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 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 lists the specific dental services that are covered. Oral hygiene instruction is not listed and therefore is not a covered service. 2D oral or facial photographic image is not listed and therefore is not a covered service. Cone beam CT is not listed and therefore is not a covered service either. You can find this information on the Dental Plan's 2021 Schedule of Dental Benefits.
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 for coverage of the extended ophthalmoscopy, the patient's medical record must contain documentation that fully supports the medical necessity for extended ophthalmoscopy for each eye, as it is covered by Medicare. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation supporting the medical necessity should be legible, maintained in the patient's record, and must be available to the carrier upon request. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Local Coverage Article, Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (A56726).
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 one to two levels, either unilateral or bilateral, are allowed per session per spine region. The 
need for a three or four-level procedure bilaterally may be considered under unique circumstances and with 
sufficient documentation of medical necessity on appeal. A session is a time period, which includes all 
procedures (i.e., MBB, IA, facet cyst ruptures, and RFA ablations) that are performed during the same day. 
 
You can find this information in the 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.
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 tumor treatment field therapy (E0766) will be denied as not reasonable and necessary for the treatment of recurrent Glioblastoma Multiforme (GBM). You can find this rule at Local Coverage Determination (LCD): Tumor Treatment Field Therapy (TTFT) (L34823).

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 for purposes of rental and purchase of durable medical equipment (DME) a beneficiary's home may be his/her own dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution (such as an assisted living facility, or an intermediate care facility for individuals with intellectual disabilities). However, an institution may not be considered a beneficiary's home if it:
- Meets at least the basic requirement in the definition of a hospital; or
- Meets at least the basic requirement in the definition of a skilled nursing facility.
Thus, if an individual is a patient in an institution or distinct part of an institution which provides the services described in the bullets above, the individual is not entitled to have separate Part B payment made for rental or purchase of DME. This is because such an institution may not be considered the individual's home. The same concept applies even if the patient resides in a bed or portion of the institution not certified for Medicare. You can find these rules in Medicare Benefit Policy Manual Chapter 15, Section 110.1(4)(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 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 Plan contract does not
list porcelain-ceramic crown and core buildup as covered benefits. The Plan contract states that we cover one
set of complete or partial dentures every five years. You can find this information on page 51 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 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 Plan contract also includes a list of covered supplemental dental benefits. The surgical implant placement (D6010), prefabricated abutment (D6056) and implant supported crown (D6065) are not on this list and are not covered supplemental benefits. You can find this information in the Plan's 2021 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.
Medicare rules state that the coverage indications for 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 3/10 or more (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. Exceptions to the 4-week
wait may include:
- pain from Herpes Zoster
- at least moderate pain with significant functional loss at work or home.
- severe pain unresponsive to outpatient medical management.
- inability to tolerate non-surgical, non-injection care due to co-existing medical condition(s)
- prior successful injections for same specific condition with relief of at least 3 months' duration.
The coverage limitations are:
1. For a patient with low back pain only, a simple disc bulge or annular tear/fissure is insufficient to justify
performance of an epidural.
2. Patient must not have major risk factors for spinal cancer (e.g., LBP with fever) or, if cancer is present,
but the pain is clearly unrelated, an epidural may be indicated if one of the "Indications" previously
listed is present.
3. A co-existing medical or other condition that precludes the safe performance of the procedure precludes
coverage of the procedure, e.g., new onset of LBP with fever, risk factors for, or signs of, cauda equina
syndrome, rapidly progressing (or other) neurological deficits.
4. Numbness and/or weakness without paresthesia/dysesthesia or pain precludes coverage.
5. There is no role for "series of three" epidurals. Response to each epidural should be determined prior to
determining the value of a repeat epidural and the specific methods used for subsequent epidurals.
You can find these rules in Local Coverage Determination (LCD) Lumbar Epidural Injections (L34980).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that there is a $500 deductible which applies to certain items and services. The Plan deductible applies to the anesthesia services. You can find this information on pages 4-2 to 4-4 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $35 copayment for each Medicare-covered individual or group visit. You can find this information on page 83 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 pays for care in a skilled nursing facility (SNF) when all of the following four factors are met: 1. The patient requires skilled nursing or skilled rehabilitation services; 2. The patient requires these services on a daily basis; 3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and 4. The services are reasonable and necessary for the treatment of the patient's illness or injury, or the services must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from getting worse. You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30. The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110.
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are covered only when they are medically reasonable and necessary. Therapy services are considered reasonable and necessary when:
1. The services are specific and effective treatment for the patient's condition,
2. The services require the skills or direct supervision of a therapist,
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, or carry out a maintenance program.
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2.
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 the Form CMS-1450, also known as the UB-04 form, is a uniform institutional provider bill
used in billing multiple third party payers. You can find this rule in the Center for Medicare Services (CMS)
Internet-Only Manual, Publication 100-4, Medicare Claims Processing Manual, Chapter 25, Section 70.1.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that ferritin, iron and either iron binding capacity or transferrin are useful in the differential diagnosis of iron deficiency, anemia, and for iron overload conditions.

