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 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. First intraoral periapical x-ray and each additional intraoral periapical x-ray are not included on this list and are not covered supplemental benefits. You can find this information on pages 88 and 89 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 payment may not be made for more than a total of 190 days of inpatient psychiatric hospital
services during the patient's lifetime. The limitation applies only to services furnished in a psychiatric hospital.
You can find this rule in the Medicare Benefit Policy Manual, Chapter 4, Section 50.
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. Application of desensitizing medicament is not included on this list and is not a covered supplemental benefit. You can find this information on pages 87 to 88 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 covered indication for RFA include:-Patient must have history of at least 3 months of moderate to severe pain with functional impairment and pain is inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical therapy (as tolerated).-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.Thermal Medial Branch Radiofrequency Neurotomy (includes RF and microwave technologies):-Only when dual MBBs provide greater than or equal to 80% relief of the primary or index pain and duration of relief is consistent with the agent employed may facet joint denervation with RF medial branch neurotomy be considered. -Repeat denervation procedures involving the same joint will only be considered medically necessary if the patient experienced greater than or equal to 50% improvement of pain and improvement in patient specific ADLs documented for at least 6 months.You can find this rule in the Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L35936) effective December 5, 2019.
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 payment for inpatient psychiatric hospital services is to be made only foractive 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; and3. besupervised 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).
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 only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).
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 we only cover manual manipulation of the spine to correct subluxation. Other services performed by a chiropractor are not covered. You can find this information on page 63 of the plan's 2019 Evidence of Coverage. The Plan contract says that you pay 50% coinsurance for Medicare covered chiropractic services provided by an out of network provider. You can find this information on page 63 of the plan's 2019 Evidence of Coverage. The Plan contract says that as a member of our plan, you can choose to receive care from out-of-network providers. However, please note providers that do not contract with us are under no obligation to treat you, except in emergency situations. Our plan 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 you use an out-of-network provider, your share of the costs for your covered services may be higher. You can find this information on pages 46-47 of the plan's 2019 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 at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that CT scans are covered if there is literature to support its use for the patient's condition and the scan is reasonable and necessary for the patient. You can find this rule in the Medicare National Coverage Determinations Manual, Section 220.1(A).The rules say that for purposes of Medicare coverage of lung cancer screening with LDCT, beneficiaries must meet all of the following eligibility criteria:-Age 55 -77 years;-Asymptomatic (no signs or symptoms of lung cancer);-Tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes);-Current smoker or one who has quit smoking within the last 15 years; and-Receive a written order for lung cancer screening with LDCT.Written orders for lung cancer LDCT screenings must be appropriately documented in the beneficiary's medical records, and must contain the following information:1. Beneficiary date of birth;2. Actual pack -year smoking history (number);3. Current smoking status, and for former smokers, the number of years since quitting smoking;4. Statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer); and5. National Provider Identifier (NPI) of the ordering practitioner.You can find this rule in National Coverage Determination (NCD) for Lung Cancer Screening with Low Dose Computed Tomography (LDCT) (210.14) -Effective February 5, 2015.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 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 maxillary denture (D5110) and complete mandibular denture (D5120) and are each limited to one procedure every five plan years. You can find this information on page 4-88 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that enrollees must pay a $20 copayment per visit to a specialist. You can find this information on
pages 79 to 80 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 Home Health Aide (HHA) services may be covered only if the enrollee needs one or more of the following qualified skilled services: 1. Skilled nursing care; 2. Physical therapy; 3. Occupational therapy; or 4. Speech pathology services. HHA services are no longer covered for enrollees once the qualifying skilled service has ended. To be covered, home health aide services must be reasonable and necessary. You can find this rule at 42 CFR Sections 409.44 and 409.45. The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also custodial care services. You can find this rule at Medicare Benefit Policy Manual Ch. 16, Section 110.
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 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. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).
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 of the Plan's 2019 EOC. The Plan contract also says that the only covered chiropractic service is manual manipulation of the spine to correct a subluxation. Services other than Medicare covered chiropractic services are not covered. You can find this information on pages 69 and 113 of the Plan's 2019 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 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). 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 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 47 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 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 Plancovers 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 29 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 payfor it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A).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 minimally-invasive surgical (MIS) fusion of the sacroiliac (SI) joint is considered medically
necessary when ALL of the following criteria are met:
- Have moderate to severe pain with functional impairment and pain persists despite a minimum six months of
intensive nonoperative treatment that must include medication optimization, activity modification, bracing, and
active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip including a home exercise program
- Patient's report of typically unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized over the
posterior SIJ, and consistent with SIJ pain
- A thorough physical examination demonstrating localized tenderness with palpation over the sacral sulcus
(Fortin's point, i.e. at the insertion of the long dorsal ligament inferior to the posterior superior iliac spine or
PSIS) in the absence of tenderness of similar severity elsewhere (e.g. greater trochanter, lumbar spine, coccyx)
and that other obvious sources for their pain do not exist
- Positive response to a cluster of 3 provocative tests (e.g. thigh thrust test, compression test, Gaenslen's test,
distraction test, Patrick's sign, posterior provocation test).
- Absence of generalized pain behavior (e.g. somatoform disorder) or generalized pain disorders (e.g.
fibromyalgia)
- Diagnostic imaging studies that include ALL of the following:
o Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of destructive lesions
(e.g. tumor, infection), fracture, traumatic SIJ instability, or inflammatory arthropathy that would not be
properly addressed by percutaneous SIJ fusion
o Imaging of the pelvis (AP plain radiograph) to rule out concomitant hip pathology
o Imaging of the lumbar spine (CT or MRI) to rule out neural compression or other degenerative condition that
can be causing low back or buttock pain
- At least 75 percent reduction of pain for the expected duration of two anesthetics (on separate visits each with
a different duration of action), and the ability to perform previously painful maneuvers, following an imageguided,
contrast-enhanced intra-articular SIJ injection.
- A trial of at least one therapeutic intra-articular SIJ injection (i.e. corticosteroid injection)
You can find this rule in the Local Coverage Determination (LCD): Minimally-Invasive Surgical (MIS) Fusion
of the Sacroiliac (SI) Joint (L36494) effective December 26, 2019.
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 also says that the plan covers up to a $230 allowance for comprehensive dental services every quarter. Any amount not used at the end of a quarter will carry over to the next quarter. Any amount not used at the end of the calendar year will expire. You can find this information on page 57 of the Plan's 2020 Evidence of Coverage (EOC).