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 state that the following are examples of wound care items which are non-covered under the surgical 
dressing benefit because they do not meet the statutory definition of a dressing (not all-inclusive): 
 
    - Skin sealants or barriers (A6250) 
    - Wound cleansers (A6260) or irrigating solutions 
    - Solutions used to moisten gauze (e.g., saline) 
    - Silicone gel sheets (A6025) 
    - Topical antiseptics 
    - Topical antibiotics 
    - Enzymatic debriding agents 
    - Gauze or other dressings used to cleanse or debride a wound but not left on the wound 
    - First-aid type adhesive bandage (A6413) 
    - Any item listed in the latest edition of the Orange Book (e.g., an antibiotic-impregnated dressing which 
requires a prescription 
    - Gradient compression stockings (A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, 
A6541, A6544, A6549) 
    - Surgical stockings (A4490, A4495, A4500, A4510) 
    - Non-elastic binder for an extremity (A4465) 
    - Small adhesive bandages (e.g., Band-Aid or similar product) are not primarily used for the treatment of 
wounds addressed in the Surgical Dressings policy. 
 
These dressings are noncovered under the surgical dressing benefit. 
 
You can find this information in the Local Coverage Article: Surgical Dressings - Policy Article (A54563). 
 
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 cover for the use of home PT/INR monitoring for chronic, oral anticoagulation 
management for patients with mechanical heart valves, chronic atrial fibrillation, or venous thromboembolism 
(inclusive of deep venous thrombosis and pulmonary embolism) on warfarin.  The monitor and the home 
testing must be prescribed by a treating physician as provided at 42 CFR 410.32(a), and all of the following 
requirements must be met: 
1. The patient must have been anticoagulated for at least 3 months prior to use of the home INR device; 
and, 
2. The patient must undergo a face-to-face educational program on anticoagulation management and must 
have demonstrated the correct use of the device prior to its use in the home; and, 
3. The patient continues to correctly use the device in the context of the management of the 
anticoagulation therapy following the initiation of home monitoring; and, 
4. Self-testing with the device should not occur more frequently than once a week. 
You can find this rule in the Medicare National Coverage Determination for Home Prothrombin 
Time/International Normalized Ratio (PT/INR) Monitoring for Anticoagulation Management, 190.11. 
 
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 $30 copayment for specialist visits. You can find this information in 
Chapter 4 on pages 80 - 81 of the Plan's 2020 EOC. 
 
The Plan contract also says that enrollees must pay a $30 copayment for basic radiological services provided in 
a specialist's office. You can find this information in Chapter 4 on pages 74 - 75 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 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 90 to 91 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 1 
periodic or comprehensive oral exam, prophylaxis, bitewing x-rays, scaling and root planing, fillings and 
anesthesia. Limited oral evaluation is not listed and therefore is not a covered service. Periapical x-ray is not 
listed and therefore is not a covered service. You can find this information on page 94 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 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 $0 copayment for mammography and ultrasounds and a $150 
copayment for all other diagnostic and nuclear medicine radiological services. You can find this information in 
Chapter 4 on page 51 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. Covered dental services are 
listed on page 65 of the plan's 2021 Evidence of Coverage. Any service not listed is not covered.
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. 
Local Coverage Article:  Surgical Dressings - Policy Article (A54563): The following are examples of wound 
care items which are non-covered under the surgical dressing benefit because they do not meet the statutory 
definition of a dressing (not all-inclusive): 
Skin sealants or barriers (A6250) 
Wound cleansers (A6260) or irrigating solutions 
Solutions used to moisten gauze (e.g., saline) 
Silicone gel sheets (A6025) 
Topical antiseptics 
Topical antibiotics  Enzymatic debriding agents 
Gauze or other dressings used to cleanse or debride a wound but not left on the wound 
First-aid type adhesive bandage (A6413) 
Any item listed in the latest edition of the Orange Book (e.g., an antibiotic-impregnated dressing which 
requires a prescription 
Gradient compression stockings (A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6539, 
A6540, A6541, A6544, A6549) 
Surgical stockings (A4490, A4495, A4500, A4510) 
Non-elastic binder for an extremity (A4465) 
Small adhesive bandages (e.g., Band-Aid or similar product) are not primarily used for the treatment of 
wounds addressed in the Surgical Dressings policy. 
These dressings are noncovered under the surgical dressing benefit. 
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 radionuclide imaging may be employed in the assessment of a variety of conditions 
associated with primary coronary artery disease. Some of these conditions include: 

 
1. Assessment of the functional and prognostic importance of angina, chest pain, or angina equivalent 
symptoms. 
2. Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG/EKG changes 
occurring naturally or caused by drugs, bundle branch block, or left ventricular hypertrophy. 
3. Risk assessment of re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with 
known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a 
revascularization procedure within the past two years or greater than 2 years since last imaging study.  
4. Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed 
heart failure or left ventricular systolic dysfunction. 
5. Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization/coronary 
angiography is not planned. 
6. Evaluation of myocardial perfusion viability or function before and more than or equal to 5 years after 
coronary artery bypass surgery or greater than or equal to 2 years after percutaneous perfusion procedures, 
unless new clinical signs or symptoms necessitate reevaluation. 
7. Quantification and surveillance of myocardial infarction and prognostication in patient with infarction. 
8. Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery or perioperative 
management 
9. Evaluation of ventricular function in patients with non-ischemic myocardial disease. 
10. Evaluation of patients in whom an accurate measure of the ejection fraction is needed to make a 
determination of whether to implant a defibrillator or biventricular pacemaker. 
11. Evaluation of patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., Adriamycin, 
Herceptin). 
 
You can find this rule in Local Coverage Determination (LCD): Cardiovascular Nuclear Medicine (L35083) - 
Effective October 17, 2019. 
 
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 $90 copayment for emergency room services. You can see this on page 
63 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 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 $25 copayment for Outpatient Diagnostic Tests. You can find this 
information on page 82 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 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 $360 copayment per day for days 1-5. There is a $0 copayment for 
additional days for inpatient hospital care. You can find this information on pages 48-49 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. 
 
A pneumatic compression device (PCD) coded as E0652 is covered for the treatment of lymphedema extending 
onto the chest, trunk and/or abdomen when all of the following are met: 
 
 The beneficiary has lymphedema of an extremity. 
 The coverage criteria for an E0650 or E0651 PCD are met. 
 The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the 
limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to 
improve with a four-week trial. 
 
A four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651 
PCD is required. The four-week trial of conservative therapy must include all of the following: 
 
 At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 PCD after 
careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and 
successfully uses the appliance provided 
 Compliant use of an appropriate compression bandage system or compression garment to provide 
adequate graduated compression 
 Elevation where appropriate 
 Manual lymphatic drainage (where available) and self-manual lymphatic drainage (MLD) for at least 30 
minutes per day 
 Evaluation of diet and implementation of any necessary change 
 Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.)  
Correction (where possible) of anemia and/or hypoproteinemia 
 
You can find this information at Local Coverage Determination (LCD): Pneumatic Compression Devices 
(L33829). 
 
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 Plan contract includes a list of covered supplemental dental services. Implant services are not included on this list and are not a covered supplemental benefit. You can find this information on pages 60 to 62 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 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 one of 
D3310, D3320, D3330, D3351, D3352, or D3353 per a lifetime per tooth. You can find this information on 
page 70 of the Plan's 2020 Dental Office Reference Manual.
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 does not include 
coverage for therapeutic pulpotomy (D3220). You can find this information on pages 4-62 to 4-72 of the Plan's 
2020 Evidence of Coverage (EOC).