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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the 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 Section 423.578(b)(5)(ii). 
 
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 page 76 of the 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 DME is defined as equipment can withstand repeated use; i.e., could normally be rented, and 
used by successive patients. You can find this rule in National Coverage Determination (NCD) for Durable 
Medical Equipment (DME) Reference List (280.1) - Effective April 1, 2003. 
 
The rules say that catheters are denied, as they are considered non-reusable and a disposable supply. You can 
find this rule in National Coverage Determination (NCD) for Durable Medical Equipment (DME) Reference 
List (280.1) - Effective April 1, 2003. 
 
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: 
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 
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. 
 
Per Medicare references listed below the rules state: "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. 
Physicians must report services correctly. This manual discusses general coding principles in Chapter I and 
principles more relevant to other specific groups of HCPCS/CPT codes in the other chapters. There are certain 
types of improper coding that physicians must avoid. Procedures should be reported with the most 
comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A 
HCPCS/CPT code may be reported only if all services described by that code have been performed." We have 
insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. 
You can find this information in the Medicare Program Integrity Manual, Chapter 3 - Verifying Potential 
Errors and Taking Corrective Action, Section 3.3.2.1-Documents on Which to Base a Determination and 
National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1-General Correct Coding 
Policies, Section A-Introduction, page I-7 and I-8. 
 
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 a power wheelchair (K0013) is covered if the beneficiary has the mental and physical 
capabilities to safely operate the power wheelchair that is provided or the beneficiary is unable to safely operate 
the power wheelchair, the beneficiary has a caregiver who is unable to adequately propel an optimally 
configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is 
provided, and the beneficiary's home provides adequate access between rooms, maneuvering space, and 
surfaces for the operation of the power wheelchair that is provided. You can find these rules and full coverage 
criteria in Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
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 one 
complete or partial denture every five years. You can find this information on page 83 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 ATN1 testing is not covered. You can find this rule in the Local Coverage Determination 
(LCD) for Molecular Pathology Procedures, L35000. This LCD is effective for services provided on or after 
July 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 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 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 Section 423.578(b)(5)(ii). 
 
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 page 110 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 spinal cord stimulators may be covered as therapy for relief of chronic intractable pain, 
provided that the following conditions are met: 
 
a) The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic 
intractable pain;  
b) With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for 
the given patient;  
c) Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation);  
d) All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be available; 
and  
e) Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find this rule in the Medicare National Coverage Determinations Manual, Section 160.7(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.
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 genetic testing for the MTHFR gene for all risk factors, signs, symptoms, diseases, or 
conditions, including cardiovascular risk assessment, are non-covered except for pregnant patients.  
You can find these rules in the Local Coverage Determination (LCD) for MolDX: Genetic Testing for 
Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR), L35984. This 
LCD is effective for services provided on or after October 31, 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 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 2 oral 
exams, 2 cleanings and 2 fluoride treatments per year and dental x-rays. You can find this information on pages 
65-68 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. This benefit includes all of 
the covered dental codes on page 20-29 of the 2020 Evidence of Coverage. Any service not listed here is not 
covered.
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 CT scans are covered if there is literature to support its use for the patient's condition and the 
scan is reasonable and necessary for the patient. You can find this rule in the Medicare National Coverage 
Determinations Manual, Section 220.1(A). 
 
The rules say that the single photon emission computed tomograph (SPECT) acquires information on the 
concentration of radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical 
conditions including: 
 
-stress fracture. 
-spondylosis. 
-infection (e.g., discitis). 
-tumor (e.g., osteoid osteoma). 
-analyze blood flow to an organ, as in the case of myocardial viability. 
-differentiate ischemic heart disease from dilated cardiomyopathy. 
 
You can find this rule in National Coverage Determination (NCD) for Single Photon Emission Computed 
Tomography (SPECT) (220.12) - Effective October 1, 2002. 
 
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 routine (yearly) re-evaluation of patients with heart failure (systolic or diastolic) in whom
there is no change in clinical status is deemed not medically necessary.
You can find these rules in the Local Coverage Determination (LCD) for Transthoracic Echocardiography
(TTE), L33577. This LCD is effective for services provided on or after October 1, 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 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 one 
upper and one lower partial denture every five years. Crown lengthening, post and core additions, retainer 
crowns, precision attachments, and pontics are not listed as covered benefits. You can find this information on 
page 82 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. This benefit includes 2 oral 
exams per year, 2 cleanings per year, 1 set of bitewing x-rays per year and 1 panoramic x-ray every 3 years. 
You can find this information on page 84-85 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. This benefit includes 
coverage for scaling and root planing code D4341 for one procedure per quadrant every two plan years, not to 
exceed four unique quadrants every two plan years. You can find this information in Chapter 4 on pages 4-53 
to 4-62 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 items that do not contribute meaningfully to the treatment of an illness or injury or the 
functioning of a malformed body member are not covered. You can find this rule at the Medicare Benefit 
Policy Manual, Chapter 16, Section 80. 
 
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.