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 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; 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-coveredcontinuous subcutaneous insulin infusion (CSII) pump; and, 
4. The beneficiarys 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. 
 
If any of coverage criteria (1-6) are not met, the CGM and related supply allowance will be denied as not 
reasonable and necessary. You can find these rules in Local Coverage Determination (LCD) Glucose Monitors 
(L33822). 
 
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). 
 
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). 
 
CMS has not issued specific coverage criteria in the form of an LCD (Local Coverage Determination) or NCD 
(National Coverage Determination) for this particular item or service. However, per Social Security Act, 
Section 1862 (a)1(A) and the 42 CFR Section 411.15(k), Medicare does not pay for any items or services that 
are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member. The determination of medical necessity must be tailored to the 
individual patient and their unique clinical scenario. CMS considers services to be medically reasonable and 
necessary if they are:  
 
- Safe and effective; 
- Not mainly for the convenience of the patient or the physician; 
- Not experimental or investigational; and 
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of 
whether it is: 
   - Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the 
patient's condition or to improve the function of a malformed body member; 
   - Furnished in a setting appropriate to the patient's medical needs and condition; 
   - Ordered and furnished by qualified personnel; 
   - One that meets, but does not exceed, the patient's medical need; and 
   - At least as beneficial as an existing and available medically appropriate alternative. 
You can find this rule in the Medicare Program Integrity Manual, Chapter 13, Section 13.5.4. 
 
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 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). 
 
Facet joint blocks will be considered reasonable and necessary for chronic pain (persistent pain for three (3) 
months 
or greater) suspected to originate from the facet joint. Facet joint block is one of the methods used to 
document/confirm suspicions of posterior element biomechanical pain of the spine. Hallmarks of posterior 
element 
biomechanical pain are: 
The pain does not have a strong radicular component. 
There is no associated neurological deficit and the pain is aggravated by hyperextension, rotation or lateral 
bending of the spine, depending on the orientation of the facet joint at that level. 
You can find this information in Local Coverage Determination (LCD): 
Paravertebral Facet Joint Blocks (L33930). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract lists the specific 
dental services that are covered. Implants are not listed and therefore are not a covered service. General 
anesthesia is not listed and therefore is not a covered service. The contract also says if a dental item or service 
is not listed in the benefit chart or listed with NC, then it is not covered. You can find this information on pages 
22 to 29 of the Dental Plan's 2020 Customer Handbook 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. 
 
The rules say that precautionary-type equipment is considered nonmedical in nature and not covered. You can 
find this rule at the Medicare Benefit Policy Manual, Chapter 15, 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 state that Dorsal column stimulators may be covered as therapies for the relief of chronic intractable 
pain under the following circumstances: 
1. To treat chronic pain caused by lumbosacral arachnoiditis that has not responded to medical 
management including physical therapy. (Presence of arachnoiditis is usually documented by presence 
of high levels of proteins in the Cerebrospinal Fluid [CSF] and/or by myelography or Magnetic 
Resonance Imaging [MRI]). 
2. To treat intractable pain caused by nerve root injuries, post-surgical or post-traumatic including that of 
post-laminectomy syndrome (failed back syndrome). 
3. To treat intractable pain caused by complex regional pain syndrome I & II. 
4. To treat intractable pain caused by phantom limb syndrome that has not responded to medical 
management. 
5. To treat intractable pain caused by end-stage peripheral vascular disease, when the patient cannot 
undergo revascularization or when revascularization has failed to relieve painful symptoms and the pain 
has not responded to medical management. 
6. To treat intractable pain caused by post-herpetic neuralgia. 
7. To treat intractable pain caused by plexopathy. 
8. To treat intractable pain caused by intercostal neuralgia that did not respond to medical management 
and nerve blocks. 
9. To treat intractable pain caused by cauda equina injury. 
10. To treat intractable pain caused by incomplete spinal cord injury. 
You can find these rules in the Local Coverage Determination (LCD) for Spinal Cord Stimulation (Dorsal 
Column Stimulation) (L35450. This LCD is effective for services provided on or after September 26, 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 the Centers for Medicare & Medicaid Services (CMS) covers percutaneous LAAC for non-
valvular atrial fibrillation (NVAF) through Coverage with Evidence Development (CED) with the following 
conditions: 
a. LAAC devices are covered when the device has received Food and Drug Administration (FDA) 
Premarket Approval (PMA) for that devices FDA-approved indication and meet specified conditions. 
b. The patient is enrolled in, and the MDT and hospital must participate in, a prospective, national, audited 
registry that: 1) consecutively enrolls LAAC patients, and, 2) tracks the following annual outcomes for 
each patient for a period of at least 4 years from the time of the LAAC. 
Registries must be reviewed and approved by CMS. Potential registry sponsors must submit all registry 
documentation to CMS for approval, including the written executable analysis plan and auditing plan. The 
registrys national clinical trial number must be recorded on the claim. LAAC is non-covered for the treatment 
of NVAF when not furnished under CED according to the above-noted criteria. You can find this rule in the 
Medicare National Coverage Determination for Percutaneous Left Atrial Appendage Closure (LAAC), 20.34. 
 
