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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit is limited to 
services performed by a participating general dentist. 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 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 $20 copayment per visit for lab services. You can find this information 
on page 76 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 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 coverage for NMES/FES for walking will be covered in SCI patients with all of the 
following characteristics: 
 
Persons with intact lower motor units (L1 and below) (both muscle and peripheral nerve); 
Persons with muscle and joint stability for weight bearing at upper and lower extremities that can    
demonstrate balance and control to maintain an upright support posture independently; 
Persons that demonstrate brisk muscle contraction to NMES and have sensory perception electrical stimulation 
sufficient for muscle contraction; 
    Persons that possess high motivation, commitment and cognitive ability to use such devices for walking; 
    Persons that can transfer independently and can demonstrate independent standing tolerance for at least 3 
minutes; 
    Persons that can demonstrate hand and finger function to manipulate controls; 
    Persons with at least 6-month post recovery spinal cord injury and restorative surgery; 
    Persons without hip and knee degenerative disease and no history of long bone fracture secondary to 
osteoporosis; and 
    Persons who have demonstrated a willingness to use the device long-term. 
 
You can find this information in the National Coverage Determination (NCD) for Neuromuscular Electrical 
Stimulation (NMES) (160.12). 
 
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 glaucoma surgical aqueous drainage devices will be considered medically reasonable and 
necessary when approved by the FDA and used within accordance of the FDA-approved/cleared indications. 
 
1. A single insertion per eye of an anterior segment aqueous drainage device(s), without extraocular reservoir, 
via internal approach into the trabecular meshwork or with creation of intraocular reservoir into the supraciliary 
space is considered medically reasonable and necessary in conjunction with cataract surgery for the treatment 
of adults with mild or moderate open-angle glaucoma and a cataract when the individual is currently being 
treated with an ocular hypotensive medication. 
 
2. A single insertion per eye of an aqueous drainage device(s) without extraocular reservoir, via internal 
approach into the subconjunctival space is considered medically reasonable and necessary as a standalone 
treatment for refractory glaucoma, defined as prior failure of filtering/cilio-ablative procedure and/or 
uncontrolled IOP (progressive damage and/or mean diurnal medicated IOP greater than or equal to 20 mmHg) 
on maximally tolerated medical therapy (i.e., greater than or equal to 4 classes of topical IOP-lowering 
medications, or fewer in the case of tolerability or efficacy issues). 
 
You can find this rule in Local Coverage Determination (LCD): Micro-Invasive Glaucoma Surgery (MIGS) 
(L38223) - Effective December 30, 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 a 20% coinsurance for durable medical equipment. You can find this 
information on page 77 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drug. You can find 
this information on page 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 after myofascial pain syndrome (MPS) is established, trigger point injection may be 
considered medically reasonable and necessary: 
1. When noninvasive medical management is unsuccessful (e.g., analgesics, passive physical therapy, 
ultrasound, range of motion and active exercises). 
2. As a bridging therapy to relieve pain while other treatments are also initiated, such as medication or 
physical therapy; or as a single therapeutic maneuver. The logic behind such therapeutic decision 
making should be obvious in the medical record and available upon Contractor request. 
3. When joint movement is mechanically blocked as is the case of the coccygeus muscle. 
You can find this rule at Local Coverage Determination (LCD): Trigger Point Injections (L35010) (eff. 
1/21/20). 
 
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 an inpatient admission is generally appropriate when the admitting physician expects the 
patient to need hospital care that crosses at least two midnights. The expectation should be based on such 
complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and 
medical risk. The factors must be documented in the medical record.  
 
If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be 
considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as 
"inpatient only" is generally appropriate, regardless of the length of stay. An inpatient admission may be 
appropriate if the admitting physician expects a patient to require hospital care for only a limited period of 
time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be 
supported by the medical record. You can find this rule at 42 CFR Section 412.3. 
 
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.
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 providers must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(A). 
 
