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 pays for therapeutic continuous glucose monitors (CGMs) when they are medically 
reasonable and necessary. Therapeutic CGMs are defined in CMS Ruling 1682R. You can find these rules in 
Local Coverage Article A52464, effective on and after January 12, 2017. 
 
CGMs consist of three components: a glucose sensor, a transmitter, and a receiver. CGMs are considered 
therapeutic CGMs if they are: 
- approved by the FDA for use in place of a blood glucose monitor for making diabetes treatment decisions (for 
example, changes in diet and insulin dosage); 
- generally not useful to the individual in the absence of an illness or injury; 
- appropriate for use in the home; and 
- those which include a durable component that can withstand repeated use, are expected to last at least three 
years, and are capable of displaying the trending of the continuous glucose measurements. 
 
The rules also say that a CGM which does not replace a blood glucose monitor for making diabetes treatment 
decisions is not covered. You can find these rules in CMS Ruling 1682R. 
 
The rules say 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 Codes that are Covered" section of 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. When a 
therapeutic CGM (code K0554) is covered, the related supply allowance (code K0553) is also covered. 
 
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 this rule in the Local Coverage Determination (LCD): Glucose 
Monitors (L33822) effective January 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: 
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 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 one 
crown procedure per tooth every five plan years. You can find this information on pages 42-43 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 Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 47 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 POWER OPERATED VEHICLES (K0800, K0801, K0802, K0806, K0807, K0808, K0812): 
 
A POV is covered if all of the basic coverage criteria (A-C) have been met and if criteria D-I are also met. 
 
    The beneficiary is able to: 
 
Safely transfer to and from a POV, and 
Operate the tiller steering system, and 
Maintain postural stability and position while operating the POV in the home. 
The beneficiary's mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are       
sufficient for safe mobility using a POV in the home. 
 
The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the POV that is provided. 
 
The beneficiary's weight is less than or equal to the weight capacity of the POV that is provided and greater 
than or equal to 95% of the weight capacity of the next lower weight class POV  i.e., a Heavy Duty POV is 
covered for a beneficiary weighing 285 - 450 pounds; a Very Heavy Duty POV is covered for a beneficiary 
weighing 428 - 600 pounds. 
 
Use of a POV will significantly improve the beneficiary?s ability to participate in MRADLs and the beneficiary 
will use it in the home. 
 
The beneficiary has not expressed an unwillingness to use a POV in the home. 
 
If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable 
and necessary. 
 
Group 2 POVs (K0806, K0807, K0808) have added capabilities that are not needed for use in the home. 
Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary. 
 
If a POV will only be used outside the home, see related Policy Article for information concerning 
noncoverage. 
 
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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 22-25 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 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 partial 
dentures, which are covered once every five plan years. You can find this information on page 4-89 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 sacroiliac (SI) joint injections would be considered medically reasonable and necessary for 
the diagnosis and/or treatment of chronic low back pain that is considered to be secondary to suspected 
sacroiliac joint dysfunction. Diagnostic and therapeutic injections of the SI joint would not likely be performed 
unless conservative therapy and noninvasive treatments (i.e., rest, physical therapy, NSAIDs, etc.) have failed. 
Diagnostic blocks of a sacroiliac joint can be performed to determine whether it is the source of low back pain. 
Arthropathy (joint disease) is diagnosed through a double-comparative local anesthetic blockade of the joint by 
the intra-articular injection of a small volume of local anesthetics of different durations of actions. A positive 
response should demonstrate initial pain relief greater than or equal to 75% - 100%, and the ability to perform 
previously painful maneuvers. Steroids may be injected in addition to the local anesthetic.  
 
Therapeutic sacroiliac (SI) joint injections of an anesthetic and/or steroid to block the joint for immediate, and 
potentially long lasting, pain relief are considered medically reasonable and necessary if it is determined that 
the SI joint is the source of pain in the lower back. If previous diagnostic or therapeutic SI injections of an 
anesthetic and/or steroid to block the joint for immediate, and potentially long lasting, pain relief have not 
effectively relieved the pain, further injections would not be considered medically necessary. Radiofrequency 
ablation used for sacro-iliac joint pain is considered not medically necessary/investigational whether performed 
using traditional, cooled, or pulsed radiofrequency. You can find this rule in the Local Coverage Determination 
for Pain Management, L33622 (eff 06/24/20). 
 
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 state that therapeutic continuous glucose monitors 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 blood glucose monitor 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 blood glucose monitor or continuous glucose monitor testing results; and, 
5. Within six (6) months prior to ordering the continuous glucose monitor, 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 continuous glucose monitor, the treating 
practitioner has an in-person visit with the beneficiary to assess adherence to their continuous glucose 
monitor regimen and diabetes treatment plan. 
 
If any of coverage criteria (1-6) are not met, the continuous glucose monitor 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 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 $10 copayment for outpatient diagnostic tests/basic radiological 
services/specialist's. You can find this information on pages 75-78 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 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 Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on pages 51-52 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 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 $235 copayment per day for days 1-7. There is not charge for additional 
days for inpatient hospital care. You can find this information on pages 66-67 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 Medicare has established limited coverage for adenomatous polyposis coli (ADP) testing 
with code 81202, which is only covered when billed with certain, specific diagnosis codes. Diagnostic codes 
C57.01, C78.6, C79.61, C79.62, and C79.89 are not among those for which procedure code 81202 may be 
covered. You can find this rule in Local Coverage Article (LCA) Billing and Coding: MolDX: APC and 
MUTYH Gene Testing (A57353). 
 
The rules state that Medicare has established limited coverage for neuroblastoma RAS (NRAS) genetic testing 
with procedure code 81311, which is only covered when billed with certain primary and secondary diagnosis 
codes. Diagnosis code C57.01 is not among the primary diagnosis codes for which procedure code 81311 may 
be covered. You can find this rule in Local Coverage Article (LCA) Billing and Coding: MolDX: NRAS 
Genetic Testing (A57487). 
 
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.
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 Medicare Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 12 of the 2020 Evidence 
of Coverage (EOC).