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 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 30 of the 2021 Evidence
of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $150 copayment for outpatient hospital services/services performed at an outpatient facility. You can find this information on pages 82-86 of the Plan's 2020 Evidence of Coverage (EOC). The Plan contract says that enrollees must pay a $45 copayment for physician/practitioner services/specialist. You can find this information on pages 89-91 of the Plan's 2020 EOC. The Plan contract says that enrollees must pay a $50 copayment for outpatient diagnostic tests/in-network/diagnostic tests. You can find this information on pages 80-81 of the Plan's 2020 (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Sections 422.2 and 422.136.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You can find this information in Chapter 4 on pages 94 to 95 of the Plan's 2021 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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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 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 pages 3-4 and 3-7 of the Plan's 2020 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that 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 provides coverage for both in-network and out-of-network services. Services obtained out-of-network carry a higher cost-share. An exception is made if the plan cannot provide the service with network providers. This information can be found on page 10 of the 2021 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 each patient must be thoroughly evaluated by a physician or non-physician practitioner whose license and state scope of practice allow evaluation and treatment outlined in this LCD. A central or systemic source of pain or neurologic deficit shall be determined prior to epidural injection. If a central or systemic process is present, but the pain or neurologic deficit is clearly unrelated, injection therapy or EI may still be indicated when at least one of the indications listed below is present. 1. Pain from Herpes Zoster or suspected radicular pain based on radiation of pain along the dermatome of a nerve. 2. Pain from Neurogenic claudication that includes any of the following: Pain severe enough to cause some degree of functional deficit; Failure of at least four weeks of noninvasive care*; Imaging demonstrating a correlative region of nerve/cord impingement. 3. Pain from CervicoThoracic or Lumbar radicular pain with any of the following: Pain severe enough to cause some degree of functional deficit; Failure of at least four weeks of non-invasive care*; Imaging demonstrating a correlative region of nerve impingement. 4. Back pain without lower extremities symptoms and failure of four weeks of non-surgical, non-injection care* with either: documented VAS for pain or NPRS greater than or equal to 3/10 (moderate to severe pain), OR functional impairment in ADLs; AND the pain or functional impairment is associated with any of the following: substantial imaging abnormality, such as a central disc herniation or high intensity zone; documented severe degenerative disc disease or central spinal stenosis; discogenic pain, not attributable to facet joint or sacroiliac joint pain. You can find this information in Medicare's Local Coverage Determination (LCD): Epidural Injections for Pain Management (L36920).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your home may be a dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, an institution may not be considered your home if it is an acute hospital or a skilled nursing facility (SNF). You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D). The rules say that the applicable payments made under the prospective payment systems (PPS) are payment in full for all facility or hospital services, as defined in 42 CFR 409.10. CMS does not pay any provider or supplier other than the facility or hospital for supplies furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements (as defined in 42 CFR 409.3). You can see this in 42 CFR 412.50 - "Furnishing of inpatient hospital services directly or under arrangements." Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and necessary for the following indications:
1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have not responded to non-surgical medical management (e.g. narcotic and/or non- narcotic medication, physical therapy modalities) with and without methods of immobility (e.g. rest, bracing).
- Both PVP and PVA will be considered reasonable and necessary when ALL of the following criteria are met:
~ Acute (less than 6 weeks) or subacute (6 to 12 weeks) osteoporotic VCF (T5 - L5) confirmed by recent (within 30 days) advanced imaging demonstrating bone marrow edema on MRI or bone-scan/SPECT/CT uptake and
~ The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or Visual Analog Scale [VAS] pain score 8 or greater) or is non-hospitalized with moderate to severe pain (NRS or VAS 5 or greater) despite optimal non-surgical management (NSM) with one of the following:
i. Worsening Pain or
ii. Stable to improved pain (but NRS or VAS 5 or greater) when 2 or more of the following are present:
a. Progression of vertebral body height loss
b. Greater than 25% vertebral body height reduction
c. Kyphotic deformity
d. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) greater than 17)
2. Malignant Vertebral Fractures: Osteolytic vertebral metastasis or myeloma with severe back pain related to a destruction of the vertebral body, not involving the major part of the cortical bone.
The exclusions for percutaneous vertebroplasty and percutaneous vertebral augmentation procedures include:
1. Absolute contraindication
- Current back pain is not primarily due to the identified acute or subacute VCF(s).
- Osteomyelitis, discitis or active systemic infection
- Pregnancy
- Greater than three vertebral fractures
2. Relative contraindication
- Allergy to bone cement or opacification agents
- Uncorrected coagulopathy
- Spinal instability
- Myelopathy from the fracture
- Neurologic deficit
- Neural impingement
- Fracture retropulsion / canal compromise
These procedures are not indicated for treatment to the sacrum or coccyx area. You can find these rules in Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L35130).
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 when billing for auricular electrostimulation devices, the not otherwise classified code 64999. The service for auricular peripheral nerve stimulation (CPT code 64999) will be denied as non-covered. This service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary under Section 1862(a)(1) of the Act. While the information given in this article is directed to Neurostim system/NSS, P-Stim, ANSiStim, E-Pulse, and NSS-2 Bridge, other current or future devices when used for the procedure auricular peripheral nerve stimulation or electro-acupuncture, would also be considered a non-covered service. You can find this information in the Local Coverage Article: Billing and Coding: Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device) (A55240).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. You can find this information on page 56 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 tooth extractions covered at 50%. This benefit does not list deep sedation/general anesthesia, drugs dispensed for home use, nitrous oxide/analgesia, therapeutic parenteral drugs or unspecified preventative procedures. You can find this information on pages 87-88 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 may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Sections 422.2 and 422.136.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You can find this information on pages 92-93 of the Plan's 2021 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.
A pneumatic compression device (PCD) coded as E0652 is covered for the treatment of lymphedema extending
onto the chest, trunk and/or abdomen when all of the following are met:
- The beneficiary has lymphedema of an extremity.
- The coverage criteria for an E0650 or E0651 PCD are met.
- The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the
limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to
improve with a four-week trial.
You can find this information at Local Coverage Determination (LCD): Pneumatic Compression Devices
(L33829).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 list fluoride treatments or bone replacement grafts as covered services. You can find this information on page 33 of the Plan's 2021 Evidence of Coverage (EOC) and in the Plan's dental vendor's Benefit Booklet.
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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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 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 40 of the Plan's 2020
Evidence of Coverage.