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 Original Medicare pays for the routine costs of qualifying clinical trials. Medicare also pays 
for reasonable and necessary items and services used to diagnose and treat complications arising from 
participation in all clinical trials. The rules also say that Medicare plans must cover these services even if they 
are not available through in-network providers. Medicare plans may require reporting when enrollees 
participate in clinical trials but cannot require prior authorization or approval. You can find these rules in the 
Medicare National Coverage Determinations Manual, Chapter 1, Section 310.1. 
 
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. The Plan 
contract also says that a clinical research study or clinical trial is a way that doctors and scientists test new 
types of medical care. They test new medical care procedures or drugs by asking for volunteers to help with the 
study. This kind of study is one of the final stages of a research process that helps doctors and scientists see if a 
new approach works and if it is safe. 
 
An enrollee who is in a clinical research study may stay enrolled in the Plan and continue to get the care that is 
not related to the study through the Plan. Enrollees must tell the plan before they start participating in a clinical 
research study. 
 
If an enrollee participates in a Medicare-approved study, Original Medicare pays most of the costs for the 
covered services received as part of the study. After Medicare has paid its share of the cost for these services, 
the Plan will also pay for part of the costs. The Plan will pay the difference between the cost-sharing in 
Original Medicare and the cost-sharing as a member of the Plan. This means the enrollee will pay the same 
amount for the services received as part of the study as he or she would if these services were received from the 
Plan. You can find this information on pages 42-43 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 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 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 Appeal Number is: 
1-9501337256 
 
The rules state that the criteria for BRCA1 and BRCA2 genetic tests include: 
- Individual with breast, ovarian, pancreatic, or prostate cancer from a family with a known deleterious 
 BRCA1 or BRCA2 gene mutation. 
- Individual with a personal history of ovarian cancer 
- Individual with a breast cancer diagnosis meeting any of the following criteria: 
   - Diagnosed at age 45 years or younger 
   - Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR) 
     negative, and human epidermal growth factor receptor 2 (HER2) negative) breast cancer 
     diagnosed at age 60 years or younger 
   - Diagnosed at age 46 to 50 years with: 
        o An additional breast cancer primary 
        o 1 or more first, second, or third-degree relative with breast cancer at any age, or 
        o 1 or more first, second, or third-degree relative with prostate cancer or 
        o An unknown or limited family history 
    - Breast cancer diagnosed at any age, and 
         o 1 or more first, second, or third degree relative with breast cancer at age 50 years or 
            younger, or 
         o 1 or more first, second, or third-degree relative with ovarian cancer at any age, or 
         o 1 or more first, second, or third-degree relative with metastatic prostate cancer or 
            pancreatic cancer at any age, or 
         o 2 or more additional diagnoses of breast cancer at any age in patient and/or in close 
            blood relatives, or 
         o A first, second, or third-degree male relative with breast cancer\ 
         o For an individual of ethnicity associated with higher mutation frequency (e.g. Ashkenazi 
            Jewish) no additional family history may be required 
    - Male breast cancer 
 
You can find these rules in Local Coverage Determination (LCD) MolDX: BRCA1 and BRCA2 Genetic 
Testing (L36813). 
 
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 patients medical records must establish medical necessity for a hospital bed due to one of the following 
reasons: 
 
1. The patients condition requires positioning of the body; e.g., to alleviate pain, promote good body 
alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or  
 
2. The patients condition requires special attachments that cannot be fixed and used on an ordinary bed.  
You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.7(A). 
 
In order to qualify for a semi-electric hospital bed, the patients condition must require frequent change in body 
position and/or there may be an immediate need for a change in body position (i.e., no delay can be tolerated) 
and the patient can operate the controls and cause the adjustments. Exceptions may be made to this last 
requirement in cases of spinal cord injury and brain damaged patients. You can find this rule in the Medicare 
National Coverage Determinations Manual, Section 280.7(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.
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). 
 
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 
offers Special Supplemental Benefits for the Chronically Ill that includes transportation for non-medical needs, 
allowance for healthy food purchases and/or electricity, water and/or phone bill payments and home assistance 
services. For an enrollee to be a candidate for these benefits they must have one or more of the eligible chronic 
conditions documented in the Evidence of Coverage and require intensive care coordination, and must be at 
high risk of hospitalizations or adverse health outcomes. These rules can be found on pages 113 to 116 of the 
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 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 facet joint blocks will be considered reasonable and necessary for chronic pain (persistent 
pain for three (3) months or greater) suspected to originate from the facet joint. Facet joint block is one of the 
methods used to document/confirm suspicions of posterior element biomechanical pain of the spine. Hallmarks 
of posterior element biomechanical pain are: 
 
    - The pain does not have a strong radicular component. 
    - There is no associated neurological deficit and the pain is aggravated by hyperextension, rotation or lateral 
      bending of the spine, depending on the orientation of the facet joint at that level. 
 
