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 will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services,
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit does not list
tooth extractions or periapical x-rays as covered services. You can find this information on page 65 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 a bacterial urine culture is used when a patient has clinical signs and symptoms indicative of 
a possible urinary tract infection (UTI). You can find this rule in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations 
(NCD) Manual, Section 190.12.

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 the CMS and CDC confirms that all laboratories are subject to federal regulations cited under the Clinical Laboratory Improvement Amendments (CLIA) statute which has established quality standards for laboratory testing performed on human specimens. Under this statute, laboratories are required to request and maintain records in accordance with CMS specified documentation requirements. The CMS cites specific documentation requirements for laboratory services before tests are performed. Per the CMS, the treating physician must order all laboratory and diagnostic tests for a specified medical diagnosis, and the results of the laboratory and diagnostic tests must be utilized in the treatment of the patient's specified medical problem. To meet this standard, the medical record documentation must include: 

- A physician's order for all tests to be performed. 
- A diagnosis supporting the laboratory and diagnostic tests ordered. 
- Progress notes or office notes. 
- Laboratory results. 
- Attestation or signature log for illegible signature(s) (MLN-ICN 909221)(CMS)(CLIA)(CDC) The CMS Manual further clarifies that special stains, as identified on these claims, are a follow-up test performed after a routine hematoxylin and eosin (H&E) staining. The result of the H&E test must be documented, and the pathology notes must explain why the follow-up special stain test was performed. Cooperation between ordering and referring providers and facilities that perform follow-up tests is crucial to reducing errors and avoiding claim denials. (MLN-ICN 909221)(CMS) Special stains are not covered when: 
- Claim data and documentation does not indicate the presence of signs, symptoms, complaints, or personal history of disease or injury as required for special stains. 
- Claim data and documentation does not indicate the special stain was utilized for the diagnosis or treatment of the patient's illness. 
- Documentation does not verify that the test was ordered by the treating provider. 
- The provider fails to submit documentation showing the reason the test(s) were performed/ordered. 
- Claim data and documentation does not include an ICD-10-CM code appropriate for the ordered test (CMS). 

You can find this guidance in the Medicare Benefit Policy Manual Chapter 15 - Covered Medical and Other Health Services (Centers for Medicare & Medicaid Services Medicare Processing Manual.(CMS);Centers for
Medicare & Medicaid Services Clinical Laboratory Improvement Amendments (CLIA);Medicare Learning Network Fact Sheet; Complying with Documentation Requirements for Laboratory Services, ICN 909221, August 2018.(MLN-ICN 909221 and Centers for Disease Control and Prevention: Clinical Laboratory Improvement Amendments (CLIA) Law & Regulations (CDC).

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 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 $35 copayment for each physician specialist visit for Medicare-covered
services. You can find this information on pages 80-81 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 a $50 copayment for Physician/Practitioner services, including doctor's office visits. You can find this information on page 96 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 the CMS and CDC confirms that all laboratories are subject to federal regulations cited under
the Clinical Laboratory Improvement Amendments (CLIA) statute which has established quality standards for
laboratory testing performed on human specimens. Under this statute, laboratories are required to request and
maintain records in accordance with CMS specified documentation requirements. The CMS cites specific
documentation requirements for laboratory services before tests are performed. Per the CMS, the treating
physician must order all laboratory and diagnostic tests for a specified medical diagnosis, and the results of the
laboratory and diagnostic tests must be utilized in the treatment of the patient's specified medical problem. To
meet this standard, the medical record documentation must include:
- A physician's order for all tests to be performed.
- A diagnosis supporting the laboratory and diagnostic tests ordered.
- Progress notes or office notes.
- Laboratory results.
- Attestation or signature log for illegible signature(s) (MLN-ICN 909221)(CMS)(CLIA)(CDC)
The CMS Manual further clarifies that special stains, as identified on these claims, are a follow-up test
performed after a routine hematoxylin and eosin (H&E) staining. The result of the H&E test must be
documented, and the pathology notes must explain why the follow-up special stain test was performed.
Cooperation between ordering and referring providers and facilities that perform follow-up tests is crucial to
reducing errors and avoiding claim denials. (MLN-ICN 909221)(CMS) Special stains are not covered when:
- Claim data and documentation does not indicate the presence of signs, symptoms, complaints, or
personal history of disease or injury as required for special stains.
- Claim data and documentation does not indicate the special stain was utilized for the diagnosis or
treatment of the patient's illness.
- Documentation does not verify that the test was ordered by the treating provider.
- The provider fails to submit documentation showing the reason the test(s) were
performed/ordered.
- Claim data and documentation does not include an ICD-10-CM code appropriate for the ordered
test (CMS). You can find this guidance in the Medicare Benefit Policy Manual Chapter 15 - Covered Medical
and Other Health Services (Centers for Medicare & Medicaid Services Medicare Processing Manual. (CMS);
Centers for Medicare & Medicaid Services Clinical Laboratory Improvement Amendments (CLIA); Medicare
Learning Network Fact Sheet; Complying with Documentation Requirements for Laboratory Services, ICN
909221, August 2018. (MLN-ICN 909221 and Centers for Disease Control and Prevention: Clinical Laboratory
Improvement Amendments (CLIA) Law & Regulations (CDC).
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 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 $275 copayment for each Medicare-covered one-way trip via ground ambulance. You can find this information on page 57 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 payment may be made for only one screening mammography performed on a woman over age 34, but under age 40. For an asymptomatic woman over age 39, payment may be made for a screening mammography performed after at least 11 months have passed following the month in which the last screening mammography was performed. You can find this rule in the You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 220.4.  

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 we cover one screening mammogram every 12 months for women age 40 or older. You can find this information on page 66 of the 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 one limited exam to evaluate a problem per plan year. This benefit does not list cone beam CT scans or incomplete root canals as covered services. You can find this information on pages 4-79 to 4-92 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 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 for bundled procedures, payment for covered services is always bundled into payment for other services not specified. There will be no relative value units (RVUs), or payment amounts for these codes and no separate payment is ever made. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. 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 30.2.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare 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 that you may see any licensed dental provider who accepts Medicare patients in the U.S. and has not opted out of Original Medicare. You can find this information on pages 45 and 63 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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 health Plan contract says that only manual manipulation of the spine to correct subluxation is covered. Excluded from coverage is any other service other than manual manipulation of the spine to correct subluxation. You can find this information on page 4-12 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 costs of certain ESRD laboratory services performed by either the ESRD facility or an independent 
laboratory are included in the composite rate and are not separately payable. These tests are either performed 
by the facility, in which case payment is included in the composite rate, or by an outside laboratory for the 
facility, in which case the laboratory bills the facility directly. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 8, Section 50.1.

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.
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 screening tests are excluded from coverage. The only exceptions are for the following 
services:

1. screening mammography, 
2. colorectal cancer screening tests,
3. screening pelvic exams, 
4. prostate cancer screening tests, 
5. glaucoma screening exams, 
6. ultrasound screening for abdominal aortic aneurysms (AAA), 
7. cardiovascular disease screening tests, 
8. diabetes screening tests, and
9. screening electrocardiograms, and
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service.

You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64.

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 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 in Chapter 3 on page 3-7 of the plan's 2020 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 20% coinsurance for Medicare-covered Part B chemotherapy, prescription
drugs and immunizations from a network provider. You can find this information on page 87 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 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). 

In the Medicare Managed Care Manual, Chapter 4 Benefits and Beneficiary Protections, 20.3 (MAO Responsibility), 110.1 (Access and Availability Rule), Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services 20.0-40.4 Physician Services and Physician/Practitioner.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.