The rules say that all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patients medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patients 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 
and 5.10. 
 
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 $30 specialist copayment for Physician Services Specialists Office, and 
20% coinsurance for Medicare Part B prescription drugs. You can find this information on pages 72 and 79 of 
the Plan's 2020 Evidence of Coverage. of the Plan's  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, if during the course of the screening colonoscopy, a lesion or growth is detected which 
results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy 
with biopsy or removal should be billed. You can find this rule in the Medicare Claims Processing Manual, 
Chapter 18, 60.2. 
 
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 $250 copayment for each outpatient surgery provided at an ambulatory 
surgical center or outpatient hospital facility. You can find this information in Chapter 4 on page 95 of the 
Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health
plan contract says that enrollees must pay a $75 copayment for each Medicare-covered physical therapy visit
received from an out-of-network provider. You can find this information in Chapter 4 on pages 4-42 of the
plan's 2019 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 $40 copayment for Medicare-covered occupational therapy visits. You 
can find this information on page 4-41 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 state that oximeters (E0445) and replacement probes (A4606) will be denied as non-covered because 
they are monitoring devices that provide information to the treating practitioner to assist in managing the 
beneficiary's treatment. You can find this information in Local Coverage Determination (LCD):Oxygen and 
Oxygen Equipment (L33797). 
 
The rules say that home blood pressure monitors (A4660) and home blood pressure cuffs (A4663) are 
considered home dialysis supplies. These items are only covered for patients on home dialysis. You can find 
this rule in the Medicare Claims Processing Manual, Chapter 8, Section 90.3.2(A).  
 
The rules also say that ambulatory blood pressure monitoring (ABPM) may be covered in some instances. This 
service involves the use of a non-invasive device which is used to measure blood pressure in 24-hour cycles. 
These 24-hour measurements are stored in the device and are later interpreted by the physician. ABPM is only 
covered for those patients with suspected white coat hypertension. Suspected white coat hypertension is 
defined as 
 
1. Office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate 
measurements made at each visit; 
2. At least two documented blood pressure measurements taken outside the office which are <140/90 mm Hg; 
and 
3. No evidence of end-organ damage. 
 
You can find this information in the National Coverage Determination (NCD) for Ambulatory Blood Pressure 
Monitoring (20.19). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that Sclerotherapy is indicated when: 
 
1. A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive 
therapy, and avoidance of prolonged immobility where appropriate, has failed, AND 
 
2. The patient is symptomatic and has one, or more, of the following: 
     a. Pain or burning in the extremity severe enough to impair mobility 
     b. Recurrent episodes of superficial phlebitis  
     c. Non-healing skin ulceration  
     d. Bleeding from a varicosity  
     e. Stasis dermatitis  
     f. Refractory dependent edema 
 
You can find this information in the Local Coverage Article: Billing and Coding: Treatment of Varicose Veins 
of the Lower Extremities (A57706). 
 
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 there is no payment under the OPPS for services that CMS designates to be "inpatient-only"
services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together 
in Addendum E of each year's OPPS/ASC final rule. You can find this rule in the Medicare Claims Processing 
Manual, Chapter 4, Section 180.7. 
 
Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the 
beneficiary while an inpatient. The facility or hospital must furnish all necessary covered services to the 
beneficiary either directly or under arrangements made between the facility and hospital and outside vendors. If 
the physician furnishes services to beneficiaries in providers, the carrier pays on a fee schedule basis provided 
the following requirements are met: 
 
(1) The services are personally furnished for an individual beneficiary by a physician. 
 
(2) The services contribute directly to the diagnosis or treatment of an individual beneficiary. 
 
(3) The services ordinarily require performance by a physician. 
 
(4) In the case of radiology or laboratory services, the additional requirements in 415.120 or 415.130, 
respectively, are met. 
 
You can find this rule at 42 CFR, Sections 412.50 and 415.102. 
 
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.