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 state that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will 
be considered medically reasonable and necessary when ALL of the following conditions are met: 
 
    The patient is symptomatic. Such symptoms may include pain which interferes with the activities of daily living such 
as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness  
    The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space narrowing, 
subchondral sclerosis, osteophytes and sub-chondral cysts 
    If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, laboratory and 
imaging studies (i.e. the pain and functional disability is not considered likely to be due to a diagnosis other than 
osteoarthritis of the knee.) 
    The patient has failed at least three months of conservative therapy. Conservative therapy is defined as: 
        Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss, physical 
therapy if indicated); and 
        If not contraindicated, simple analgesics and NSAIDS. 
    The patient has failed to respond to aspiration of the knee and intra-articular corticosteroid injection therapy when 
inflammation is a significant component of the patient?s symptoms and intra-articular corticosteroids are not 
contraindicated. 
 
Viscosupplementation of joints other than the knee(s) will be considered not reasonable and necessary and will not be 
subject to coverage.  
 
You can find this information in Local Coverage Determination (LCD): Viscosupplementation Therapy For Knee 
(L33767). 
 
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 for diagnostic procedures and tests enrollees must pay a $0 copayment for services provided 
by your primary care physician in their office. Enrollees pay a $75 copayment for services performed by a 
provider other than your primary care physician. If the enrollee receives more than one covered service where 
copays have been applied, from a PCP or specialist, then the enrollee is responsible for the highest copayment. 
Additionally, one exam every year for a routine eye exam is covered. You can find this information on pages 
56, 76, and 90 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 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 
coverage of partial dentures once every 60 months. You can find this information in the Plan?s 2020 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 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 
coverage only for services listed in the plan contract. Services that are not listed are not covered. You can find 
this information in the Plan's 2020 Dental Reference Manual.
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 codes A9276 (SENSOR; INVASIVE (E.G., SUBCUTANEOUS), DISPOSABLE, FOR USE 
WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM, ONE UNIT = 1 DAY 
SUPPLY) and A9277 (TRANSMITTER; EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS 
GLUCOSE MONITORING SYSTEM) describe the supplies used with a non-therapeutic CGM. Codes A9276 
and A9277 are not used to bill for supplies used with code K0554. You can find this rule in Local Coverage 
Article: Glucose Monitor - Policy Article (A52464) ? Effective June 7, 2018. 
 
The rules say that continuous glucose monitors that are covered by Medicare under the DME benefit are 
defined by CMS ruling 1682R as therapeutic monitors. You can find this rule in Local Coverage Determination 
(LCD): Glucose Monitors (L33822) - 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 cochlear implants are covered based on the Medicare coverage criteria and the medical 
record documentation establishing medical necessity for this type of hearing device. You can find this in the 
National Coverage Determination (NCD) for Cochlear Implantation section 50.3. 
 
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). 
 
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 does not 
list endodontic therapy and periodontal scaling and root planing as covered benefits. You can find this 
information on pages 57-58 of the 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 presumptive UDT testing is limited due to 
a. Primarily screens for drug classes rather than specific drugs, and therefore, the practitioner may not be 
able to determine if a different drug within the same class is causing the positive; 
b. Produces erroneous results due to cross-reactivity with other compounds or does not detect all drugs 
within a drug class; 
c. Not all prescription medications or synthetic/analog drugs are detectable; it is unclear as to whether 
other drugs are present 
d. Cut-off value may be too high to detect presence of drug 
Presumptive UDT may be ordered when it is necessary to rapidly obtain and integrate results into clinical 
assessment and treatment decisions. 
Definitive UDT is reasonable and necessary for the following circumstances: 
&#61623; Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT screen; 
&#61623; Definitively identify specific drugs in a large family of drugs; 
&#61623; Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, 
Meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
&#61623; Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., 
discontinuation of THC use according to a treatment plan); 
&#61623; Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patient?s 
self- report, presentation, medical history, or current prescribed pain medication plan; 
&#61623; Rule out an error as the cause of an unexpected presumptive UDT result; 
&#61623; Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; 
and 
&#61623; Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
Definitive UDT may be reasonable and necessary based on patient specific indications, including historical use, 
medication response, and clinical assessment, when accurate results are necessary to make clinical decisions. 
The clinician?s rationale for the definitive UDT and the tests ordered must be documented in the patient?s 
medical record. You can find this rule at Local Coverage Determination (LCD): Controlled Substance 
Monitoring and Drugs of Abuse Testing (L36393) (eff. 10/1/19). 
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 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 
coverage only for the preventative services listed on page 77 of the 2020 Evidence of Coverage. Fillings are not 
listed as a covered benefit.
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% coinsurance for Medicare-covered Part B prescription drugs. You 
can find this information on page 74 of the Plan's 2020 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $200 copayment per visit for Medicare-covered outpatient surgery in an 
ambulatory surgical center or hospital outpatient facility. You can find this information on page 83 of the Plan's 
2020 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $50 copayment for each Medicare-covered standard x-ray and 
ultrasound. You can find this information on page 75 of the Plan's 2020 EOC. 
 
the Plan contract says that enrollees must pay a $600 copayment per visit for Outpatient surgery. You can find 
this information on page 83 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 $5 copayment for diagnostic lab services and diagnostic procedures and 
tests (per day, per facility). You can find this information on page 91 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 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 dental 
services beyond Medicare coverage. There is a $75 annual deductible. You must pay the deductible on covered 
dental services before coverage begins. You can find this information on page 107 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 $100 copayment for all other outpatient diagnostic and therapeutic 
services and supplies, such as CT scans. You can find this information on page 78 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 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 
coverage of the crown - porcelain fused to high noble metal (D2750) once per tooth every 60 months. You can 
find this information on pages 20-29 of the Plan?s 2020 Preventive & Comprehensive Dental 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 only 
services listed in the benefit chart. Retainer crowns (D6740) and pontics (D6245) are not listed. You can find 
this information on pages 22 to 30 of the Plan's 2020 Preventative and Comprehensive Dental Coverage 
Customer Handbook.