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 state that an "order" is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 80.6.
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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 list gingival irrigation as a covered service. Any service not listed is not covered. You can find this information on pages 4-88 to 4-102 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 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 durable medical equipment (DME) and related supplies. You can find this information in Chapter 4 on pages 75 - 76 of the Plan's 2020 Evidence of Coverage (EOC) and in Chapter 4 on pages 78 - 79 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.
Medicare rules state that facet joint interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all of the following criteria:
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale; and
2. Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive conservative care management (as tolerated); and
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst); and
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity.
You can find these rules in Local Coverage Determination (LCD) Facet Joint Interventions for Pain Management (L34892).
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 skin protection seat cushion (E2603, E2604, E2622, E2623) is covered for a beneficiary who meets both of the following criteria:
1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and
2. The beneficiary has either of the following (a or b):
a. Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface as reflected in a diagnosis code; or
b. Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift as reflected in a diagnosis code
A positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, E2616, E2620, E2621), and positioning accessory (E0953, E0955, E0956, E0957, E0960) are covered for a beneficiary who meets both of the following criteria:
1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and
2. The beneficiary has any significant postural asymmetries that are due to certain diagnoses
A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) is covered for a beneficiary who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. You can find these rules in Local Coverage Determination (LCD) Wheelchair Seating (L33312).
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 for services performed on or after January 21, 2020, Medicare will now provide limited coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may be provided by a physician in accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Section 30.3.3.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan offers additional coverage for acupuncture beyond what is covered by Medicare. This benefit covers acupuncture for chronic low back pain. You can find this information on page 64 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 botulinum toxins (Botox?, Dysport?, Xeomin? and Myobloc?), will be considered medically reasonable and necessary when administered for treatment of FDA-labeled indications and Off-label indications (as applicable) below:
1. FDA3 indications for onabotulinumtoxinA (Botox?) as noted on the FDA website
2. Off-Label indications for onabotulinumtoxinA (Botox?) may be considered medically reasonable and necessary in patients for the following conditions:
&#61623; Esophageal achalasia in adults who are considered poor surgical candidates4
&#61623; Chronic anal fissure for patients with inadequate response to conservative or pharmacologic treatment5
&#61623; Essential hand tremor for patients with a high amplitude tremor that disrupts activities of daily living and have had inadequate response to oral pharmacotherapy such as propranolol and primidone6
&#61623; Focal limb dystonia6
&#61623; Hemifacial spasm in adults (cranial nerve VII disorder)6
&#61623; Isolated oromandibular dystonia in adults7
&#61623; Laryngeal dystonia (spastic dysphonia) for adductor type (ADSD)6
&#61623; Bothersome simple motor tics in adolescents and adults when the benefits of treatment outweigh the risks8
&#61623; Severely disabling or aggressive vocal tics in older adolescents and adults when the benefits of treatment outweigh the risks8
3. FDA9 indications for abobotulinumtoxinA (Dysport?) as noted on the FDA website
4. Off-label indications for abobotulinumtoxinA (Dysport?) may be considered medically reasonable and necessary in patients for the following conditions:
&#61623; Blepharospasm in adults6,7
&#61623; Hemifacial spasm in adults (cranial nerve VII disorder)6
&#61623; Isolated oromandibular dystonia in adults7
5. FDA10 indications for incobotulinumtoxinA (Xeomin?) as noted on the FDA website
6. FDA11 indications for rimabotulinumtoxinB (Myobloc?) as noted on the FDA website
You can find this rule at Local Coverage Determination (LCD) L38809: Botulinum Toxins (eff. 3/21/21). 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 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 DME and related supplies. You can find this
information in Chapter 4 on page 43 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 a group 2 power operated vehicle (POV) (K0807) has added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD) - Power Mobility Devices (L33789) - Effective January 1, 2020. The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your home may be a dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, an institution may not be considered your home if it is an acute hospital or a skilled nursing facility (SNF). You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 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.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that reversal of sterilization procedures is not covered by the Plan. You can find this information on page 4-74 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 state that multiplex respiratory viral panels of 3-5 pathogens are covered under limited
circumstances. Specifically, the test must be ordered either in a healthcare setting that is equipped to care for
and routinely does care for critically ill patients, or it must be ordered by an infectious disease specialist, unless
an infectious disease specialist is not available. You can find this rule in Local Coverage Determination (LCD):
MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels (L37713).
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 acupuncture for stimulation of auricular points is not a covered Medicare benefit. You can find this rule in Local Coverage Article: Billing and Coding: Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device) (A55240) - Effective January 21, 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 pay for an IRF admission when the services are reasonable and medically
necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing
rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of
the therapies must be physical therapy or occupational therapy. The patient must need and be expected to
actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive
rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per
week. The patient does not need to be expected to achieve complete independence in self-care nor be expected
to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation
physician. The physician must see the patient at least three days per week throughout the stay. You can find
these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02,
Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622.
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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 extractions, an upper partial denture, or a lower partial denture. You can find this information on pages 81-83 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 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).
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 there is a $203 deductible depending on your level of Medicaid. The Plan contract also
says that based on the Plan benefits for outpatient radiology, you have a 20% coinsurance after you pay the
$203 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. You can find
this information on pages 56 and 87-88 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 a $0 copayment for oral evaluations, and a 50% coinsurance for extractions. The contract also says for services obtained out of network; the plan only pays up to a certain amount. If you choose to see an out of network dentist, you might be billed for any amount greater than what the plan pays. You can find this information on pages 4-57 to 4-70 of the Plan's 2021 Evidence of Coverage (EOC).