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 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 page 71 of the 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare allows payment for one annual wellness visit (AWV) for enrollees who have not had an AWV within the past 12 months. You can find this information in the Medicare Claims Processing Manual, Chapter 18, Section 140. The rules say that the Annual Wellness Visit will include the establishment of, or update to, the individual's medical and family history, measurement of his or her height, weight, body-mass index (BMI) or waist circumference, and blood pressure (BP), with the goal of health promotion and disease detection and fostering the coordination of the screening and preventive services that may already be covered and paid for under Medicare Part B. This is seen in the CMS MLN Matters article number MM7079 (effective January 1, 2011).
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 there is a $10 copayment for physician visits. You can see this on page 88 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 Medicare will pay for durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers 
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment 
already available to an enrollee. Equipment which the beneficiary owns or is a capped rental item may be 
replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural 
disaster (e.g., fire, flood). A physician's order and/or new Certificate of Medical Necessity, when required, is 
needed to reaffirm the medical necessity of the item. In the absence of program instructions, A/B MACS (B) 
may determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years. You can 
find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1(C) and 110.2. 
 
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 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 the indications for coverage of lumbar epidural injections are: 
1. Pain associated with 
 
- Herpes Zoster and/or 
- Suspected radicular pain, based on radiation of pain along the dermatome (sensory distribution) of a 
nerve and/or 
- Neurogenic claudication and/or 
- Low back pain, NPRS &#8805; 3/10 (moderate to severe pain) associated with significant impairment of 
activities of daily living (ADLs) and one of the following:  
a. substantial imaging abnormalities such as a central disc herniation, 
b. severe degenerative disc disease or central spinal stenosis. 
2. Failure of four weeks (counting from onset of pain) of non-surgical, non-injection care, which includes 
appropriate oral medication(s) and physical therapy to the extent tolerated...  
o Exceptions to the 4-week wait may include: 
a. pain from Herpes Zoster 
b. at least moderate pain with significant functional loss at work or home. 
c. severe pain unresponsive to outpatient medical management. 
d. inability to tolerate non-surgical, non-injection care due to co-existing medical 
condition(s) 
e. prior successful injections for same specific condition with relief of at least 3 months? 
duration. 
You can find this information in the Local Coverage Determination (LCD): Lumbar Epidural Injections 
(L35937) 
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 pneumatic compression device (PCD) that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a 
preventative service or function are excluded from coverage under the Medicare DME benefit. 
 
You can find this information in the Local Coverage Article:  Pneumatic Compression Devices - Policy Article 
(A52488). 
 
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 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 says that crowns are limited to one per tooth every five years when medically reasonable and 
necessary. You can find this information on pages 78 and 122 of the Plan's 2020 Evidence of Coverage. 
 
The contract also says that the criteria for coverage of a crown on permanent molar teeth must have pathologic 
destruction to the tooth by caries or trauma, and should involve four or more surfaces and two or more cusps. 
You can find this information on page 32 of the Plan?s supplemental dental coverage handbook.
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 pages 29 and 31 of the Plan's 
2020 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 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. This benefit includes only 
services listed in the dental benefits chart. Any service not listed is not covered. Dentures are not listed. You 
can find this information on pages 4-58 to 4-68 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 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. This benefit includes an 
implant supported crown once every 84 months. You can find this information on page 144 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 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. This benefit includes exams, 
cleanings, bitewing x-rays, a panoramic x-ray, fillings, simple or surgical extractions, crowns, root canals, 
implants, periodontal scaling and root planing, complete or partial dentures, denture alignments/relines, and 
medically necessary surgical procedures including analgesia. You can find this information on pages 55-56 and 
90-102 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that for purposes of Medicare coverage of lung cancer screening with LDCT, beneficiaries must 
meet all of the following eligibility criteria: 
 
    - Age 55  77 years; 
    - Asymptomatic (no signs or symptoms of lung cancer); 
    - Tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one 
year; 1 pack = 20 cigarettes); 
    - Current smoker or one who has quit smoking within the last 15 years; and 
    - Receive a written order for lung cancer screening with LDCT. Written orders for lung cancer LDCT 
screenings must be appropriately documented in the beneficiary?s medical records, and must contain the 
following information: 
        - Beneficiary date of birth; 
        - Actual pack  year smoking history (number); 
        - Current smoking status, and for former smokers, the number of years since quitting smoking; 
        - Statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer); and 
        - National Provider Identifier (NPI) of the ordering practitioner. 
 
