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 the use of molecular testing to assess thyroid nodules may be considered medically necessary ONCE per nodule workup when ALL of the following criteria are met: 1. Thyroid fine-needle aspiration(s) (FNA) performed secondary to established indications based on ultrasound characteristics, size and clinical findings 2. Presence of indeterminate thyroid FNA cytopathology described as a. Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) (i.e., Bethesda category III), or b. Follicular neoplasm (FN) or suspicious for a follicular neoplasm (SFN) (i.e., Bethesda category IV) 3. The need for thyroidectomy is unclear after consideration of clinical, imaging, and cytologic features 4. Local institutional malignancy rates are known and used for optimal extrapolation of results to thyroid cancer risk 5. Informed patient willing to potentially undertake surveillance You can find this rule in the Local Coverage Determination (LCD) - Thyroid Nodule Molecular Testing (L38968) - Effective December 1, 2021.
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 pays only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41(a). 

The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. The Plan contract says that we cover up to 24 one-way routine trips for non-emergency, medical-related purposes. You can find this information on page 93 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 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 $290 copayment per date of service regardless of the number of trips by ground or air ambulance. You can find this information on pages 59-60 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 $295 copayment per day for days 1-5, and a $0 copayment for
additional days for inpatient hospital care. You can find this information on page 69 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 Plan contract includes a list of covered supplemental dental services. The contract specifically says that any procedure not listed is not covered. First intraoral periapical x-ray (D0220) and each additional intraoral periapical x-ray (D0230) are not included on this list and are not covered supplemental benefits. You can find this information on pages 4-76 to 4-80 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 facet joint interventions are considered medically reasonable and necessary for the diagnosis
and treatment of chronic pain in patients who meet ALL of the following criteria:
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit
measured on pain or disability scale, and
2. Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive
conservative care management (as tolerated), and
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet
joint synovial cyst)
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of
the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity.
You can find this rule in Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management
(L38773) - Effective April 25, 2021.
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 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.
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 $275 copayment for advanced imaging services at an outpatient hospital facility. You can find this information on page 74 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 some
preventative and comprehensive services that may be subject to limitations in frequency or other exclusions.
Services not listed are not covered The Plan can cover up to one crown procedure per calendar year. You can
find this information on pages 85-86 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 does not list crowns as a covered service. You can find this information on pages 90-91 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 manual wheelchair for use inside the home (K0004) is covered if:
&#8722; Criteria A, B, C, D, and E are met; and
&#8722; Criterion F or G is met.
A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing,
grooming, and bathing in customary locations in the home. A mobility limitation is one that:
1. Prevents the beneficiary from accomplishing an MRADL entirely, or
2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary
to the attempts to perform an MRADL; or
3. Prevents the beneficiary from completing an MRADL within a reasonable time frame.
B. The beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately
fitted cane or walker.
C. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for
use of the manual wheelchair that is provided.
D. Use of a manual wheelchair will significantly improve the beneficiary's ability to participate in
MRADLs and the beneficiary will use it on a regular basis in the home.
E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the
home.
F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities
needed to safely self-propel the manual wheelchair that is provided in the home during a typical day.
Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or
absence of one or both upper extremities are relevant to the assessment of upper extremity function.
G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the
wheelchair.
You can find this rule in the Local Coverage Determination for Manual Wheelchair Bases, L33788 (eff
01/01/20).
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 a power seat elevation feature or power standing feature are non-covered because they are
not primarily medical in nature. You can find this rule in Local Coverage Article (LCA) Wheelchair
Options/Accessories (A52504).
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 pays for ambulance services that meet certain origin and destination requirements. Medicare will cover the following ambulance transportation: 

1. From any point of origin to the nearest hospital or skilled nursing facility (SNF) capable of furnishing appropriate care for a patient's illness or injury; 

2. From a hospital or SNF to a patient's home; 

3. From a SNF to the nearest supplier of medically necessary services not available at the SNF where the patient resides, including the return trip; and 

4. For a patient receiving renal dialysis for end stage renal disease, from the patient's home to the nearest facility that furnishes renal dialysis, including the return trip. You can find these rules at CFR Section 410.40(f).

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 50% coinsurance for optional supplemental benefit/class 3 major services. You can find this information on pages 121-124 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 pays only for ambulance transport. Ambulance vehicles must be designed and
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens,
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You
can find this rule at 42 CFR Section 410.41(a).
The rules say that plans may offer a supplemental benefit to provide transport not covered by original
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the
doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit
covers thirty-two (32) trips, one-way trip or return trip, each year. Each one-way trip or return trip means one
individual trip. You can find this information on page 120 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 Plan contract says that services are covered when medically necessary and based on the benefit limitations and clinical criteria described in the Plan's Office Manager Reference Manual (ORM). You can find this information on page 66 of the Plan's 2021 Evidence of Coverage. 

The ORM includes a list of covered supplemental dental services. Surgical placement of implant body: endosteal implant (D6010), prefabricated abutment (D6056), and abutment supported porcelain fused to metal crown (D6060) are not included on this list and are not covered supplemental benefits. You can find this information on pages 305 to 344 of the Plan's 2021 ORM.