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 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 35 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 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 cleanings, dental x-ray(s), and oral exams. Dental implants are not included on this list and are not a covered supplemental benefit. You can find this information on page 66 of the Plan's 2021 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 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 2 crowns per calendar year. You can find this information on page 94 of the Plan's 2021 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 Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract includes a list of covered supplemental dental services. The contract specifically says that any procedure not listed is not covered. Pontic (D6245), retainer crown (D6740), and bone replacement graft for ridge preservation (D7953) are not included on this list and are not covered supplemental benefits. You can find this information on pages 22 to 30 of the Plan's 2020 Preventive & Comprehensive Dental Coverage Customer Handbook and on pages 22 to 33 of the Plan's 2021 Preventive & Comprehensive Dental Coverage Customer Handbook.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that 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 3-4 of the Plan's 2021 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 an IUD (code 58300) and Levonorgestrel IU contracept (code J7302) is not covered by Medicare. You can find this rule at Physician Fee Schedule CodeBook - 2021 Index of "Non-covered Services."

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 services not covered reversal of sterilization procedures and or non-prescription contraceptive supplies are not covered under any condition. You can find this information in Chapter 4 on pages 148-152 of the plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract lists the specific dental services that are covered. Core build up is not listed and therefore is not a covered service. You can find this information on pages 88 to 98 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 Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that covered, non-routine dental care is limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. You can find this information on page 70 of the Plan's 2020 Evidence of Coverage and on page 71 of the Plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that headgear is covered once every six months. Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not reasonable and necessary. You can find this rule at Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718) (eff. 1/1/20).

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 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 pages 27 to 28 of the Plan's 2021 Member Handbook.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

Medicare rules state that a total electric hospital bed is not covered. The height adjustment feature is a convenience feature. You can find this rule in the DME MAC Local Coverage Determination L33820, Hospital Beds and Accessories (effective October 1, 2015).

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 pay for durable medical equipment that is mainly used to serve a medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly used for medical purposes. Medicare will not pay for:

1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1.

Equipment which is primarily and customarily used for a nonmedical purpose may not be considered "medical" equipment for which payment can be made under the medical insurance program. This is true even though the item has some remote medically related use. You can find this information in Medicare Benefit Policy Manual, Chapter 15, 110.1. 

Exercise equipment is not primarily medical in nature. National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1).

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 home blood pressure monitors and home blood pressure cuffs 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 state that a repeat series of hyaluronan knee injection(s) for patients who have responded to a prior series is considered to be reasonable and necessary under the following circumstances:

1. Symptoms have recurred, and;
2. At least six months have elapsed since the prior series of injections These rules can be found in Local Coverage Determination (LCD): Hyaluronan Acid Therapies for Osteoarthritis of the Knee (L35427).

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 no payment may be made for the implantation of dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the conditions listed below have been met:

- The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic intractable pain;
- With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for the given patient;
- Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. (Such screening must include psychological, as well as physical evaluation);
- All the facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment training, and follow up of the patient (including that required to satisfy item c) must be available; and
- Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation.

You can find this rule in the National Coverage Determination Manual, Section 160.7.

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 the Prolaris assay is covered only when the following clinical conditions are met:

- Needle biopsy with localized adenocarcinoma of prostate (no clinical evidence of metastasis or lymph node involvement), and
- FFPE prostate biopsy specimen with at least 0.5 mm of cancer length, and
- Patient Stage as defined by the one of the following:
o Very Low Risk Disease (T1c AND Gleason Score &#8804; 6 AND PSA &#8804; 10 ng/mL AND <3 prostate cores with tumor AND &#8804; 50% cancer in any core AND PSA density of < 0.15 ng/mL/g) OR
o Low Risk Disease (T1-T2a AND Gleason Score &#8804; 6 AND PSA &#8804; 10 ng/mL), and
- Patient has an estimated life expectancy of greater than or equal to 10 years, and
- Patient is a candidate for and is considering conservative therapy and yet and would be eligible for definitive therapy (radical prostatectomy, radiation therapy or brachytherapy), and
- Result will be used to determine treatment between definitive therapy and conservative management, and
- Patient has not received pelvic radiation or androgen deprivation therapy prior to the biopsy, and
- Test is ordered by a physician certified in the Myriad Prolaris Certification and Training Registry (CTR), and
- Patient is monitored for disease progression according to established standard of care, and
- Physician must report the development of metastasis or prostate cancer deaths in patients not treated definitively who were deemed low risk by the assay.

You can find this rule at Local Coverage Determination (LCD): MolDX: Prolaris Prostate Cancer Genomic Assay (L36350) (eff. 12/1/19).

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 upper eyelid and brow surgical procedures will be considered covered when performed as functional/reconstructive surgery to correct:

- Visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis, or brow ptosis.
- Visual impairment secondary to redundant skin weighting down on upper lashes.
- Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin which has not been successfully treated by normal first line measures such as education regarding hygiene, antibiotics, etc.
- Prosthesis difficulties in an anophthalmia socket.
- Interference with vision or the visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis, pseudotosis or dermatochalasis.

You can find this rule at Local Coverage Determination (LCD): Upper Eyelid and Brow Surgical Procedures (L34028) (eff. 1/8/19).

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 ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive pulmonary disease (COPD). You can find this rule in the Medicare National Coverage Determinations Manual, Chapter 1, Section 280.1.

The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device is made based upon the specifics of each person's medical condition. There must be enough detailed information in the medical record to justify the treatment selected. You can find this rule in the Local Coverage Determination (LCD): Respiratory Assist Devices (L33800), effective for services performed on or after January 1, 2017.

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.