You can find this information on the National Coverage Determination (NCD) for Lung Cancer Screening with 
Low Dose Computed Tomography (LDCT) (210.14). 
 
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 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 virtual colonoscopy is only indicated in those patients in whom a diagnostic or surveillance 
instrument colonoscopy of the entire colon is incomplete due to an inability to fully pass the colonoscope 
proximally, and a repeat attempt is not indicated. Virtual colonoscopy is intended for use in pre-operative 
planning only when imaging of the non-visualized colon proximal to the obstruction is medically necessary in 
making decisions involving the approach to the patient. 
 
Incomplete colonoscopy must be due to one of the following: 
 
1. An obstructing neoplasm, 
 
2. Intrinsic scarring, stricture, aberrant anatomy, or obstruction from prior surgery, radiation, or diverticular 
disease. 
 
3. Extrinsic compression. 
 
4. Patient safety. There are few absolute contraindications to instrument colonoscopy. Relative 
contraindications do not create medical necessity for using virtual colonoscopy as a screening procedure, and 
the above indications must still be met. 
 
The following relative contraindications to instrument colonoscopy may be indications for virtual colonoscopy 
if well documented in the medical record and the patient's primary physician and the colonoscopist agree on the 
increased risk to the patient: 
 
-Severe coagulopathy 
-Long-term anticoagulation 
- Increased sedation risk (such as from severe COPD or previous anesthesia adverse reaction) 
 
Limitations: 
 
- Virtual colonoscopy is not covered when used for screening, or in the absence of signs or symptoms of 
disease, regardless of family history or other risk factors for the development of colonic disease. 
 
- Virtual colonoscopy is not covered when used as an alternative to instrument colonoscopy for screening or in 
the absence of signs or symptoms of disease. 
 
- Virtual colonoscopy is not covered following incomplete colonoscopy if the reason for the colonoscopy is 
other than one of those described above. 
 
You can find this information in the Local Coverage Determination (LCD): Virtual Colonoscopy (CT 
Colonography) (L34055). 
 
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). 
 
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). 
 
Facet injections, also known as facet blocks, may be given for diagnostic purposes to determine if the facet 
joint is the source of suspected spinal pain or for therapeutic purposes to treat facet pain that has been 
previously established. Imaging findings are of little value in diagnosing facet syndrome. It is usually a 
diagnosis of exclusion. Clinical signs alone cannot diagnose facet joint-mediated pain, but may be of value in 
selecting candidates for controlled diagnostic local anesthetic blocks. The response pattern to diagnostic facet 
joint injections has become the gold standard for diagnosing facet syndrome. Temporary or prolonged abolition 
of the spinal pain suggests that facet joints were the source of the symptoms. The facet block procedure is an 
injection of a local anesthetic, with or without a steroid medication, either into the facet joint (intra-articular) or 
outside the joint space around the nerve supply to the joint (the medial branch nerve) known as medial branch 
block (MBB). Imaging guidance (fluoroscopy or CT per code descriptor) is used to assure accurate placement 
of the needle for the injection. You can find this information in Local Coverage Determination (LCD): Facet 
Joint Interventions for Pain Management (L34892). 
 
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. This benefit includes oral 
surgery. You can find this information in the Plan's 2020 and 2021 Dental Handbook.
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 if any power operated vehicle (POV) or PWC is only for use outside the home, it will be 
denied as noncovered. 
 
You can find this information in the Local Coverage Article: Power Mobility Devices - Policy Article 
(A52498). 
 
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 IGH@ (Immunoglobulin heavy chain locus) is considered medically necessary for acute 
lymphoblastic leukemia (ALL) and lymphoma, B-cell to guide therapeutic decision making. You can find this 
rule at Local Coverage Determination (LCD): Molecular Pathology Procedures (L35000) (eff. 7/1/20). 
 
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.