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 does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 hearing aids purchased outside of the Plan hearing network are not covered. You can 
find this information on page 4-23 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 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 
doctors 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 routine transportation up to 12 one-way trips are covered each year by the Plans designated provider 
(limited to ground transportation only). Trips must be to or from plan-approved locations, such as network 
providers, medical facilities, pharmacies, or hearing and vision appointments. Each one-way trip must not 
exceed 50 miles of driving distance. A trip is one-way transportation; a round trip is 2 trips. You can find this 
information in Chapter 4 on page 54 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 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 the 
requested item or service but is limited to one D0140 every Plan year. This benefit does not include D0460. 
You can find this information on pages 4-58 to 4-71 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 the 
requested item or service but is limited to one D0150 every 36 months. You can find this information on page 
125 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that for claims with dates of service on or after July 1, 2017, through December 31, 2022, a non-
adjunctive CGM must be billed with code K0554. For claims with dates of service on or after January 1, 2023, 
a non-adjunctive CGM must be billed with code E2103. Code E2103 or K0554 describes a non-adjunctive 
CGM that meets the requirements of the DME benefit. To be eligible for Medicare reimbursement, all CGM 
devices billed as E2103 must have received coding verification review by the Pricing, Data Analysis and 
Coding (PDAC) contractor and be listed on the Product Classification List (PCL) for HCPCS code E2103. 
 
The rules say that a Freestyle Libre 3 is not specified as a product that may be billed using code E2103. You 
can find this information in the Product Classification List (PCL) on the Pricing Data Analysis, and Coding 
(PDAC) contractor web site 
(https://www4.palmettogba.com/pdac_dmecs/searchProductClassificationResults.do?manufacturer=&codeDeci
sion=k0554&productName=&modelNumber=&classification=). 
 
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 
enrollees may be billed by the out-of-network provider for any charged amount greater than the payment made 
by the Plan. You can find this information on pages 91-92, 110-112 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 the following indications are covered for implanted permanent single chamber or dual 
chamber cardiac pacemakers: 
 
    Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and 
    Documented non-reversible symptomatic bradycardia due to second degree and/or third degree 
atrioventricular block 
 
You can find this information in the National Coverage Determination (NCD) Cardiac Pacemakers: Single 
Chamber and Dual Chamber Permanent Cardiac Pacemakers 20.8.3. 
 
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 shower/bath chairs and raised toilet seats are not covered because they are considered 
hygienic equipment that is not primarily medical in nature. You can find this rule in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determinations Manual, Section 280.1. 
 
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 also say that Medicare started a new initiative on April 4, 2022, that will cover up to eight over the counter COVID-19 tests each calendar month, at no cost to you. Medicare will cover these tests if you have Part B, including those enrolled in a plan. If you are in a plan, the tests covered under this initiative will be covered outside of your existing plan's coverage, and in addition to any over-the-counter tests that may be covered under the plan as a supplemental benefit. You can get over the counter COVID-19 tests at any pharmacy or health care provider that participates in this initiative. Enrollees cannot submit a claim for these tests to Medicare or their plan (unless covered by a supplemental benefit) for reimbursement under this initiative. The participating provider would bill Medicare directly for reimbursement of the tests provided to the enrollee. You can find this information on the Centers for Medicare and Medicaid Services website at https://www.cms.gov/newsroom/fact-sheets/medicare-covers-over-counter-covid-19-tests.
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 $45 copayment for each covered visit or consultation in an outpatient location with a specialist. You can find this information on page 106 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 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 a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. You can find this in the Local Coverage Article: Wheelchair Options/Accessories -Policy Article (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 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 date of service (DOS) policy for either a clinical laboratory test or the technical component of physician pathology service is as follows: General Rule: The DOS of the test/service must be the date the specimen was collected. Variation: If a specimen is collected over a period that spans two calendar days, then the DOS must be the date the collection ended. Exceptions: The following three exceptions apply to the DOS policy for either a clinical laboratory test or the technical component of physician pathology service: A. DOS for Tests/Services Performed on Stored Specimens: In the case of a test/service performed on a stored specimen, if a specimen was stored for less than or equal to 30 calendar days from the date it was collected, the DOS of the test/service must be the date the test/service was performed only if: - The test/service is ordered by the patient's physician at least 14 days following the date of the patient's discharge from the hospital; - The specimen was collected while the patient was undergoing a hospital surgical procedure; - It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted; - The results of the test/service do not guide treatment provided during the hospital stay; and - The test/service was reasonable and medically necessary for treatment of an illness. If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service must be the date the specimen was obtained from storage. You can find this in the Medicare Claims Processing Manual Chapter 16 under Laboratory Services, section 40.8, Date of Service (DOS) for Clinical Laboratory and Pathology Specimens. The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid information for all these elements may be returned as un-processable.
You can find this rule in the Medicare Claims Processing Manual, Chapter 1, Section 80.3.1. The rules state that when completing the 1500 claim form, providers must enter the correct Place of Service (POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. You can find this rule at Medicare Claims Processing Manual Ch. 26 Section 10.6.
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 the
requested services but are limited to one exam every six months and one periapical X-ray every three years.
You can find this information on page 67 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 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 2021 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 Durable medical equipment (DME) and
related supplies. You can find this information on page 77 of the Plan's 2021 Evidence of Coverage (EOC).
The 2022 Plan contract also says that there is a $450 deductible which applies to certain items and services.
The Plan deductible applies to covered in-network medical services, including durable medical equipment. You
can find this information on pages 60 and 80 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 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 Next Generation Sequencing (NGS) the Nationally Covered Indications are as follows:
1. Somatic (Acquired) Cancer
Effective for services performed on or after March 16, 2018, the Centers for Medicare & Medicaid Services
(CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable
and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments
(CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements
are met:
a. Patient has:
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy).
b. The diagnostic laboratory test using NGS must have:
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and,
ii. an FDA-approved or -cleared indication for use in that patient's cancer; and,
results provided to the treating physician for management of the patient using a report template to
specify treatment options.
iii.
2. Germline (Inherited) Cancer
Effective for services performed on or after January 27, 2020, CMS has determined that NGS as a diagnostic
laboratory test is reasonable and necessary and covered nationally for patients with germline (inherited) cancer,
when performed in a CLIA-certified laboratory, when ordered by a treating physician and when all of the
following requirements are met:
a. Patient has:
i. ovarian or breast cancer; and,
ii. a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer; and,
iii. a risk factor for germline (inherited) breast or ovarian cancer; and
not been previously tested with the same germline test using NGS for the same germline genetic
content.
iv.
b. The diagnostic laboratory test using NGS must have all of the following:
i. FDA-approval or clearance; and, results provided to the treating physician for management of the patient
using a report template to specify treatment options. You can find these rules in the Medicare National
Coverage Determination (NCD) Next Generation Sequencing (NGS) 90.2.
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.