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 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 also says that they will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. However, if the enrollee uses an out-of-network provider, their share of the costs for their covered services may be higher. You can find this information on page 44 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 only when dual medial branch blocks (MBB's) provide 80% relief of the primary or index 
pain, with ability to perform previously painful movements consistent with the expected physiological effects 
of the agents utilized, may radiofrequency (RF) medial branch neurotomy be considered. 
 
You can find this information at Medicare Local Coverage Determination (LCD): Facet Joint Injections, 
Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L34832). 
 
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. 
 
The rules say that telephone alert systems are not a covered benefit, as these are emergency communications 
systems and do not serve a diagnostic or therapeutic purpose. You can find this rule in National Coverage 
Determination (NCD) for Durable Medical Equipment (DME) Reference List (280.1) - Effective April 1, 2003. 
 
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 quantity of ostomy supplies needed by a beneficiary is determined primarily by the type 
of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will 
be variation according to individual beneficiary need and their needs may vary over time. The table in the LCD 
lists the maximum number of items/units of service that are usually reasonable and necessary. The actual 
quantity needed for a particular beneficiary may be more or less than the amount listed depending on the 
factors that affect the frequency of barrier and pouch change. 
 
The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in 
the beneficiary?s medical record. If adequate documentation is not provided when requested, the excess 
quantities will be denied as not reasonable and necessary. 
 
The usual maximum quantity of skin barrier wipes or swabs (A5120) is 150 per 6 months. There is not a set 
usual maximum for adhesive remover wipes (A4456) and ostomy deodorant (A4394). 
 
You can find these rules in Local Coverage Determination (LCD): Ostomy Supplies (L33828). 
 
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 does not include 
coverage for the core buildup (D2950) and pontic-porcelain fused to high noble metal (D6240). You can find 
this information on pages 20-29 of the Plan's 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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. You can find 
this information on page 88 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 the quantity of test strips (code A4253) and lancets (code A4259) that are covered depends on the usual 
medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin, regardless of their 
diagnostic classification as having Type 1 or Type 2 diabetes mellitus. For a beneficiary who is not currently being 
treated with insulin injections, more than 100 test strips and more than 100 lancets every 3 months are covered if criteria 
(a) (c) below are met. For a beneficiary who is not currently being treated with insulin injections, more than 100 test 
strips and more than 100 lancets every 3 months are covered if criteria (a) (c) below are met. 
For a beneficiary who is currently being treated with insulin injections, more than 300 test strips and more than 300 
lancets every 3 months are covered if criteria (a) (c) below are met. 
a. Basic coverage criteria for all home glucose monitors and related accessories and supplies are met; and, 
b. Within the six months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, the 
treating practitioner has had an in-person visit with the beneficiary to evaluate their diabetes control and their 
need for the specific quantity of supplies that exceeds the usual utilization amounts described above; and, 
c. Every six months, for continued dispensing of quantities of testing supplies that exceed the usual utilization 
amounts, the treating practitioner must verify adherence to the high utilization testing regimen. 
If neither basic coverage criterion is met, all testing supplies will be denied as not reasonable and necessary. If quantities 
that exceed the utilization guidelines are provided and criteria are not met, the amount in excess will be denied as not 
reasonable and necessary. You can find this rule in the Local Coverage Determination for Glucose Monitors, L33822 (eff 
01/01/20). 
 
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 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 1 oral 
exam every 6 months, 1 cleaning every 6 months and dental x-rays. There is a $500 annual maximum. You can 
find this information on page 65 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 20% coinsurance for in-network Medicare Part B prescription drugs. 
Additionally, for the administration of that drug, you will pay the cost-sharing that applies to primary care, 
specialist, or outpatient hospital services depending on where you received drug administration or infusion 
services. You can find this information in Chapter 4 on pages 4-33 to 4-35 of the Plan's 2020 Evidence of 
Coverage.  
 
The Plan contract says that enrollees must pay $325 copayment for in-network services provided at an 
outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical 
charges. You can find this information in Chapter 4 on pages 4-48 to 4-50 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 
complete dentures (upper and lower) every five years. You can find this information on pages 81-82 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 a sip and puff interface (E2325) is a non-proportional interface in which the beneficiary 
holds a tube in their mouth and controls the wheelchair by either sucking in (sip) or blowing out (puff). A 
mechanical stop switch is included in the allowance for the code. E2325 does not include the breath tube kit 
which is described by code E2326. If an attendant control (E2331) is provided in addition to a beneficiary-
operated drive control system, it will be denied as non-covered. You can find this information in the 
Wheelchair Options/Accessories - Policy Article (A52504). 
 
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 MBBs are indicated for: 
 Patient must have a history of at least 3 months of moderate to severe pain with functional impairment 
and the pain is inadequately responsive to conservative care such as non-steroidal anti-inflammatory 
drugs (NSAIDs), acetaminophen and/or physical therapy (as tolerated). 
 The pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with 
radiculopathy or neurogenic claudication.  
 There is no non-facet pathology that could explain the source of the patient's pain, such as fracture, 
tumor, infection or significant deformity. 
 Clinical assessment implicates the facet joint as the putative source of pain. 
 Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably high 
false positive rate of single MBB injections. 
 A second confirmatory MBB is allowed if documentation indicates the first MBB produced significant 
relief of primary (index) pain; 50% as evidenced by documented functional improvement, increased 
range of motion, a decreased requirement for pain medications and duration of relief is consistent with 
the agent employed. 
 Intra-articular facet block will not be reimbursed as a diagnostic test unless medial branch blocks cannot 
be performed due to specific documented anatomic restrictions. 
You can find this rule at Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, 
and Facet Joint Radiofrequency Neurotomy (L36471) (eff. 10/10/19). 
 
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. If a dental item or service is 
not listed in the benefit chart then it is not covered. You can find this information on page 29 of the Plan's 2020 
Preventative & Comprehensive Dental Coverage Customer Handbook and on page 66 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 $40 copayment for outpatient mental healthcare. You can find this 
information in Chapter 4 on page 76 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 there is insufficient published clinical literature demonstrating safety and effectiveness in the 
Medicare population to establish the medical necessity for crutch substitutes. You can find this rule at Region 
C DME MAC Bulletin ?E0118 ? Crutch Substitute? (eff. February 18, 2010). 
 
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 epidural injections and/or infusions will be considered medically reasonable and necessary 
for the following conditions: 
- Management of pain caused by intervertebral disc disease with or without myelopathy. 
- Management of pain caused by spinal stenosis. 
- Management of intractable radicular pain due to postlaminectomy syndrome/failed back syndrome. 
- Management of intractable pain due to complex regional pain syndrome. 
- Management of intractable pain due to post herpetic neuralgia and acute herpes zoster. 
- Management of intractable pain due to traumatic neuropathy of the spinal nerve roots. 
- Management of intractable and severe pain secondary to neuropathy from other causes (e.g., diabetic or 
metabolic). 
- Management of severe, intractable pain in patients with advanced stages of cancer with estimated life 
expectancy of 4 months or less. 
- Management of pain caused by radiculitis (inflammation of the nerve roots). 
You can find this rule at Local Coverage Determination (LCD): Epidural (L33906) (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 a contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 160. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.