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 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).
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 Manual states that criteria for periodontal treatment includes: -A minimum of four (4) teeth affected in the quadrant. -Periodontal charting indicating abnormal pocket depths in multiple sites. -Additionally at least one of the following must be present: 1) Radiographic evidence of root surface calculus. 2) Radiographic evidence of noticeable loss of bone support. Criteria for crowns includes: - Permanent molar teeth must have pathologic destruction to the tooth by caries or trauma, and should involve four or more surfaces and two or more cusps. You can find this information on pages 29 through 30 of the 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 Concentric adjustable torsion style mechanisms used to assist knee joint extension are coded 
as L2999 and are covered for beneficiaries who require knee extension assist in the absence of any co-existing 
joint contracture. 
 
Concentric adjustable torsion style mechanisms used to assist ankle joint plantarflexion or dorsiflexion are 
coded as L2999 and are covered for beneficiaries who require ankle plantar or dorsiflexion assist in the absence 
of any co-existing joint contracture. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Ankle-Foot/Knee-Ankle-
Foot Orthosis (L33686). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 payment for inpatient psychiatric hospital services is to be made only for active treatment. 
For services to be designated as active treatment they must: 
 
1. be provided under an individualized treatment or diagnostic plan; 
 
2. reasonably be expected to improve the patient's condition, or for the purpose of diagnosis; and 
 
3. be supervised and evaluated by a physician.   
You can find these rules in the Medicare Benefit Policy Manual, Chapter 2, Sections 30.2.2 and 30.2.2.1. 
 
The rules say that Medicare will not pay any expenses for items or services which are not medically necessary 
and reasonable for the diagnosis or treatment of illness or injury. This exclusion extends to claims for services 
which are provided in inappropriate settings. You can find this rule in the Social Security Act, Section 
1862(a)(1). 
 
Medicare patients admitted to inpatient psychiatric hospitalization must be under the care of a physician who is 
knowledgeable about the patient. The physician must certify/recertify (see "Documentation Requirements" 
section in the related Billing and Coding Article) the need for inpatient psychiatric hospitalization. The patient 
must require "active treatment" of his/her psychiatric disorder. The patient or legal guardian must provide 
written informed consent for inpatient psychiatric hospitalization in accord with state law. If the patient is 
subject to involuntary or court-ordered commitment, the services must still meet the requirements for medical 
necessity in order to be covered by Medicare. 
You can find this information in Local Coverage Determination (LCD): Psychiatric Inpatient Hospitalization 
(L33624). 
 
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 a Pneumatic Compression Devices (PCD) that provides intermittent limb compression for 
the purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for 
a preventative service or function are excluded from coverage under the Medicare DME benefit. Therefore, 
claims for E0676 will be statutorily denied as no Medicare benefit. You can find this rule in Local Coverage 
Article: Pneumatic Compression Devices - Policy Article (A52488). 
 
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 to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The 
documentation must show that the patient is mobile in the home and would benefit from the use of portable 
oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood 
gas studies obtained during sleep. You can find this rule in the Medicare National Coverage Determinations 
Manual, Section 240.2(E).  
 
Medicare will not pay for precautionary equipment. You can find these rules in the Medicare Benefit Policy 
Manual, Chapter 15, - 110.1. 
 
The rules say that Medicare will pay for durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers 
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment 
already available to an enrollee. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, 
Section 110.1(C). 
 
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 contract says that 
prosthodontic services, which include dentures, partials and bridges are limited to one every five calendar 
years. 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 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 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.
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 epidural steroid injections are indicated when the patient has: 
 
1. Pain associated with Herpes Zoster and/or Suspected radicular pain, based on radiation of pain along the 
dermatome (sensory distribution) of a nerve and/or Neurogenic claudication and/or Low back pain, NPRS = 
3/10 (moderate to severe pain) associated with significant impairment of activities of daily living (ADLs) and 
one of the following: a. substantial imaging abnormalityies such as a central disc herniation, b. severe 
degenerative disc disease or central spinal stenosis. 
 
