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 plans may choose the networks of providers available to enrollees and may require enrollees
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare
Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care
and services. The only exceptions are emergencies, urgently needed care when the network is not available
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan
authorizes the use of out-of-network providers. You can find this information on pages 3-3 and 3-4 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 indications for lumbar fusion include any of the following.
A patient must have at least 1 of the following:
1. Radiographic or clinical evidence of instability due to any 1 of the following:
a. Congenital deformities,
b. Trauma,
c. Fractures,
d. Chronic degenerative conditions,
e. Tumor,
f. Infection,
g. Erosive conditions,
h. Space-occupying lesions, or
i. Iatrogenic causes, including expected instability as a consequence of another medically necessary spine procedure.
If more than 1 level is fused under this indication, the record must reflect that each fused level is affected by 1 of the above conditions.
2. Symptomatic spinal deformity (in the absence of instability or neural compression) which meets the following criteria:
Both of the first 2 criteria must be met:
a. Functional limitation in daily activities due to back pain or discomfort and
b. Nonresponse to at least 1 year of non-operative treatment
Any 1 of these 3 criteria must be met:
c. Sagittal or coronal imbalance by at least 5 cm as measured on radiographic imaging of the entire spine, or
d. Progression of deformity by at least 10 degrees, or
e. Scoliotic curvature of greater than 30 degrees
3. Revision surgery for pseudarthrosis following an initial spine surgery if the following conditions are all met.
a. The patient had a period of reduced pain initially following surgery and
b. The time since the prior surgery has been at least 1 year and
c. There is clear radiographic evidence of pseudarthrosis and
d. The patient has exhausted available conservative treatment measures
The medical record must clearly reflect which conservative treatments the patient has tried or is not a candidate for and why, including medical therapies, physical and exercise therapies and injections.
Outcomes for fusion in revision surgery, usually do not lead to pain relief and as such fusion is considered a last resort treatment option only when all other treatment options have failed. This information must be communicated to the patient prior to surgery to allow for appropriate shared decision making with a well-informed patient. The medical record must reflect that this counseling was done and that the patient wished to undergo surgery with the appropriately informed consent.
4. Symptomatic compression of neural elements for which disc excision is necessary for decompression. The record must reflect disc compression of neural elements for each level fused based on this indication.
You can find this in the Local Coverage Determination (LCD): Lumbar Spinal Fusion (L37848).
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 $10 copayment for telephonic and web-based medical consultation, diagnosis and/or treatment of urgent conditions. You can find this information on page 112 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 cleanings, routine oral exams, comprehensive oral exams, and bitewing x-rays. Problem focused limited oral evaluation (D0140) and panoramic x-rays (D0330) are not included on this list and are not covered benefits. You can find this information on page 77 of the Plan's 2020 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 effective for services performed on or after April 4, 2005, cochlear implantation may be
covered for treatment of bilateral pre- or-post-linguistic, sensorineural, moderate-to-profound hearing loss in
individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined
by test scores of less than or equal to 40% correct in the best-aided listening condition on tape-recorded tests of
open-set sentence cognition. Medicare coverage is provided only for those patients who meet all of the
following selection guidelines.
- Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from
appropriate hearing (or vibrotactile) aids;
- Cognitive ability to use auditory clues and a willingness to undergo an extended program of
rehabilitation;
- Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to
implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous
system;
- No contraindications to surgery; and
- The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling.
You can find this in the National Coverage Determination (NCD): Cochlear Implantation (50.3).
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 the Correct Coding Initiative was developed to promote correct coding and to control improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9.
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 allows payment for one annual wellness visit (AWV) for enrollees who have not 
had an AWV within the past 12 months. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
18, Section 140.

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 the plan covers an annual routine physical exam. You can find this information on page 
4-8 of the 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services,
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes periodic
oral exam(s), preventive cleaning(s), and bitewing dental x-ray(s). Panoramic x-ray (D0330) is not included on
this list and is not a covered benefit. You can find this information on page 63 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 each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the patient's continuing need for home care. You can find this information in the 42 CFR, 484.55.
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
periodontal maintenance two times every 12 months. You can find this information on pages 71-72 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 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 Medicare covers application of skin substitutes to Ulcers or Wounds with Failed Response 
that are:

- Partial- or full-thickness ulcers, not involving tendon, muscle, joint capsule or exhibiting exposed bone or 
sinus tracts, with a clean granular base;
- Skin deficit at least 1.0 square centimeter (cm) in size;
- Clean and free of necrotic debris or exudate; Have adequate circulation/oxygenation to support tissue 
growth/wound healing as evidenced by physical examination (e.g., Ankle-Brachial Index [ABI] of no less than 
0.60, toe pressure greater than 30 millimeters of mercury [mmHg]);
- For diabetic foot ulcers, the patient's medical record reflects a diagnosis of Type 1 or Type 2 Diabetes and 
also reflects medical management for this condition.

Application of a skin substitute graft for lower extremity chronic wound (DFU and VLU) will be covered when 
the following conditions are met for the individual patient:

-Presence of neuropathic diabetic foot ulcer(s) having failed to respond to documented conservative wound-
care
measures of greater than four weeks, during which the patient is compliant with recommendations, and without 
evidence of underlying osteomyelitis or nidus of infection.
-Presence of a venous stasis ulcer for at least 3 months but unresponsive to appropriate wound care for at least
30 days with documented compliance.
-Presence of a full thickness skin loss ulcer that is the result of abscess, injury or trauma that has failed to
respond to appropriate control of infection, foreign body, tumor resection, or other disease process for a period
of 4 weeks or longer.

You can find this rule in the Centers for Medicare and Medicaid Services, Internet Manual, Local Coverage 
Determinations (LCD) (L35041): Application of Bioengineered Skin Substitutes to Lower Extremity Chronic 
Non-Healing Wounds. 

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 except in an emergency, the hospital, your physician, or you must obtain prior authorization from the Plan for inpatient hospital care. The Plan contract also says that enrollees must pay an $80 copayment for outpatient hospital services. The Plan contract also says that enrollees must pay a $25 copayment for each in-person specialist visit. You can find this information on pages 88, 94, and 99 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.

Medicare rules state that devices listed by the Food & Drug Administration (FDA) as electro-acupuncture 
devices used for stimulation of auricular acupuncture points are non-covered. Acupuncture for stimulation of 
auricular points is not a covered Medicare benefit. An electrical nerve stimulation (percutaneous nerve field 
stimulator (PNFS) system) is described as nearly identical to an electronic auricular device for a different 
intended use. This device is non-covered by Medicare when used for acupuncture for any indication. You can 
find these rules in Local Coverage Article (LCA) Billing and Coding: Auricular Peripheral Nerve Stimulation 
(Electro-Acupuncture Device) (A55240).

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 also says the Plan lists all covered procedures. Any code not listed is not covered. You receive bitewing x-rays, intraoral periapical x-rays and endodontic therapy once per calendar year. A prefabricated post and core in addition to a crown and a 2D oral/facial photographic image are not listed and therefore, not covered services. Additionally, you receive an annual maximum of $2,000 per calendar year, for dental services. You can find this information on pages 88-90 of the Plan's 2020 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, 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 37 to 41 of the Plan's
2021 Evidence of Coverage.