a. The following presentations are examples that may support the use of these studies for evaluating iron deficiency: certain abnormal blood count values (i.e., decreased mean corpuscular volume (MCV), decreased hemoglobin/hematocrit when the MCV is low or normal, or increased red cell distribution width (RDW) and low or normal MCV); abnormal appetite (pica); acute or chronic gastrointestinal blood loss; hematuria; menorrhagia; malabsorption; status post-gastrectomy; status post-gastrojejunostomy; malnutrition; preoperative autologous blood collection(s); malignant, chronic inflammatory and infectious conditions associated with anemia which may present in a similar manner to iron deficiency anemia; following a significant surgical procedure where blood loss had occurred and had not been repaired with adequate iron replacement.
b. The following presentations are examples that may support the use of these studies for evaluating iron overload: chronic hepatitis; diabetes; hyperpigmentation of skin; arthropathy; cirrhosis; hypogonadism; hypopituitarism; impaired porphyrin metabolism; heart failure; multiple transfusions; sideroblastic anemia; thalassemia major; cardiomyopathy, cardiac dysrhythmias and conduction disturbances.
2. Follow-up testing may be appropriate to monitor response to therapy, e.g., oral or parenteral iron, ascorbic acid, and erythropoietin.
3. Iron studies may be appropriate in patients after treatment for other nutritional deficiency anemias, such as folate and vitamin B12, because iron deficiency may not be revealed until such a nutritional deficiency is treated.
4. Serum ferritin may be appropriate for monitoring iron status in patients with chronic renal disease with or without dialysis.
5. Serum iron may also be indicated for evaluation of toxic effects of iron and other metals (e.g., nickel, cadmium, aluminum, lead) whether due to accidental, intentional exposure or metabolic causes.

You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 190.18.

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 effective for claims with dates of service on or after January 12, 2017, Medicare covers therapeutic Continuous Glucose Monitor (CGM) devices under the Durable Medical Equipment (DME) benefit. CGM devices covered by Medicare are defined in CMS Ruling 1682R as therapeutic CGM. CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit). There is no Medicare benefit for supplies and accessories used with equipment that is not classified as DME. Coverage of a CGM system supply allowance (K0553) is available for those therapeutic CGM systems where the beneficiary uses a receiver classified as DME to display glucose data. You can find this information in the Local Coverage Article: Glucose Monitor - Policy Article (A52464). 

The rules say that code A9277 describes a supply used with a non-therapeutic CGM. You can find this information in the Local Coverage Article Glucose Monitor - Policy Article (A52464).

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 Plan 
contract includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. Mandibular interim partial denture (D5821) is not included on this list and 
is not a covered supplemental benefit. You can find this information on pages 4-77 to 4-87 of the Plan's 2021 
Evidence of Coverage.