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 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 Plan contract says that covered, non-routine dental care is limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. You can find this information on page 62 of the Plan's 2020 Annual Notice of Changes.
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 only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41. The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 30.3.
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 contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers non-medical transportation (NMT). All NMT ride requests must go through ALC. Rides will only be authorized through companies/drivers contracted with ALC. Other forms of NMT will not be covered. You can find this information on page 92 of the Plan's 2020 Member Handbook.
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 9-10 of the 2020 Evidence of Coverage (EOC). The Plan contract says that when you choose your PCP, you are also choosing the hospitals and specialty network associated with your PCP. If there is a particular network specialist or hospital you want to use, check first to be sure your PCP makes referrals to that specialist or uses that hospital. You can find this information on page 41 of the 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 that the indications for facet joint injections are: -At least 3 months of moderate to severe pain with functional impairment inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical therapy (if tolerated). -Predominant axial pain that is not associated with radiculopathy or neurogenic claudication. -Absence of non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor, infection, or significant deformity. -Clinical assessment that implicates the facet joint as the putative source of pain. You can find this rule in Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L35936) - Effective December 5, 2019. The rules say that only when dual medial branch blocks (MBBs) provide 80% or more relief of the primary or index pain, and duration of relief is consistent with the agent employed, may facet joint denervation with RF medial branch neurotomy be considered. You can find this rule in Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L35936) - Effective December 5, 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

1. We read all the papers in the file.
2. We checked Medicare rules.
3. We checked the contract with the Plan.
4. If required, we sent the file to a Maximus Federal Services physician reviewer.
To make our decision we read all the papers in the file very carefully. We used the Medicare rules. We looked
to see if the Plan correctly followed Medicare rules and regulations.
 
Medicare rules say that the Plan must give the member a subscriber agreement. It is a contract between the Plan
and the member. It is usually called the "Evidence of Coverage" (EOC) or "Member Agreement." We read this
contract carefully to see what the Plan is supposed to cover.
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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for a person who meets the following criteria: 
1. The person must have a personal mobility deficit; 
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, grooming and bathing in customary locations within the home; 
3. The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD. 
You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.3(B).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules 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 $40 copayment for Outpatient Mental Health Services. You can find this information on page 4-36 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 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 42-49 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 typically, psychological testing will require from four (4) to six (6) hours to perform,
including administration, scoring and interpretation. Supporting documentation in the medical record must be
present to justify greater than 8 hours per patient per evaluation. If the testing is done over several days, the
testing time should be combined and reported all on the last date of service. If the testing time exceeds eight (8)
hours, medical necessity for extended time should be documented. Medical records may be requested. You can
find this rule in Local Coverage Determination (LCD): Psychiatry and Psychology Services (L33632) -
Effective November 28, 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 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 $20 per visit for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. You can find this information on page 67 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 that percutaneous vertebral augmentation is covered in patients with both of the following:

1. Inclusion criteria (ALL ARE REQUIRED)

a. Acute (less than six weeks) osteoporotic VCF (T5-L5) by recent (within 30 days) advanced imaging (bone
marrow edema on MRI or bone scan/SPECT/CT uptake

b. Symptomatic (ONE)

i. Hospitalized with severe pain (NRS or VAS of 8 or more)
ii. Non-hospitalized with moderate to severe pain (NRS or VAS of 5 or more) despite optimal non-surgical
management (ONE)

1. Worsening pain
2. Stable to improved pain (but NRS or VAS still 5 or more) (with 2 or more of the following):

A. Progression of vertebral body height loss
B. More than 25% of vertebral body height reduction
C. Kyphotic deformity
D. Severe impact of VCF on daily functioning

c. Multidisciplinary team consensus (ALL ARE REQUIRED)

i. Referring physician (e.g., rheumatologist, endocrinologist)
ii. Treating physician (i.e., performing the PVA)
iii. Radiologist
iv. Neurologist

2. Exclusion criteria (Can have NONE of the following):

a. Absolute contraindication

1. Current back pain is not primarily due to the identified acute VCF(s).
2. Osteomyelitis, discitis or active systemic infection
3. Pregnancy
4. Greater than three vertebral fractures

b. Relative contraindication

1. Allergy to bone cement or opacification agents
2. Coagulopathy
3. Spinal instability
4. Myelopathy from the fracture
5. Neurologic deficit
6. Neural impingement
7. Fracture retropulsion/canal compromise

You can find this rule in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation (PVA)
for Osteoporotic Vertebral Compression Fracture (VCF) (L38213) - Effective December 16, 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. The Plan contract says that you must access all dental treatment from providers through the Plan's contracted dental network. You can find this information on page 64 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 the definition of K0801 is "POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS." You can find this rule in Local Coverage Determination (LCD): 
Power Mobility Devices (L33789) - Effective January 1, 2020. 

The rules say that a power operated vehicle is covered if the beneficiary's weight is less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC - i.e., a Heavy Duty PWC is covered for a beneficiary weighing 285 - 450 pounds; a Very Heavy Duty PWC is covered for a beneficiary weighing 428 - 600 pounds; an Extra Heavy Duty PWC is covered for a beneficiary weighing 570 pounds or more. You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices (L33789) - 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 only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41. 

The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 30.3.

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 contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers routine transportation up to 50 miles one-way. You can find this information on page 92 and 93 of the 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 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 Plan
contract includes a list of covered supplemental dental services. The contract specifically says that any
procedure not listed is not covered. Pontic (D6245) and retainer crown (D6740) are not included on this list and
are not covered supplemental benefits. You can find this information on pages 21 to 29 of the Plan's 2020
Preventive & Comprehensive Dental Coverage Customer Handbook.
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 following indications are covered for implanted permanent single chamber or dual chamber cardiac pacemakers:

1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and 
2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.

You can find this rule in National Coverage Determination (NCD) for Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (20.8.3) - Effective August 13, 2013. 

The rules say that the following indications are non-covered for implanted permanent single chamber or dual chamber cardiac pacemakers: 

1. Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia, 
2. Asymptomatic first degree atrioventricular block, 
3. Asymptomatic sinus bradycardia, 
4. Asymptomatic sino-atrial block or asymptomatic sinus arrest, 
5. Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia, 
6. Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle (a component of the electrical conduction system of the heart), 
7. Syncope of undetermined cause, 
8. Bradycardia during sleep, 
9. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent atrioventricular block, 
10. Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker drug therapy, 
11. Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the control of tachycardia, and 
12. A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated with a reasonable likelihood that pacing needs will become prolonged. 

You can find this rule in National Coverage Determination (NCD) for Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (20.8.3) - Effective August 13, 2013.

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.