Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $150 copayment for advanced imaging services received in a 
freestanding radiological facility. 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 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 45-46 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 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 Medicare will consider their removal as medically necessary, and not cosmetic, if one or 
more of the following conditions are present and clearly documented in the medical record: 
 
The lesion has become symptomatic or has undergone a change in appearance or displays evidence of 
inflammation or infection. 
The lesion obstructs an orifice. 
The lesion clinically restricts eye function. For example, the lesion 
        restricts eyelid function 
        causes misdirection of eyelashes or eyelid 
        restricts lacrimal puncta and interferes with tear flow 
        touches the globe 
        interferes with vision 
There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration 
based on lesion appearance or prior biopsy of a related or similar lesion suggesting malignancy. 
A prior histological exam or biopsy suggests or is indicative of atypia (e.g., atypical nevus) or malignancy. 
The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such 
trauma has occurred. 
Removal of molluscum contagiosum. 
Benign epidermal or pilar cyst with history of infection, drainage, or rupture. 
Wart removals will be covered under guidelines above. In addition, wart destruction will be covered when any 
of the following clinical circumstances are present: 
            Periocular warts associated with chronic recurrent conjunctivitis thought to be secondary to lesion virus   
 shedding 
            Warts showing evidence of spread from one body area to another 
            Lesions are condyloma acuminate 
 
You can find this information in the Local Coverage Determination (LCD): Removal of Benign Skin Lesions 
(L34938). 
 
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 the IHS providers are paid for covered outpatient services based upon an all-inclusive 
outpatient per visit rate (AIR). The AIR is established by CMS and IHS based upon a review of yearly cost 
reports prepared by IHS's contractor. All charges, except for therapies, telehealth originating site facility fee, 
PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and 
reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient). You can find this 
information in the Medicare Claims Processing Manual, Chapter 19, Section 100.5. 
 
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 Plan 
contract includes a list of covered supplemental dental services. Gingival irrigation, maxillofacial prosthesis, 
and application of desensitizing resin are not included on this list and are not covered supplemental benefits. 
The contract also says that amalgam (silver) or resin-based composite (white) fillings are limited to four 
procedures per calendar year. You can find this information on pages 82 and 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 state that sacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-
frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation 
to determine if an implantable stimulator would be effective and a permanent implantation in appropriate 
candidates. Both the test and the permanent implantation are covered. 
 
The following limitations for coverage apply to all three indications: 
 
    -Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical 
corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur. 
    -Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with 
peripheral nerve involvement) which are associated with secondary manifestations of the above three 
indications are excluded. 
    -Patient must have had a successful test stimulation in order to support subsequent implantation. Before a 
patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through 
test stimulation. Improvement is measured through voiding diaries. 
    -Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of 
the implant procedure can be properly evaluated. 
 
You can find these rules in National Coverage Determination (NCD) for Sacral Nerve Stimulation For Urinary 
Incontinence (230.18). 
 
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 for coverage of Percutaneous Left Atrial Appendage Closure, the patient must have a formal 
shared decision making interaction with an independent non-interventional physician using an evidence-based 
decision tool on oral anticoagulation in patients with NVAF prior to LAAC. Additionally, the shared decision 
making interaction must be documented in the medical record. You can find this information in the National 
Coverage Determination (NCD) for Percutaneous Left Atrial Appendage Closure (LAAC) (20.34). 
 
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 at42 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).If  you  want  to read these  Medicare  rules,  you  can go to this  website www.medicareappeal.com.The Plan  contract  says that the  Plancovers  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 PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities 
alone. A PCD coded as E0652, is covered for the treatment of lymphedema extending onto the chest, trunk 
and/or abdomen when all of the following are met: 
1. The beneficiary has lymphedema of an extremity as defined above 
 
2. The coverage criteria for an E0650 or E0651 are met 
 
3. The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits 
of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve 
with a four-week trial. 
 
You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).  
 
The rules say that the only time that a segmented, calibrated gradient pneumatic compression device (HCPCS 
code E0652) would be covered is when the individual has unique characteristics that prevent them from 
receiving satisfactory pneumatic compression treatment using a nonsegmented device in conjunction with a 
segmented appliance or a segmented compression device without manual control of pressure in each chamber.  
 
You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).  
 
The rules say that a four-week trial of conservative therapy demonstrating failed response to treatment with and 
E0650 or E0651 is required for coverage of E0652. You can find this rule in Local Coverage Determination 
(LCD): Pneumatic Compression Devices (L33829). 
 
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 page 15 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 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 49-50 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 state that Medicare Part B pays for MNT services provided by a registered dietitian or nutrition professional when the beneficiary is referred for the service by the treating physician. Medical nutrition therapy services means nutritional diagnostic, therapeutic, and counseling services provided by a registered dietitian or nutrition professional for the purpose of managing diabetes or a renal disease. "Registered dietitian or nutrition professional" means an individual who holds a bachelor's degree or higher with completion of the academic requirements of a program in nutrition or dietetics, who is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. You can find this information in the Title 42 Code of Federal Regulations, Sections 410.130 and 410.134.

The rules say that Medicare does not pay for nutritional supplements. You can find this rule in the Medicare National Coverage Determination Manual, Chapter 1, Section 180.2.

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.
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 $75 copayment for radiological diagnostic services, including 
ultrasounds. You can find this information 4-39 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 in Chapter 3 on pages 53 to 54 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 presumptive UDT testing is limited for the following reasons:
- 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 result;
- Produces erroneous results due to cross-reactivity with other compounds or does not detect all drugs
within a drug class;
- Given that not all prescription medications or synthetic/analog drugs are detectable or have assays
available, it is unclear as to whether other drugs are present when some tests are reported as positive;
- Cut-off may be too high to detect presence of a drug. This information could cause a practitioner to
make a wrong assumption or clinical decision.
Definitive UDT is reasonable and necessary in order to:
- Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT;
- Definitively identify specific drugs in a large family of drugs;
- Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl,
meperidine, synthetic cannabinoids and other synthetic/analog drugs;
- 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);
- 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;
- Rule out an error as the cause of a presumptive UDT result;
- Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances;
and
- 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 these rules at Local Coverage Determination (LCD): Controlled Substance
Monitoring and Drugs of Abuse Testing (L35006) (eff. 10/17/19).
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.