontal separation. This information is found in Medicare Local Coverage Article: Blepharoplasty - Medical 
Policy Article (A52837). 
 
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 blepharoplasty, blepharoptosis repair, and brow ptosis repair (brow lift) are surgeries that 
may be functional (i.e., to improve abnormal function) and therefore reasonable and necessary, or cosmetic 
(i.e., to enhance appearance). These surgeries (either individually or in the minimum combination required to 
achieve a satisfactory surgical outcome) are functional when overhanging skin or upper lid position secondary 
to dermatochalasis, blepharochalasis, blepharoptosis, or pseudoptosis is sufficiently low to produce a visually-
significant field restriction considered by this policy to be approximately 30 degrees or less from fixation. 
Published literature correlates this amount of field restriction with a Margin Reflex Distance (MRD) of 2.0 mm 
or less. 
 
For Upper Blepharoplasty and/or Brow Ptosis Repair: 
 Redundant eyelid tissue hanging over the eyelid margin resulting in pseudoptosis where the pseudo 
margin produces a central "pseudo-MRD" of 2.0 mm or less, or 
 Redundant eyelid tissue predominantly medially or laterally that clearly obscures the line of sight in 
corresponding gaze. 
 
In the expected to be rare circumstance where a patient would fail the MRD criterion for a given surgery but 
the provider feels that visual field testing would, despite that fact, support performance of surgery for a 
functional reason, this can be considered on appeal. If an anatomic abnormality of the eye (such as an eccentric 
or elongated pupil) makes the MRD either difficult to establish or meaningless for this purpose, it is expected 
the surgeon will include a statement outlining his or her rationale that an equivalent standard has been met. 
  
Photographs of the affected eyelid(s) in both frontal (straight ahead) and lateral (from the side) positions 
demonstrate the physical signs in Section A. Oblique photos are only necessary if needed to better demonstrate 
a finding not clearly shown by frontal and lateral photos. You can find this rule in the Local Coverage 
Determination for Blepharoplasty, Eyelid Surgery, and Brow Lift, L36286 
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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. 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(A). 
 
The rules say that under the home health prospective payment system as refined by the Patient-Driven 
Groupings Model, a case-mix adjusted payment for a 30-day period of care is made using one of 432 home 
health resource groups (HHRGs). On Medicare claims, these HHRGs are represented as Health Insurance 
Prospective Payment System (HIPPS) codes. HIPPS code rates represent specific characteristics (or case-mix) 
on which Medicare payment determinations are made. HIPPS codes are used in association with special 
revenue codes used on institutional claims submitted to A/B MACs (HHH). For HH PPS periods of care, the 
distinct 5-position, alphanumeric home health HIPPS codes are created as follows: 
 The first position represents a combination of the referral source (community or institutional) and the 
period timing (early or late). 
 The second and third positions represent the clinical and functional domains of the HHRG coding 
system. 
 The fourth position represents the co-morbidity category that applies to the patient. 
 The fifth position is a placeholder for future use, required only because the field used to report HIPPS 
codes requires five positions. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.1.8-9.  
 
The rules say that each 30-day period of care will be classified into one of two admission source categories, 
community or institutional, depending on what healthcare setting was utilized in the 14 days prior to home 
health. Thirty-day periods of care for beneficiaries with any inpatient acute care hospitalizations, inpatient 
psychiatric, inpatient rehabilitation, skilled nursing facility, or long-term acute care hospital stays within 14 
days prior to a home health admission will be designated as institutional admissions. You can find this rule in 
the Federal Register, Volume 84, No 217.  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 to be payable, the medical record and the information on the claim form must consistently 
and  accurately report covered therapy services, as documented in the medical record. Documentation must be 
legible, relevant and sufficient to justify the services billed. In general, services must be covered therapy 
services provided according to Medicare requirements. Medicare requires that the services billed be supported 
by documentation that justifies payment. Documentation must comply with all requirements applicable to 
Medicare claims. You can find this rule in the Center for Medicare Services (CMS) Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 15, Section 220.3. 
 
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.
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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. 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(A). 
 
The rules say that effective January 1, 2018, anesthesia services furnished in conjunction with and in support of 
a screening colonoscopy are reported with CPT code 00812 and coinsurance and deductible are waived. When 
a screening colonoscopy becomes a diagnostic colonoscopy, anesthesia services are reported with CPT code 
00811 and with the PT modifier; only the deductible is waived. You can find this rule in the Local Coverage 
Article (LCA) - Billing and Coding: Colorectal Cancer Screening - Medical Policy Article (A52378). 
 
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 canes (E0100, E0105) and crutches (E0110, E0111, E0112, E0113, E0114, E0116) are 
covered if all of the following criteria (1-3) are met: 
 
    The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADL) in the home. 
 
The MRADLs to be considered in this and all other statements in this policy are toileting, feeding, dressing, 
grooming, and bathing performed in customary locations in the home. 
 
A mobility limitation is one that: 
 
        Prevents the beneficiary from accomplishing the MRADL entirely, or, 
        Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the 
attempts to perform an MRADL; or, 
        Prevents the beneficiary from completing the MRADL within a reasonable time frame; 
 
And, 
 
    The beneficiary is able to safely use the cane or crutch; and, 
    The functional mobility deficit can be sufficiently resolved by use of a cane or crutch. 
 
If all of the criteria are not met, the cane or crutch will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Canes and Crutches L33733. 
 
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 providers/suppliers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. 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(A).
The rules say that carriers may not pay for the technical component (TC) of radiology services furnished to hospital patients. Payment for physicians' radiological services to the hospital, e.g., administrative or supervisory services, and for provider services needed to produce the radiology service, is made by the fiscal intermediary (FI)/AB MAC to the hospital as a provider service. Radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 13, 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.
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 ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device is made 
based upon the specifics of each persons medical condition. There must be enough detailed information in the 
medical record to justify the treatment selected. Claims for ventilators used to provide continuous positive 
airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this Respiratory Assist Devices 
(RAD) policy will be denied as not reasonable and necessary. One of the conditions described in the RAD 
policy is chronic obstructive pulmonary disease (COPD). You can find this rule 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. 
 
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 20% coinsurance for each Medicare-covered medical supply. Supplies for which an appropriate separate charge is made by providers (such as, chemical agents used in certain diagnostic procedures) are subject to cost-sharing as shown. You can find this information on page 4-41 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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2. 
 
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 health 
Plan contract says that you can receive your care from either a network provider or an out of network provider. 
While you can get your care form an out of network provider, the provider must be eligible to participate in 
Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the 
full cost of the services you receive. You can find this information on page 38 of the Plans 2022 Evidence of 
Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that compression burn garments (A6504) are covered under the Surgical Dressings benefit when 
they are used to reduce hypertrophic scarring and joint contractures following a burn injury. You can find this 
information in the Local Coverage Article: Surgical Dressings - Policy Article (A54563). 
 
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.