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 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 non-radiological diagnostic services and tests. You 
can find this information on page 4-40 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 the medical necessity for special enteral formulas (B4149, B4153, B4154, B4155, B4157, 
B4161, and B4162) must be justified in each beneficiary. If a special enteral nutrition formula is provided and 
if the medical record does not document why that item is medically necessary, it will be denied as not 
reasonable and necessary. This information can be found in Local Coverage Determination (LCD): Enteral 
Nutrition (L33783). 
 
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 $170 copayment for each covered diagnostic procedure or test at a 
network outpatient facility. You can find this information on page 73 of the Plan's 2019 Evidence of Coverage 
(EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that automatic external defibrillators are covered for beneficiaries at high risk for sudden cardiac 
death (SCD) due to one of the conditions described under I or II. It is expected the treating practitioner be 
experienced in the management of beneficiaries at risk for SCD. A wearable defibrillator (K0606) is covered 
for beneficiaries if they meet one of the criteria (1-4), described below: 
 
1. A documented episode of ventricular fibrillation or a sustained, lasting 30 seconds or longer, ventricular 
tachyarrhythmia. These dysrhythmias may be either spontaneous or induced during an electrophysiologic (EP) 
study, but may not be due to a transient or reversible cause and not occur during the first 48 hours of an acute 
myocardial infarction; or 
2. Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrhythmia such as long 
QT syndrome or hypertrophic cardiomyopathy; or 
3. Either documented prior myocardial infarction or dilated cardiomyopathy and a measured left ventricular 
ejection fraction less than or equal to 0.35; or 
4. A previously implanted defibrillator now requires explantation 
 
You can find this rule in Local Coverage Determination (LCD): Automatic External Defibrillators (L33690) - 
Effective January 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 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 fillings, 
crowns, root planing and scaling, x-rays and other diagnostic imaging, extractions, prophylaxis, topical fluoride 
treatments, apicoectomy, dentures, fixed prosthodontics and some orthodontic services. You can find this 
information on page 46 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 beneficiaries who fail the initial 12 week trial are eligible to re-qualify for a PAP device but 
must have both: 
 
    1. In-person clinical re-evaluation by the treating practitioner to determine the etiology of the failure to 
respond to PAP therapy; and, 
 
    2. Repeat sleep test in a facility-based setting (Type 1 study). This may be a repeat diagnostic, titration or 
split-night study. 
 
You can find these rules in  Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices 
for the Treatment of Obstructive Sleep Apnea (L33718). 
 
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. 
 
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion 
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the 
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find 
this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 290(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 if the enrollee uses an out-of-network provider the enrollee?s share of the costs for the 
covered services may be higher. You can find this information on page 31 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 the maximum utilization limit for A7034 is 1 per 3 months. You can find this rule in Local 
Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive 
Sleep Apnea (L33718) - Effective January 1, 2020. 
 
The rules say that the maximum utilization limit for A7035 is 1 per 6 months. You can find this rule in Local 
Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive 
Sleep Apnea (L33718) - Effective January 1, 2020. 
 
The rules say that the maximum utilization limit for A7037 is 1 per 3 months. You can find this rule in Local 
Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive 
Sleep Apnea (L33718) - Effective January 1, 2020. 
 
The rules say that the maximum utilization limit for A7038 is 2 per 1 month. You can find this rule in Local 
Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive 
Sleep Apnea (L33718) - Effective January 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 pays for care in a skilled nursing facility (SNF) when all of the following four 
factors are met: 

1. The patient requires skilled nursing or skilled rehabilitation services; 
2. The patient requires these services on a daily basis; 
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and 
4. The services are reasonable and necessary for the treatment of the patient?s illness or injury or the services 
must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from 
getting worse.  
 
You can find these rules at 42 CFR Section 409.31 and in the Medicare Benefit Policy Manual, Chapter 8, 
Section 30.   
 
The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need 
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of 
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, 
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also 
custodial care services. You can find this rule in the Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that hearing services and hearing aids must be provided in network. The provider must 
follow prior authorization requirements. You can see this on pages 4-16 and 4-17 of the 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 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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that there is a $1500 deductible for 2020. You can see this on page 57 of the 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 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). 
 
No more than two transforaminal injections may be performed at a single setting (e.g. single level bilaterally or 
two levels unilaterally). You can find this information in Local Coverage Determination (LCD): Lumbar 
Epidural Injections (L35937). 
 
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 Therapeutic CGMs and related supplies are covered by Medicare when all of the following 
coverage criteria (1-6) are met: 
 
1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses); and, 
 
2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and, 
 
3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump; and, 
 
4. The beneficiary?s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results; and, 
 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the 
beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and, 
 
6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person 
visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
You can find these rules in the Local Coverage Determination (LCD) for Glucose Monitors, L33822. This 
LCD is effective for services provided on or after January 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 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 1 upper 
partial denture with cast metal framework and resin denture bases, and 1 lower partial denture with cast metal 
framework and resin denture bases every 5 plan years. You can find this information on page 4-57 of the Plan?s 
2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the thermal radiofrequency destruction of cervical, thoracic or lumbar paravertebral facet 
joint (median branch) nerves will be considered to be medically reasonable and necessary as follows: 
 
    - Initial thermal RF ablation: 
        - After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with 
each one providing a minimum of 80% relief of primary (index) pain (with the duration of relief being 
consistent with the agent used) or at least 50% improvement in the ability to perform previously painful 
movements and ADLs;  
        OR 
        - After the patient has had at least one (1) medically reasonable and necessary therapeutic injection that 
provided at least 50% pain relief for at least three (3) months. 
    - Repeat thermal facet joint RF ablation at the same anatomic site is considered medically reasonable and 
necessary provided the patient had a minimum of 50% improvement in pain for at least six (6) months.  
 
You can find the information in the Local Coverage Determination (LCD):  Facet Joint Interventions for Pain 
Management (L34892). 
 
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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 there is a $300 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses at a network optical provider (1 per calendar year). You can find this information on page 87 of 
the Plan's 2020 Evidence of Coverage. The Plan contract also says that in order for reimbursement you must 
send the Plan your request for payment, along with your bill and documentation of any payment you have 
made. You can find this information on page 136 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that items can only be covered by Medicare if they fall into a certain benefit category, such as 
durable medical equipment (DME). The DME contractor, which processes claims for such items, provides a 
list of items which are not covered. Some items may not meet the definition of a Medicare benefit or may be 
statutorily excluded. Items on this list will always be denied as noncovered. This includes sit to stand systems 
described by HCPCS code E0637. You can find this information at 
https://med.noridianmedicare.com/web/jadme/topics/noncovered-items which is based on the Medicare 
National Coverage Determinations Manual, Chapter 1, Section 280.1. 
 
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 plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances, 
Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that a contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 160. 
 
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.