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 the destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) 
nerves will be considered to be medically reasonable and necessary as follows: 
; The paravertebral facet joint(s) have been identified as the source of the patients pain by undergoing a 
diagnostic paravertebral facet joint (median branch) block. Temporary or prolonged abolition of the 
pain suggests that the facet joint (s) are the source of the symptoms and appropriate for treatment; and 
; The patient failed conservative treatment. Conservative treatment may include local heat, traction, 
nonsteroidal anti-inflammatory medications and anesthetic and  
; The paravertebral facet joint(s) destruction is performed by appropriately trained providers.  
If pain recurs in the same distribution and nature, the procedure may be provided at the same anatomic site 
(side and spinal level) 6 months from prior treatment.  
  
Limitations 
The destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves will not be 
considered medically reasonable and necessary when: 
; Performed without fluoroscopic guidance. A mandatory requirement of paravertebral facet joint 
(median branch) destruction is the use of fluoroscopic guidance to confirm the proper positioning of the 
needle electrode. Failure to use fluoroscopic guidance will result in the services receiving a denial; or 
; The medical records do not support that the patient experienced temporary or prolonged abolition of the 
pain after a facet joint nerve block injection; or; The medical records do not demonstrate that destruction was performed at the median branch of the 
spinal nerve innervating the facet joint. 
; It is not expected that paravertebral facet joint destructions (median branch) will exceed five (5) levels, 
unilaterally or bilaterally on the same date of service. 
; Repeat paravertebral facet joint destruction is not medically necessary when performed at the same 
anatomic site (side and spinal level) within 6 months of a prior treatment. (So one bilateral or R(L) then 
L(R) same level is allowed in 6 months and then can be repeated in the subsequent 6 months. 
You can find this rule in the Local Coverage Determination (LCD): Destruction of Paravertebral Facet Joint 
Nerve(s) (L33814). 
 
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 following individual Tier 2 genetic tests are unlikely to impact therapeutic decision-
making, directly impact treatment, outcome and/or clinical management in the care of the beneficiary and will 
be denied as not medically necessary (Please note that this list of non-covered genes is not exhaustive, and the 
fact that a specific gene is not mentioned does not mean it is covered. In addition, many genes have several 
names that are used. The most common names have been used in this policy): 
 
--C9orf72 
 
You can find this rule in the Local Coverage Determination (LCD): Molecular Pathology Procedures (L35000) 
effective July 1, 2020. 
 
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 
complete dentures (upper and lower) once every five years. You can find this information on pages 80-81 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 health plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). The rules say that health plans must submit a complete case file to the IRE, including a copy of the enrollee's contract, appeal letter, and all documentation used to The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). The rules say that health plans must submit a complete case file to the IRE, including a copy of the enrollee's contract, appeal letter, and all documentation used to support the health plan's denial. You can find this information in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1.

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 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 root 
canal services that are limited to one procedure per calendar year. You can find this information on pages 84-85 
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 

 
Rules also state that the patient's medical record should contain documentation that fully supports the medical 
necessity for intraarticular injections of sodium hyaluronate (Hyalgan?, Supartz? or Visco-3?, Euflexxa?, 
Monovisc?, GelSyn-3?,GenVisc? 850, Durolane?, TriVisc?), hylan G-F 20 (Synvisc?, Synvisc-One ?), 
hyaluronic acid (Gel-One?), high molecular weight hyaluronan (Orthovisc?) and high molecular weight 
viscoelastic hyaluronan (Hymovis?). This documentation includes, but is not limited to, relevant medical 
history, physical examination and results of pertinent diagnostic tests or procedures, and history of 
pharmacologic therapy. Documentation of subsequent courses of treatment must clearly establish reduction of 
patient symptomatology and medication usage. This documentation must be submitted upon request. Claims 
submitted without requested supporting evidence in the medical record will be denied as being not medically 
necessary. This information can be found in Local Coverage Article:  Billing and Coding: Hyaluronans, Intra-
articular Injections of (A52420). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility 
limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices L33789 (eff 1/1/17). 
 
