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 Original Medicare pays for the routine costs of qualifying clinical trials. Medicare also pays 
for reasonable and necessary items and services used to diagnose and treat complications arising from 
participation in all clinical trials. The rules also say that Medicare plans must cover these services even if they 
are not available through in-network providers. Medicare plans may require reporting when enrollees 
participate in clinical trials but cannot require prior authorization or approval. You can find these rules in the 
Medicare National Coverage Determinations Manual, Chapter 1, Section 310.1. 
 
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. The Plan 
contract also says that a clinical research study or clinical trial is a way that doctors and scientists test new 
types of medical care. They test new medical care procedures or drugs by asking for volunteers to help with the 
study. This kind of study is one of the final stages of a research process that helps doctors and scientists see if a 
new approach works and if it is safe. 
 
An enrollee who is in a clinical research study may stay enrolled in the Plan and continue to get the care that is 
not related to the study through the Plan. Enrollees must tell the plan before they start participating in a clinical 
research study. 
 
If an enrollee participates in a Medicare-approved study, Original Medicare pays most of the costs for the 
covered services received as part of the study. After Medicare has paid its share of the cost for these services, 
the Plan will also pay for part of the costs. The Plan will pay the difference between the cost-sharing in 
Original Medicare and the cost-sharing as a member of the Plan. This means the enrollee will pay the same 
amount for the services received as part of the study as he or she would if these services were received from the 
Plan. You can find this information on pages on page 48 through 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 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 Plan contract says that 
the Plan will not pay for services you receive from an out-of-network dentist. If you receive services from an 
out-of-network dentist, you will be responsible for all costs related to those services. You can find this 
information on page 6 of the Plan's 2020 Preventive & Comprehensive Dental Coverage Customer Handbook.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 health 
plan contract says that the most you will have to pay out-of-pocket for in-network covered Part A and Part B 
services in 2019 is $4,900. The amounts you pay for your copayments and coinsurance for in-network covered 
services count toward this maximum out-of-pocket amount. You can find this information in Chapter 4 on 
pages 4-2 to 4-3 of the plan's 2019 Evidence of Coverage. 
 
The health plan contract says that enrollees must pay a $0 copayment each day for days 1 to 20. $160 
copayment each day for days 21 to 51. $0 copayment for additional Medicare-covered days, up to 100 days. 
You are covered for up to 100 days each benefit period for inpatient services in a SNF, in accordance with 
Medicare guidelines. A benefit period begins on the first day you go to a Medicare covered inpatient hospital or 
a skilled nursing facility. The benefit period ends when you haven't been an inpatient at any hospital or SNF 
for 60 days in a row. If you go to the hospital (or SNF) after one benefit period has ended, a new benefit period 
begins. There is no limit to the number of benefit periods you can have. You can find this information in 
Chapter 4 on pages 4-42 to 4-43 of the plan's 2019 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 periodic 
oral evaluation (D0120), comprehensive oral evaluation (D0150), and prophylaxis (D1110). Resin-based 
composite (D2391) is not included on this list and is not a covered benefit. You can find this information on 
page 57 of the Plan?s 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that therapeutic continuous glucose monitors (CGMs) and related supplies are covered by 
Medicare when all of the following coverage criteria (1-6) are met: 
1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article 
for applicable diagnoses); and, 
2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and, 
3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump; and, 
4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis 
of BGM or CGM testing results; and, 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with 
the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and, 
6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
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. 
 
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 Thermal Medial Branch Radiofrequency Neurotomy (includes RF and microwave 
technologies) is indicated for coverage: 
&#61623; Only when dual medial branch blocks (MBBs) provide greater than or equal to 80% relief of the 
primary or index pain and duration of relief is consistent with the agent employed may facet joint 
denervation with RF medial branch neurotomy be considered. 
&#61623; Repeat denervation procedures involving the same joint will only be considered medically necessary if 
the patient experienced greater than or equal to 50% improvement of pain and improvement in patient 
specific ADLs documented for at least 6 months. 
You can find this rule in the Local Coverage Determination for Facet Joint Injections, Medial Branch Blocks, 
and Facet Joint Radiofrequency Neurotomy, L35936 (eff 12/05/19). 
 
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 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 chemotherapy and other drugs covered by Medicare 
Part B. Covered drugs include drugs that usually aren't self-administered by the patient and are injected or 
infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. You can 
find this information on pages 67 to 68 of the Plan's 2019 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 health 
plan contract says that enrollees must pay a $295 copayment per day, days 1-5 (per in-network Medicare-
covered stay). You can find this information in Chapter 4 on page 73 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 repeat polysomnography (PSG) or PSG with CPAP titration may be indicated in the 
following circumstances: 
1. After surgical treatment of patients with OSA, to ensure satisfactory response; or 
2. After surgical treatment of patients with OSA whose symptoms return despite a good initial response to 
treatment. 
3. After substantial weight loss has occurred in patients on PAP for treatment of OSA to ascertain whether PAP 
is still needed at the previously titrated pressure; 
4. After substantial weight gain has occurred in patients previously treated with PAP successfully, who are 
again symptomatic despite the continued use of PAP, to ascertain whether pressure adjustments are needed; or 
5. When clinical response is insufficient or when symptoms return despite a good initial response to treatment 
with PAP 
6. Initial CPAP was not tolerated and BPAP is to be used in lieu of CPAP. 
 
You can find these rules in Local Coverage Determination (LCD): Polysomnography and Sleep Testing 
(L33405). 
 
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 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 patients 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 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 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 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 patients 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 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 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.
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 plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances, 
Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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 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. The contract specifically says that any 
procedure not listed is not covered. Core buildup, including any pins when required (D2950) is not included on 
this list and is not a covered supplemental benefit. You can find this information on pages 22 to 30 of the Plan's 
2020 Preventive & Comprehensive Dental Coverage Customer Handbook.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that sterilization is covered only where sterilization is a necessary part of the treatment of an 
illness or injury (e.g. removal of a uterus because of a tumor, removal of disease ovaries). Elective 
hysterectomy, tubal ligation, and vasectomy are not covered by Medicare if the primary indication for the 
procedure is sterilization. A sterilization that is performed because a physician believes a pregnancy would 
endanger the overall general health of the enrollee is not considered to be reasonable and necessary for the 
diagnosis or treatment of illness or injury according to Medicare rules. You can find these rules in National 
Coverage Determination (NCD) for Sterilization (230.3). 
 
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.
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). 
 
Normally, sleep studies and PSG for sleep disorders are performed in sleep centers or laboratories. However, 
the diagnosis of OSA for coverage of CPAP may also be established by home sleep testing (HST) as indicated 
under Sleep Apnea below.  
 
If HST is used, they may be tested in the home environment after application of the sensors and receiving 
education regarding a monitoring device from the technical, professional, or appropriately trained staff of the 
sleep center or laboratory. The overnight stay in the sleep center or laboratory is considered an integral part of 
PSG, MSLT, and MWT but not for HST. 
HSTs may be used in addition to a face to face clinical assessment by the treating physician and physical examination to diagnose Obstructive Sleep Apnea (OSA) specifically; it is 
intended only for those patients who exhibit clinical signs and symptoms of OSA. HST is not intended to be 
used for the diagnosis of narcolepsy, other respiratory disorders, impotence, parasomnia, restless legs 
syndrome, or periodic limb movements of sleep. HST is not intended to be used for patients with 
comorbidities: congestive heart failure, hypo-ventilation syndrome, moderate to severe pulmonary disease, or 
neuromuscular disease. 
 
You can find these rules in Local Coverage Determination (LCD): Polysomnography and Sleep Testing 
(L33405). 
 
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.