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 a group 2 support surface is covered if the beneficiary meets at least one of the following
three Criteria (1, 2 or 3):
1. The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis (refer to the ICD-10 code
list section in the LCD-related Policy Article for applicable diagnoses) which have failed to improve over the
past month, during which time the beneficiary has been on a comprehensive ulcer treatment program including
each of the following:
a. Use of an appropriatge group1 support surface, and
b. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and
c. Appropriate turning and positioning, and
d. Appropriate wound care, and
e. Appropriate management of moisture/incontinence, and
f. Nutritional assessment and intervention consistent with the overall plan of care
2. The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (refer to the ICD-
10 code list section in the LCD-related Policy Article for applicable diagnoses),
3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the
past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses),
and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing
facility within the past 30 days
You can find this rule in the Local Coverage Determination (LCD): Pressure Reducing Support Surfaces -
Group 2 (L33642) effective January 1, 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.
Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise
reasonable and necessary for the patient. FDA approved drugs used for indications other than what is indicated
on the official label may be covered if the use is determined to be medically accepted, taking into consideration
the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. You
can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50.4.1 and 50.4.2.
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 indications for lumbar epidural injections include:
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 greater than or equal to 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.
You can find this rule in the Local Coverage Determination for Lumbar Epidural Injections, L35937 (eff
10/17/19).
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. This benefit includes
coverage for up to 3 simple or surgical extractions per calendar year. You can find this information in the
Plan's 2020 Dental Benefit Schedule DEN049.
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 kyphoplasty is covered in patients with both of the following: 1. Inclusion criteria (ALL ARE REQUIRED) a. Acute (less than six weeks) osteoporotic VCF (T5-L5) by recent (within 30 days) advanced imaging (bone marrow edema on MRI or bone scan/SPECT/CT uptake b. Symptomatic (ONE) i. Hospitalized with severe pain (NRS or VAS of 8 or more) ii. Non-hospitalized with moderate to severe pain (NRS or VAS of 5 or more) despite optimal non-surgical management (ONE) 1. Worsening pain 2. Stable to improved pain (but NRS or VAS still 5 or more) (with 2 or more of the following) A. Progression of vertebral body height loss B. More than 25% of vertebral body height reduction C. Kyphotic deformity D. Severe impact of VCF on daily functioning c. Multidisciplinary team consensus (ALL ARE REQUIRED)
a. Acute (less than six weeks) osteoporotic VCF (T5-L5) by recent (within 30 days) advanced imaging (bone marrow edema on MRI or bone scan/SPECT/CT uptake b. Symptomatic (ONE) i. Hospitalized with severe pain (NRS or VAS of 8 or more) ii. Non-hospitalized with moderate to severe pain (NRS or VAS of 5 or more) despite optimal non-surgical management (ONE) 1. Worsening pain 2. Stable to improved pain (but NRS or VAS still 5 or more) (with 2 or more of the following) A. Progression of vertebral body height loss B. More than 25% of vertebral body height reduction C. Kyphotic deformity D. Severe impact of VCF on daily functioning c. Multidisciplinary team consensus (ALL ARE REQUIRED) i. Referring physician (e.g., rheumatologist, endocrinologist) ii. Treating physician (i.e., performing the PVA) iii. Radiologist iv. Neurologist 2. Exclusion criteria (Can have NONE of the following): a. Absolute contraindication
1. Current back pain is not primarily due to the identified acute VCF(s). 2. Osteomyelitis, discitis or active systemic infection 3. Pregnancy 4. Greater than three vertebral fractures b. Relative contraindication 1. Allergy to bone cement or opacification agents 2. Coagulopathy 3. Spinal instability 4. Myelopathy from the fracture 5. Neurologic deficit 6. Neural impingement 7. Fracture retropulsion/canal compromise
You can find this rule in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L33569) - Effective December 16, 2019.
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 power seat elevation feature (E2300) and power standing feature (E2301) are non-covered
because they are not primarily medical in nature. You can find this rule in the Local Coverage Article for
Wheelchair Options/Accessories - Policy Article (A52504).
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 20% coinsurance for Medicare Part B prescription drugs, whether
obtained from an in-network or out-of-network provider. Additionally, you may be responsible for separate
cost-sharing for the administration of Medicare Part B drugs. You can find this information in Chapter 4 on
pages 4-33 to 4-35 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 a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints
(L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both mediallateral
and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury
to or a surgical procedure on the knee(s).
Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is
ambulatory and has knee instability due to a covered condition.
For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by
examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability,
anterior/posterior Drawer test).
You can find this rule in the Local Coverage Determination (LCD): Knee Orthoses (L33318) effective January
1, 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 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 3-4 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 Part B generally does not pay for drugs that are usually self-administered by the
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for selfinjection.
The only exceptions are:
1. blood-clotting factors;
2. drugs used in immunosuppressive therapy;
3. erythropoietin for dialysis patients;
4. osteoporosis drugs for certain homebound patients;
5. certain oral cancer drugs;
6. oral anti-emetics used in certain situations;
7. drugs treated as supplies during an outpatient hospital procedure; and
8. drugs required for the effective use of durable medical equipment.
You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.
The rules say that effective January 1, 1998, Medicare also covers self-administered anti-emetics, which are
necessary for the administration and absorption of the anti-neoplastic chemotherapeutic agents when a high
likelihood of vomiting exists. You can find this information in the Medicare Benefit Policy Manual, Chapter
15, 50.5.4
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 does not include
coverage for dentures. You can find this information on page 84 of the Plan's 2020 Evidence of Coverage
(EOC) and in the Plan's 2020 Dental Benefit Schedule DEN049.
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 long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of
stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the
diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need
medical care. You can find this rule in the Medicare Program Integrity Manual, Chapter 6, Section 6.5.2.
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 Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare Program Integrity Manual Chapter 3  3.3.2.1.
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 at42 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 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 Plancovers 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).
The rules say that psychological and neuropsychological diagnostic tests are used when mental illness is
suspected, and clarification is essential for the diagnosis and the treatment plan. Testing conducted when no
mental illness/disability is suspected would be considered screening and would not be covered by Medicare.
Non-specific behaviors that do not suggest the possibility of mental illness or disability are not an acceptable
indication for testing. You can find this information in the Local Coverage Determination (LCD): Psychiatric
Codes (L35101).
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). 
 
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 as a member of the Plan, you can receive your care from either an in-network or out-ofnetwork provider. If you use an out-of-network provider, your share of the costs for covered services may be higher. While you can get care from an out-of-network provider, the provider must be eligible to participate in Medicare. Except for emergency care, the Plan cannot pay a provider who is not eligible to participate in Medicare. You can find this information in Chapter 3 on pages 41 to 42 of the Plan's 2020 Evidence of Coverage. 
 
The Plan contract says that enrollees must pay 20% coinsurance for each out-of-network inpatient hospital stay. You can find this information in Chapter 4 on pages 72 to 73 of the Plan's 2020 Evidence of Coverage. 
 
The Plan contract also says that enrollees must pay 20% coinsurance for out-of-network covered outpatient hospital services. You can find this information in Chapter 4 on page 80 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 say that for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare
Program Integrity Manual Chapter 3  3.3.2.1.
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 says that there is a 20% coinsurance for Medicare Part B drugs. You can see this on page 74 of the 2020 Evidence of Coverage.