Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that a seat lift mechanism is covered if all of the following are met:

1. The enrollee must have severe arthritis of the hip or knee or have a severe neuromuscular disease.

2. The seat lift mechanism must be a part of the treating practitioner's course of treatment and be prescribed to
improve, or stop deterioration of, the enrollee's condition.

3. The enrollee must be completely unable to stand up from a regular armchair or any chair in the home.

4. Once standing, the enrollee must have the ability to walk.
You can find this information in the Local Coverage Determination (LCD): Seat Lift Mechanisms (L33801).

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 after the patient has had at least two (2) medically reasonable and necessary diagnostic
medial branch blocks, with each one providing a consistent minimum of 80% sustained relief of primary
(index) pain (with the duration of relief being consistent with the agent used) AND
Repeat thermal facet joint radiofrequency ablation (RFA) at the same anatomic site is considered medically
reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at
least six (6) months or at least 50% consistent improvement in the ability to perform previously painful
movements and ADLs as compared to baseline measurement using the same scale;

You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain
Management (L35936).

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 does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device.
This rule does not apply to:
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after
each cataract surgery with insertion of an IOL; and
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with
an IOL.
You can find this rule at 42 CFR Section 411.15(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 standard lenses and frames, limited to 1 pair of lenses and frames every 2 years. Contact
lenses instead of lenses and frames every 2 years provided by the Plan's Vision. You can find this
information on page 4-69 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 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. The contract says that periodic oral exams and emergency diagnostic exams share a frequency limit of 2 per calendar year. You can find this information on page 87 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% coinsurance for outpatient surgery/in-network/outpatient hospital facility. You can find this information on pages 88-89 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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Section 220.1(A). The rules say that CT scans of the head and neck are not indicated for surveillance imaging for stage I or II Large B Cell Lymphoma. You can find this information in Medicare's Local Coverage Determination (LCD): MRI and CT Scans of the Head and Neck (L35175).
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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 1, Section 20.2.

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, 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 pages 54 and 60-61 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 $395 copayment for Medicare-covered surgery or other services
provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility
charges and physician or surgical charges. You can find this information on pages 4-47 to 4-49 of the Plan's
2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the 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 does
not list endosteal implants as covered services. You can find this information on pages 86-87 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 kyphoplasty is covered in patients with both of the following:
1. Inclusion criteria (ALL ARE REQUIRED)
a. Acute (less than six weeks) osteoporotic VCF (T5-L5) by recent (within 30 days) advanced imaging (bone
marrow edema on MRI or bone scan/SPECT/CT uptake
b. Symptomatic (ONE)
i. Hospitalized with severe pain (NRS or VAS of 8 or more)
ii. Non-hospitalized with moderate to severe pain (NRS or VAS of 5 or more) despite optimal non-surgical
management (ONE)
1. Worsening pain
2. Stable to improved pain (but NRS or VAS still 5 or more) (with 2 or more of the following)
A. Progression of vertebral body height loss
B. More than 25% of vertebral body height reduction
C. Kyphotic deformity
D. Severe impact of VCF on daily functioning
c. Multidisciplinary team consensus (ALL ARE REQUIRED)
i. Referring physician (e.g., rheumatologist, endocrinologist)
ii. Treating physician (i.e., performing the PVA)
iii. Radiologist
iv. Neurologist
2. Exclusion criteria (Can have NONE of the following):
a. Absolute contraindication
1. Current back pain is not primarily due to the identified acute VCF(s).
2. Osteomyelitis, discitis or active systemic infection
3. Pregnancy
4. Greater than three vertebral fractures
b. Relative contraindication
1. Allergy to bone cement or opacification agents
2. Coagulopathy
3. Spinal instability
4. Myelopathy from the fracture
5. Neurologic deficit
6. Neural impingement
7. Fracture retropulsion/canal compromise
You can find this rule in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation (PVA)
for Osteoporotic Vertebral Compression Fracture (VCF) (L33569) - Effective December 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 Advantage plans such as the enrollee's health plan cannot require pre-approval for
services related to clinical trials. You can find this information in Medicare's National Coverage Determination
(NCD) for Routine Costs in Clinical Trials (310.1).

The rules say that claim payment for managed care plan members for the covered routine costs associated with
a clinical trial is the responsibility of the original Medicare contractor, and not the managed care plan. You can
find this information in the Medicare Claims Processing Manual, Chapter 32, Section 69.9.