It is not expected that an epidural block, or sympathetic block would be provided to a patient on the same day 
as facet joint injections. Multiple blocks on same day could lead to improper or lack of diagnosis. Coverage 
will be extended for only one type of procedure during one day/session of treatment unless the patient has 
recently discontinued anticoagulant therapy for the purpose of interventional pain management. 
  
Procedures performed during the diagnostic phase should be limited to three (3) levels (whether unilateral or 
bilateral) for each anatomical region as defined in this LCD on any given date of service. 
  
A diagnostic block can be repeated once, at any given level, at least one week (preferably 2 weeks) after the 
first block. If repeated, strong consideration should be given to utilizing administration of an anesthetic of 
different duration of action. (This helps confirm the validity of the diagnostic facet block, and may reduce the 
incidence of false positive responses due to placebo effect). 
 
You can find this information in the Local Coverage Determination (LCD): Paravertebral Facet Joint Blocks 
(L33930). 
 
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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 28 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 that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Section 423.578(b)(5)(ii). 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 72, 73, and 172 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 that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You 
can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
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. 
 
Medicare rules state that a custom fabricated mandibular advancement oral appliance (E0486) used to treat 
obstructive sleep apnea (OSA) is covered if criteria A - D are met. 
 
A. The beneficiary has a face-to-face clinical evaluation by the treating practitioner prior to the sleep test to 
assess the beneficiary for obstructive sleep apnea testing. Refer to the ICD-10 code list in the LCD-related 
Policy Article for applicable diagnoses. 
B. The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 - 3): 
        1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 
events per hour with a minimum of 30 events; or, 
        2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a 
minimum of 10 events and documentation of: Excessive daytime sleepiness, impaired cognition, mood 
disorders, or insomnia; or, Hypertension, ischemic heart disease, or history of stroke; or, 
        3. If the AHI> 30 or the RDI> 30 and meets either of the following(a or b): 
            a. The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or, 
            b. The treating practitioner determines that the use of a PAP device is contraindicated. 
C. The device is ordered by the treating practitioner following a review of the report of the sleep test. (The 
practitioner who provides the order for the oral appliance could be different from the one who performed the 
clinical evaluation in criterion A.) 
D. The device is provided and billed for by a licensed dentist (DDS or DMD). 
 
These rules can be found in Local Coverage Determination (LCD): Oral Appliances for Obstructive Sleep 
Apnea (L33611). 
 
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 treatment for Symptomatic Chronic Venous Insufficiency or Varicose Veins (VV), in the 
absence of bleeding, phlebitis or skin necrosis, may be covered as medically necessary with: 
- A documented 3-month trial of conservative therapy including graduated compression stockings with a 
minimum of (12-18 mmHg), weight reduction to BMI less than 35, therapeutic leg elevation, and an 
exercise program of calf muscle pumping activity with compression of the involved veins, which results 
in limited alteration/improvement of symptoms or findings without satisfactory endpoint, and 
- Duplex venous studies of the involved lower extremity(s), mapping size and course of the greater and 
lesser saphenous vein and prominent tributaries and demonstrating the: 
o Presence and Patency of the Deep Venous System. 
o Absence of Deep Venous Thrombosis, and 
o Documented Incompetence (reflux greater than 500msec) of the Valves of the Saphenous, 
Perforator or Deep venous systems consistent with the patient's symptoms and findings. 
 
You can find these rules in Local Coverage Determination (LCD) Treatment of Varicose Veins and Venous 
Stasis Disease of the Lower Extremities (L34924). 
 
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 SSA, Section 1862(a)(12) and 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 Plan contract says that 
specifically listed dental services are covered by the plan when medically reasonable and necessary. 
Limitations and exclusions apply. You can find this information on pages 76 to 79 of the Plan?s 2020 Evidence 
of Coverage (EOC).  
 
The dental contract says that for periodontal scaling to be covered there must be a minimum of four (4) teeth 
affected in the quadrant and periodontal charting indicating abnormal pocket depths in multiple sites. 
Additionally, at least one of the following must be present: Radiographic evidence of root surface calculus or 
radiographic evidence of noticeable loss of bone support. You can find this information on page 30 of the 
Plan?s 2020 dental contract
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 SSA, Section 1862(a)(12) and 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. Surgical placement of implant body: endosteal implant (D6010) is not 
included on this list and is not a covered supplemental benefit. You can find this information on pages 4-50 to 
4-63 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 that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 5 of the Plan's 2020 
Evidence of Coverage..