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. 
 
Medicare rules say that the provider must notify the enrollee in writing before it ends coverage of home health 
services. A Notice of Medicare Non-Coverage (NOMNC) must be issued no later than two days before the last 
covered day. If the span of time between services exceeds two days, the notice should be given no later than the 
next to last time services are furnished. The notice must include: 
 
1. The date that coverage of service ends; 
2. The date the enrollee becomes responsible to pay for the service; and 
3. A description of the enrollee?s right to a fast-track appeal and other appeal procedures. You can find this rule 
at 42 CFR Section 422.624(b).  
 
A Health Plan is financially liable for continued services until two days after the enrollee receives valid notice. 
You can find this rule at 42 CFR Section 422.624(d). 
 
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 Enteral nutrition is covered for a beneficiary who has (a) permanent non-function or disease 
of the structures that normally permit food to reach the small bowel or (b) disease of the small bowel which 
impairs digestion and absorption of an oral diet, either of which requires tube feedings to provide sufficient 
nutrients to maintain weight and strength commensurate with the beneficiary's overall health status. 
The beneficiary must have a permanent impairment. Permanence does not require a determination that there is 
no possibility that the beneficiary's condition may improve sometime in the future. If the judgment of the 
treating practitioner, substantiated in the medical record, is that the condition is of long and indefinite duration 
(ordinarily at least 3 months), the test of permanence is considered met. Enteral nutrition will be denied as non-
covered in situations involving temporary impairments. The beneficiary must require tube feedings to maintain 
weight and strength commensurate with the beneficiary's overall health status. Adequate nutrition must not be 
possible by dietary adjustment and/or oral supplements. Coverage is possible for beneficiaries with partial 
impairments - e.g., a beneficiary with dysphagia who can swallow small amounts of food or a beneficiary with 
Crohn's disease who requires prolonged infusion of enteral nutrients to overcome a problem with absorption. 
Enteral nutrition products that are administered orally and related supplies are non-covered, no benefit. You 
can find this rule in the Local Coverage Article for Enteral Nutrition, A52493 (eff 04/03/20). 
 
The rules say that Medicare does not pay for nutritional supplements. You can find this rule in the Medicare 
National Coverage Determination Manual, Chapter 1, Section 180.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 

The rules say 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). 
 
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 Plan contract says that 
dentures (partial, full, immediate) are limited to one set every five (5) years. You can find this information on 
page 64 of the Plans 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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Section 423.578(b)(5)(ii). 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 106-107 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 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). 
 
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 infusion pumps cannot be placed for patients with contraindications to the pump. This 
includes enrollees with other implanted programmable devices since crosstalk between devices may 
inadvertently change the prescription. You can find this information in the National Coverage Determination 
(NCD) for Infusion Pumps (280.14). 
 
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 CGM devices covered by Medicare under the DME benefit are defined in CMS Ruling 
1682R as therapeutic CGMs. Refer to the Non-Medical Necessity Coverage and Payment Rules in the LCD-
related Policy Article for additional information. 
 
Therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria 
(1-6) are met: 
 
The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses); and, 
 
The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and, 
 
The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump; and, 
 
The beneficiarys insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results; and, 
 
Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the 
beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and, 
 
Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person 
visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
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 says that complete or partial dentures are covered once every five years when medically reasonable 
and necessary. You can find this information on pages 57 and 99 of the Plan's 2020 Evidence of Coverage. 
 
The contract also says that partial dentures are covered only for recipients with good oral health and hygiene, 
good periodontal health (AAP Type I or II), and a favorable prognosis where continuous deterioration is not 
expected. Radiographs must show no untreated cavities or active periodontal disease in the abutment teeth, and 
abutments must be at least 50% supported in bone. You can find this information on page 45 of the Plan's 2020 
supplemental dental coverage handbook.