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 a Medicare plan may restrict members to a network of providers as long as medically
necessary covered care is accessible and available through this network. The rules say that the Plan must
arrange for specialty care outside of the Plan provider network when network providers are unavailable or
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care
and services. The only exceptions are emergencies, urgently needed care when the network is not available
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan
authorizes the use of out-of-network providers. You can find this information in Chapter 3 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 Medicare plan may restrict members to a network of providers as long as medically
necessary covered care is accessible and available through this network. The rules say that the Plan must
arrange for specialty care outside of the Plan provider network when network providers are unavailable or
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care
and services. The only exceptions are emergencies, urgently needed care when the network is not available
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan
authorizes the use of out-of-network providers. You can find this information in Chapter 3 on page 33 of the
plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the 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 health
plan contract says non-routine dental care (covered services are limited to surgery of the jaw or related
structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation
treatments of neoplastic cancer disease, or services that would be covered when provided by a physician).
Dental services provided by a dentist in connection with care, treatment, filling, removal, or replacement of
teeth or structures directly supporting the teeth are not Medicare-covered benefits and not covered under this
benefit. You can find this information in Chapter 4 on pages 4-53 to 4-54 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 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).

Local Coverage Determination (LCD): Polysomnography and Other Sleep Studies (L36839): Non-covered
Services

A. Polysomnography for Chronic Insomnia Is Not Covered.
The use of polysomnography for diagnosis of patients with chronic insomnia is not covered under
Medicare because it is not reasonable and necessary under 1862(a)(1)(A) of the Act.
B. Actigraphy Testing: Actigraphy measures movement of a limb. It can be measured as part of a sleep
test but will not be paid for separately.
C. Polysomnography or a MSLT is not covered in the following situations:

1. for the diagnosis of patients with chronic insomnia;
2. to preoperatively evaluate a patient undergoing a laser assisted uvulopalatopharyngoplasty without
clinical evidence that obstructive sleep apnea is suspected;
3. to diagnose chronic lung disease (Nocturnal hypoxemia in patients with chronic, obstructive, restrictive,
or reactive lung disease is usually adequately evaluated by oximetry. However, if the patient's
symptoms suggest a diagnosis of obstructive sleep apnea, polysomnography is considered medically
necessary);
4. in cases where seizure disorders have not been ruled out;
5. in cases of typical, uncomplicated, and non-injurious parasomnias when the diagnosis is clearly
delineated;
6. for patients with epilepsy who have no specific complaints consistent with a sleep disorder;
7. for patients with symptoms suggestive of the periodic limb movement disorder or restless leg syndrome
unless symptoms are suspected to be related to a covered indication;
8. for the diagnosis of insomnia related to depression;
9. for the diagnosis of circadian rhythm sleep disorders (i.e., rapid time-zone change [jet lag], shift-work
sleep disorder, delayed sleep phase syndrome, advanced sleep phase syndrome, and non 24-hour sleep
wake disorder).

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 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).

Local Coverage Determination (LCD): Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (L35350)

1. Indications for which EGD(s) are generally not covered by Medicare are as follows:
o Distress which is chronic, non-progressive, atypical for known organic disease, and is considered functional in origin (there are occasional exceptions in which an endoscopic examination may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy);
o Uncomplicated heartburn responding to medical therapy;
o Metastatic adenocarcinoma of unknown primary site when the results will not alter management;
o X-ray findings of:
&#9642; asymptomatic or uncomplicated sliding hiatal hernia;
&#9642; uncomplicated duodenal bulb ulcer which has responded to therapy; or
&#9642; Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy;
o Routine screening of the upper gastrointestinal tract;
o Patients without current gastrointestinal symptoms about to undergo elective surgery for non-upper gastrointestinal disease; or
o When lower G.I. endoscopy reveals the cause of symptoms, abnormal signs or laboratory tests (e.g., colonic neoplasm with iron deficiency anemia). Exceptions can be considered if medical necessity for this procedure can be demonstrated.

2. Sequential or periodic diagnostic EGD is not indicated for:
o Surveillance for malignancy in patients with gastric atrophy, pernicious anemia, treated achalasia, or prior gastric operation;
o Surveillance of healed benign disease such as esophagitis, gastric or duodenal ulcer; or
o Surveillance during chronic repeated dilations of benign strictures unless there is a change in status.

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.