2. Failure of four weeks (counting from onset of pain) of non-surgical, noninjection care, which includes 
appropriate oral medication(s) and physical therapy to the extent tolerated. Exceptions to the 4-week wait may 
include: a. pain from Herpes Zoster b. at least moderate pain with significant functional lossat work or home. c. 
severe pain unresponsive to outpatient medical management. d. inability to tolerate non-surgical, non-injection 
care due to co-existing medical condition(s) e. prior successful injections for same specific condition with relief 
of at least 3 months' duration. 
 
Additionally, no more than two transforaminal injections may be performed at a single setting (e.g. single level 
bilaterally or two levels unilaterally).  One caudal or lumbar interlaminar injection per session and not in 
conjunction with a lumbar transforaminal injection. 
 
You can find this information in the Local Coverage Determination (LCD): Lumbar Epidural Injections 
(L34980). 
 
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 coverage for a spinal cord stimulator is limited to one permanent spinal cord stimulator per 
patient per lifetime. This rule can be found in Local Coverage Determination (LCD): Spinal Cord Stimulation 
for Chronic Pain (L36035). 
 
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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
CMS. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules also say that to be eligible for Medicare coverage, the individual being tested must have signs or 
symptoms of breast (invasive or ductal carcinoma in situ (DCIS), ovarian cancer (including fallopian tube and 
primary peritoneal cancer), pancreatic cancer, or prostate cancer and meet one of the criteria below. Genetic 
testing for a known mutation in a family is a covered service for individuals with signs and/or symptoms of 
cancer. Testing of an unaffected Medicare eligible individual or family member is not a covered Medicare 
benefit.  
 
You can find this rule in Local Coverage Determination (LCD) MolDX: BRCA1 and BRCA2 Genetic Testing 
(L36163). 
 
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. Routine Vision services must be received from Network 
providers. You can find this information on page 128 of the 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that  
Currently covered indications include using MRA for specific conditions to evaluate flow in internal carotid 
vessels of the head and neck, peripheral arteries of lower extremities, abdomen and pelvis, and the chest. 
Coverage is limited to MRA units that have received FDA premarket approval, and such units must be operated 
within the parameters specified by the approval. In addition, the services must be reasonable and necessary for 
the diagnosis or treatment of the specific patient involved. 
  
a. HEAD AND NECK 
Studies have proven that MRA is effective for evaluating flow in internal carotid vessels of the head and neck. 
However, not all potential applications of MRA have been shown to be reasonable and necessary. All of the 
following criteria must apply in order for Medicare to provide coverage for MRA of the head and neck:  
  ? MRA is used to evaluate the carotid arteries, the circle of Willis, the anterior, middle or posterior cerebral 
arteries, the vertebral or basilar arteries or the venous sinuses;  
  ? MRA is performed on patients with conditions of the head and neck for which surgery is anticipated and 
may be found to be appropriate based on the MRA. These conditions include, but are not limited to, tumor, 
aneurysms, vascular malformations, vascular occlusion or thrombosis. Within this broad category of disorders, 
medical necessity is the underlying determinant of the need for an MRA in specific diseases. The medical 
records should clearly justify and demonstrate the existence of medical necessity; and  
  ? MRA and CA are not expected to be performed on the same patient for diagnostic purposes prior to the 
application of anticipated therapy. Only one of these tests will be covered routinely unless the physician can 
demonstrate the medical need to perform both tests. 
 
You can find this rule in the National Coverage Determination Manual, Section 220.2(B)(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 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 in Chapter 3 on page 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 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 20-26 of the plan's 2020 
Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 provides 24 one-way trips for non-emergency services; such as visits to doctors and other medical 
related appointments, or pharmacies to pick up prescription drugs within a 50-mile limit. You can find this 
information on page 36 & 37 of the Plan?s 2020 Evidence of Coverage.