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 F2 gene (prothrombin coagulation factor II) and F5 gene (coagulation factor V) The F2 and 
F5 genetic tests are not considered to be clinically efficacious; therefore, testing is not medically necessary. 
You can find this rule at Local Coverage Article: Billing and Coding: Molecular Pathology Procedures 
(A56199) (eff. 7/1/20). 
 
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 MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the 
following conditions are met (42 CFR 422.100(l)): 
The MA plan provides all categories of DME covered under original Medicare Part B;  
The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) 
DME products or brands; 
 The MA plan?s contracted suppliers provide access to all preferred DME brands; 
 During an enrollee?s first year of enrollment in an MA plan, if the enrollee requests, the plan will 
provide a 90-day transition period (commencing with the initial time of enrollment) during which the plan 
provides (and repairs, as applicable) non-preferred DME brands furnished in the previous year; 
Although the MA plan may add brands to its preferred formulary during the year, it may not remove 
any brands mid-year; 
The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-
preferred DME product or brand with the EOC and ANOC and on its website; and 
The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories 
or subcategories annually determined by CMS to require full coverage. 
 
You can find this rule at the Medicare Managed Care Manual, Chapter 4, Section 10.12.2. 
 
 
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.
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 $175 copayment for advanced imaging services. You can find this 
information on page 77 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 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 $30 copayment for each Medicare-covered physical therapy and/or 
speech and language pathology visit. You can find this information on page 74 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 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 $370 copayment for Medicare-covered surgery or other services 
provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and 
physician or surgical charges. You can find this information on pages 4-49 and 4-50 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 sacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-
frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation 
to determine if an implantable stimulator would be effective and a permanent implantation in appropriate 
candidates. The following limitations for coverage apply to all three indications: 
? Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or 
surgical corrective therapy) and be an appropriate surgical candidate such that implantation with 
anesthesia can occur. 
? Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes 
with peripheral nerve involvement) which are associated with secondary manifestations of the above 
three indications are excluded. 
? Patient must have had a successful test stimulation in order to support subsequent implantation. Before 
a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement 
through test stimulation. Improvement is measured through voiding diaries. 
? Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical 
results of the implant procedure can be properly evaluated. 
You can find this rule in the Medicare National Coverage Determination for Sacral Nerve Stimulation for 
Urinary Incontinence, 230.18. 
 
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. 
 
Botulinum toxin injections are used to treat various focal muscle spastic disorders and excessive muscle 
contractions such as dystonias, spasms, twitches, etc. These drugs produce a presynaptic neuromuscular 
blockade by preventing the release of acetylcholine from the nerve endings. The resulting chemical denervation 
of muscle produces local paresis or paralysis and allows individual muscles to be weakened selectively. 
Botulinum toxins have the advantage of being potent neuromuscular blocking agents with good selectivity and 
duration of action. You can find this information in Local Coverage Determination (LCD): Botulinum Toxin 
Types A and B Policy (L35170). 
 
The patient's medical record should include the following elements to support the medical necessity of the 
Botulinum Toxin injection: 
?Type of Botulinum toxin used: Botox (onabotulinumtoxinA), Dysport (abotulinumtoxinA), Xeomin 
(incobotulinumtoxinA) or Myobloc (rimabotulinumtoxinB) 
?Strength of toxin used 
?A covered diagnosis (However, when a form of Botulinum toxin is used for an indication that is not a listed 
indication in the AHFS, a physician statement in the medical record stating the reason(s) why the unapproved 
form was used is also required). 
?A statement that traditional methods of treatments have been tried and proven unsuccessful (except for focal 
dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writer?s cramp, laryngeal spasm, or 
dysphonia). 
?Dosage used in the injections. 
?Support for the medical necessity of electromyography procedures if performed. 
?Support of the clinical effectiveness of the injections. 
?A complete description of the site(s) injected. 
You can find this information in Local Coverage Article: Billing and Coding: Botulinum Toxin Types A and B 
Policy (A57185). 
 
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.