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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 vision benefits are only covered by the Plan if you use a network provider. You can find 
this information on pages 86-87, and 91-92 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 state that to repair means to fix or mend and to put the equipment back in good condition after 
damage or wear. Repairs to equipment which a beneficiary owns are covered when necessary to make the 
equipment serviceable. If the expense for repairs exceeds the estimated expense of purchasing or renting 
another item of equipment for the remaining period of medical need, no payment can be made for the amount 
of the excess. Equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss 
or irreparable damage. Irreparable wear refers to deterioration sustained from day-to-day usage over time and a 
specific event cannot be identified. In the absence of program instructions, Medicare contractors may 
determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years. Replacement 
due to wear is not covered during the reasonable useful lifetime of the equipment. During the reasonable useful 
lifetime, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically 
necessary equipment owned by the beneficiary. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, 
Section 110.2. 
 
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 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 Medicare Part B prescription drugs. You can find 
this information in Chapter 4 on page 102 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 beginning January 1, 2020, claims for opioid treatment program (OTP) services are 
submitted using the 837P transaction to transmit health care claims electronically. Procedure codes G2067-
G2075 cover episodes of care of 7 continuous days and cannot be billed for the same patient more than once 
per 7 continuous day period. Claims for OTP services should use Place of Service (POS) code 58 (Non-
residential Opioid Treatment Facility  a location that provides treatment for Opioid Use Disorder (OUD) on 
an ambulatory basis. Services include methadone and other forms of medication assisted treatment). You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 39, Sections 40 and 40.1. 
 
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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that there is a $300 deductible which applies to certain items and services. The Plan 
deductible applies to an office visit. You can find this information page 1 of the Plan's 2022 Schedule of Cost 
Sharing. 
 
The Plan contract also says that enrollees must pay 20% of the total cost for each Medicare-covered primary 
care doctor visit. You can find this information on page 36 of the Plan's 2022 Schedule of Cost Sharing.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
The rules say that Contract suppliers are not required to furnish a specific brand name item or mode of delivery 
to a beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical outcome. 
You can find this information in the Medicare Claims Processing Manual, Chapter 36, Section 30.4 - 
Prescription for Particular Brand, Item, or Mode of Delivery 
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 diabetic supplies made by OneTouch/LifeScan. OneTouch/LifeScan glucose monitors 
and test strips are exclusively covered. Also, OneTouch/LifeScan lancets, solutions and lancing devices are 
cover. The Plan does not cover other brands of monitors and test strips unless you or the provider requests a 
medical exception, and it is approved. Non-LifeScan monitors and test strips without a medical exception, or a 
medical exception that is not approved, will not be covered. You can find this on page 18 of the Plan's 2022 
Schedule of Cost Sharing.
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 Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied.   
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. MUEs for HCPCS codes with an MAI of 3 are per day edits based on clinical benchmarks. 
MUEs assigned an MAI of 3 are based on criteria (e.g., nature of service, prescribing information) combined 
with data such that it would be possible but medically highly unlikely that higher values would represent 
correctly reported medically necessary services. If contractors have evidence (e.g., medical review) that the 
number of units in excess of the MUE value were actually provided, were correctly coded and were medically 
necessary, the contractor may bypass the MUE for a HCPCS code with an MAI of 3. 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(V). 
 
The unit of service for immunohistochemistry/immunocytochemistry (e.g., CPT codes 88342, 88341, and 
88344) is each single or multiplex antibody stain procedure per specimen. A multiplex antibody 
immunohistochemical staining procedure is one that uses multiple antibodies to obtain multiple separately 
reportable medically reasonable and necessary results. An antibody stain containing multiple antibodies that 
yields a single reportable result is not a multiplex stain and shall be reported with a single antibody staining 
procedure CPT code. An immunohistochemistry stain procedure with multiple antibodies that are not 
separately interpretable (e.g., antibody cocktail) shall only be reported as one unit of service per specimen. You 
can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding 
Initiative Policy Manual for Medicare Services, Chapter X(M)(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 that Medicare does not pay for gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. 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 Plan 
contract also says that in order to obtain the wellness allowance you must submit a wellness allowance 
reimbursement from along with proof of payment and any additional information outlined on the form. You 
can find this information on page 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 Indications and Limitations of Coverage 
 
Effective January 1, 2002, sacral nerve stimulation is covered for the treatment of urinary urge incontinence, 
urgency-frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test 
stimulation to determine if an implantable stimulator would be effective and a permanent implantation in 
appropriate candidates. Both the test and the permanent implantation are covered. 
 
The following limitations for coverage apply to all three indications: 
 
    Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical 
corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur. 
    Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with 
peripheral nerve involvement) which are associated with secondary manifestations of the above three 
indications are excluded. 
    Patient must have had a successful test stimulation in order to support subsequent implantation. Before a 
patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through 
test stimulation. Improvement is measured through voiding diaries. 
    Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of 
the implant procedure can be properly evaluated. 
 
You can find this information in Medicare's National Coverage Determination (NCD): Sacral Nerve 
Stimulation For Urinary Incontinence (230.18). 
 
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 the Physician Fee Schedule Status Indicator X means the code is statutorily excluded. 
Medicare uses another code for reporting of, and payment for, these services. You can find this information in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 23, 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. This benefit states that the 
Plan reimburses up to $1,000 every year for non-Medicare covered preventive dental services and non-
Medicare-covered comprehensive dental services combined. You are responsible for any amount above the 
dental coverage limit. You can find this information on pages 74-76 of the Plans 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 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 $40 copayment for each therapy visit. You can find this information on 
page 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 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 durable medical equipment. You 
can find this information in Chapter 4 on page 84 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 that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract says to be 
covered in network you need to use a provider that is contracted with the dental vendor to provide 
supplemental dental service. Care rendered by a provider is not part of the supplemental dental work is not 
covered. You can find this information on page 55 of the Plans 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 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 per visit for Medicare-covered services performed in an 
outpatient hospital setting. You can find this information on pages 88 and 89 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 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 up to 
$2,000 for comprehensive dental services. Endodontic therapy (D3330), a crown (D2750), and prefabricated 
post and core (D2954) may be covered by the Plans dental benefits. The Contract says prior authorization may 
be required. You can find this information on page 71 of the Plans 2022 Evidence of Coverage (EOC).