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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints
(L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral
and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury
to or a surgical procedure on the knee(s). Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are
also covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the
LCD-related Policy Article. You can find this information in Local Coverage Determination (LCD): Knee
Orthoses (L33318).

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 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 Center for Medicare and Medicaid Services, Internet Only Manual, Medicare Program Integrity Manual, Chapter 3, Section 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 Home Health Aide (HHA) services may be covered only if the enrollee needs one or more of the following qualified skilled services:

1. Skilled nursing care; 
2. Physical therapy; 
3. Occupational therapy; or 
4. Speech pathology services.

HHA services are no longer covered for enrollees once the qualifying skilled service has ended. To be covered, home health aide services must be reasonable and necessary. You can find this rule at 42 CFR Sections 409.44 and 409.45.

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 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 (6-12 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 greater than or equal to 8) or is nonhospitalized
with moderate to severe pain (NRS or VAS greater than or equal to 5) despite
optimal non-surgical management (NSM) 8 with one of the following:
- Worsening Pain or
- Stable to improved pain (but NRS or VAS greater than or equal to 5) when 2 or
more of the following are present:
- Progression of vertebral body height loss
- greater than 25% vertebral body height reduction
- Kyphotic deformity
- Severe impact of VCF on daily functioning (Roland Morris Disability
Questionnaire (RDQ) greater than17)

Continuum of care
All patients presenting with vertebral compression fractures (VCF) should be referred for evaluation of bone
mineral density and osteoporosis education for subsequent treatment as indicated and instructed to take part in
an osteoporosis prevention/treatment program.
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.

You can find this rule in the Centers for Medicare and Medicaid Services, Local Coverage Determination for
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF), L35130 (eff
07/12/20).

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 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
comprehensive oral evaluation (D0150) and is limited to one procedure every three plan years. The Plan
contract also lists panoramic x-ray (D0330) as a covered benefit and is limited to one procedure every three
plan years. You can find this information on pages 4-52 and 4-53 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 when a SNF resident receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, only the service's professional component (representing the physician's interpretation of the test results) is a separately billable physician service under Part B (see 20.1 of this chapter and 20.1.1 of Chapter 6). By contrast, the technical component representing the procedure itself, including any associated transportation and setup costs, would be subject to consolidated billing (the SNF "bundling" requirement for services furnished to the SNF's Part A residents), and must be included on the SNF's Part A bill for the resident's covered stay. You can find this in the Center for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 13, Section 90.5. The rules say 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 find this in the Center for Medicare and Medicaid Services, Internet Only Manual, Medicare Program Integrity Manual, Chapter 3, Section 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 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 Plan contract includes a list of covered supplemental dental services. Diagnostic casts is not included on this list and is not a covered supplemental benefit. You can find this information on pages 75 to 87 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 may cover medically accepted off-label uses for FDA-approved drugs used in an
anti-cancer chemotherapeutic regimen. Medicare maintains a list of compendia which define if a use is medically accepted. The off-label use must be supported in one or more of these compendia or in published, peer-reviewed medical literature. An off-label use must be supported in one or more of the compendia and the use must not be listed as unsupported, not indicated, not recommended, or equivalent terms, in any of the compendia. An off-label use may also be determined by the carrier in the state to be reasonable and necessary. You can find these rules and the list of the Medicare-recognized compendia in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.5.
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 $110 copayment for outpatient diagnostic tests/radiological diagnostic services. You can find this information on pages 4-30 to 4-33 of the Plan's 2020 EOC. The Plan contract says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. You can find this information on pages 4-27 to 4-28 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.

The rules say that plans must arrange for specialty care outside of the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through arrangements with contracted providers. This includes services available through contracting or non-contracting providers in the area serviced by the health plan including nursing home and community-based services. You can find this rule at 42 CFR Section 422.112.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, as a member of their plan, the enrollee can choose to receive care from out-of-network providers. The Plan will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and medically necessary. However, if the enrollee uses an out-of-network provider, their share of the costs for the covered services may be higher. You can find this information on page 14 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 medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o). The rules say that for L1833, knee instability must be documented by examination of the beneficiary and objective description of joint laxity. You can find this information in the Local Coverage Determination (LCD): Knee Orthoses (L33318).
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 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. 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 54 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 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 $40 copay for each covered specialist office visit. You can find this information on pages 79-80 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that a maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular injections, facet cyst rupture and RF ablations may be performed per rolling 12 month year in the cervical/thoracic spine and five (5) in the lumbar spine. You can find this information in Medicare's FUTURE RETIRED Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L36471).
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 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). 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 pay for durable medical equipment that is mainly used to serve a medical
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are
clearly used for medical purposes. Medicare will not pay for:
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air
conditioners, humidifiers, dehumidifiers and electric air cleaners;
2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. 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.
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 immunizations are not covered unless they are directly related to the treatment of an injury or direct exposure to a disease or condition. In the absence of injury or direct exposure, vaccination or inoculation is not covered. However, pneumococcal, hepatitis B, influenza virus vaccines, and any FDA-approved COVID-19 vaccines are exceptions to this rule. You can find this rule at 42 CFR Section 411.15(e) and Section 3713 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). 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 covered Medicare Part B immunizations include the pneumonia vaccine, flu shots, Hepatitis B vaccine, and other vaccines if you are at risk and they meet Medicare Part B coverage rules. You can find this information on page 47 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that if medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan to determine the initial level of cancer treatment needed for an enrollee. After the completion of the initial anti-cancer therapy, additional FDG PET scans may be covered at the discretion of Medicare. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, National Coverage Determinations Manual, Section 220.6.17.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.