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 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 contract lists the dental services that are covered. Topical application of fluoride varnish is not listed and therefore is not a covered service. Application of desensitizing resin is not listed and therefore is not a covered service. The contract also says 1 crown per tooth, every 5 years and 1 replacement crown every year, per tooth, is covered. The contract also says prior authorization may be required. You can find this information on pages 76 to 78 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  rules  state that  TENS therapy  for  chronic  low  back pain  (CLBP)  is only  covered when  all  of the  following criteria  are met:-The beneficiary  has one of the diagnosis  codes listed. (Refer to the "ICD-10 Codes that are Covered" section in  the  LCD-related  Policy  Article  for  applicable  diagnoses.)-The beneficiary  is enrolled  in an approved clinical  study that meets all of the requirements  set out in NCD ?160.27 (CMS Internet  Only  Manual  100-03, Chapter  1). Refer  to the  Appendices  section  for additional information  about approved clinical  studies.TENS therapy  for  CLBP that  does not  meet  these  criteria  will  be denied  as not reasonable  and necessary.You  can find  this  rule  in  Local  Coverage  Determination  (LCD):  Transcutaneous  Electrical  Nerve Stimulators (L33802).If  you  want  toread 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 amedical 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 all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. You can find this information in the 42 Code of Federal Regulations, Section 410.32.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 amedical 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 procedure code 87633 (mixed respiratory virus panel, 12-25) is used whenmore limited panels would not be medically appropriate (e.g., patient exposed, critically ill, etc.). You can find this rule at Local Coverage Article: Billing and Coding: Influenza Diagnostic Tests (A54769) (eff. 10/24/19).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. You can find this information on pages 82-84 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 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).LocalCoverage Determination  (LCD):  Transcutaneous Electrical  Nerve Stimulators  (TENS) (L33802): TENS is covered  for chronic,  intractable  pain  other  than  chronic  low  back pain  when  all  of  the following  criteria  must  be met: &#61623;The  presumed  etiology  of the pain  must  be a type  that  is  accepted as responding  to TENS therapy. Examples  of conditions  for  which  TENS therapy  is  not considered  to be reasonable  and  necessary  are (not  all-inclusive): oheadacheovisceral  abdominal  painopelvic  painotemporomandibular  joint  (TMJ)  pain&#61623;The pain  must  have  been present  for  at least  three  months.&#61623;Other appropriate  treatment  modalities  must  have  been tried  and  failed.TENS therapy  for  chronic  pain  that  does not meet  these  criteria  will  be denied  as not  reasonable  and necessary.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 amedical 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 thyroid function tests are used to define hyper function, euthyroidism, or hypofunction of thyroid disease. Thyroid testing may be reasonable and necessary to:-Distinguish between primary and secondary hypothyroidism;-Confirm or rule out primary hypothyroidism;-Monitor thyroid hormone levels (for example, patients with goiter, thyroid nodules, or thyroid cancer);-Monitor drug therapy in patients with primary hypothyroidism;-Confirm or rule out primary hyperthyroidism; and-Monitor therapy in patients with hyperthyroidism.You can find this rule in the National Coverage Determination Manual, Section 190.22The rules say that the medical community recognizes lipid testing as appropriate for evaluating atherosclerotic cardiovascular disease. Conditions in which lipid testing may be indicated include:-Assessment of patients with atherosclerotic cardiovascular disease.-Evaluation of primary dyslipidemia.-Any form of atherosclerotic disease, or any disease leading to the formation of atherosclerotic disease.-Diagnostic evaluation of diseases associated with altered lipid metabolism, such as: nephrotic syndrome, pancreatitis, hepatic disease, and hypo and hyperthyroidism.-Secondary dyslipidemia, including diabetes mellitus, disorders of gastrointestinal absorption, chronic renal failure.-Signs or symptoms of dyslipidemias, such as skin lesions.-As follow-up to the initial screen for coronary heart disease (total cholesterol + HDL cholesterol) when total cholesterol is determined to be high (>240 mg/dL), or borderline-high (200-240 mg/dL) plus two or more coronary heart disease risk factors, or an HDL cholesterol, <35 mg/dl.You can find this rule in the National Coverage Determination Manual, Section 190.23.If you want to read these Medicare rules, you can go tothis 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

You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that a portable oxygen system is covered if the beneficiary is mobile within thehome and the qualifying blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood gas study was performed during sleep, portable oxygen will be denied as not reasonable and necessary.If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary system. See exception in the related Policy Article Non-Medical Necessity Coverage and Payment Rules, OXYGEN EQUIPMENT, Initial 36-Months section.If a portable oxygensystem is covered, the supplier must provide whatever quantity of oxygen the beneficiary uses; Medicare's reimbursement is the same, regardless of the quantity of oxygen dispensed.You can find these rules in the Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment, L33797. This LCD is effective for services provided on or after August 2, 2020.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 contract says crowns are covered when there is extensive decay or destruction of the tooth where the tooth cannot be fixed with only a filling. Does not cover crowns for cosmetic reasons or for closing gaps. Veneers are not covered. Implant crowns are not covered. Does not cover "3/4" crowns. You can find this information on page 4-65 of the Plan's 2020 Evidence of Coverage.
The contract also says that any dental services that are not necessary are not covered. You can find this information on page 4-57 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:
The following supplemental preventive dental services:
Oral Exam - periodic oral evaluations and limited/comprehensive exams
Bitewing X-ray
Prophylaxis (cleaning)
Intraoral Periapical X-ray
Full mouth panoramic X-ray or intraoral complete series
The following supplemental comprehensive dental services:
Restorative - fillings, crowns
Periodontics - scaling and root planing, full mouth debridement, maintenance
Extractions
Prosthodontics - dentures (removable only), partials (removable only), adjustments, relines and repairs
Oral Surgery - removal of impacted teeth, fistula closure, closure of sinus perforation, alveoloplasty, incision
& drainage of abscess, excision of hyperplastic tissue
Endodontics are not covered. There are limitations on the number of covered services within a service
category. Frequency limits vary depending on the type of covered service. Some exclusions may apply. See
your dental member handbook for details on covered services.
You can find this information on page 44 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.A pneumatic compression device (PCD) coded as E0652 is covered for the treatment of lymphedemaextending 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 hypoproteinemiaYou 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 plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.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, with limited exceptions, members of the Plan must use network providers to get medical careand 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 46 and 49 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 state 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.
You can find these rules in the Local Coverage Determination (LCD) for Paravertebral Facet Joint Blocks, L33930. This LCD is effective for services provided on or after January 8, 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 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 9 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  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.  In  general,  preventive  and routine  dental  services  are not covered  under  Original  Medicare.   Your  Plan's  Supplemental  Dental  Benefit provides  coverage  for  the dental  services  described  in  detail  below.  Any  services not  listed  below  are not covered.  You can find  this  information  on pages 4-44 to 4-67 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 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. In general, preventive and routine dental services are not covered under Original Medicare. Your Plan's Supplemental Dental Benefit provides coverage for the dental services described in detail below. Any services not listed below are not covered. You can find this information on pages 4-73 to 4-82 of the Plan's 2020 Evidence of Coverage (EOC).