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 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 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.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the indications for coverage of facet joint injections are: 
- 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. 
 
You can find these rules in Local Coverage Determination (LCD) Facet Joint Injections, Medial Branch 
Blocks, and Facet Joint Radiofrequency Neurotomy (L34995). 
 
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). 
 
The rules say that push-rim activated power assist device (E0986) for a manual wheelchair is covered if the 
beneficiary has been self-propelling in a manual wheelchair for at least one year. You can find this information 
in the Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
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 IMRT is clinically indicated (i.e medically necessary criteria will be met) when highly 
conformal dose planning is required. IMRT planning may be clinically indicated when one or more of the 
following conditions are present: 
 
1. An immediately adjacent area has been previously irradiated and abutting portals must be established with 
high precision. 
2. Dose escalation is planned to deliver radiation doses in excess of those commonly utilized for similar tumors 
with conventional treatment. 
3. The target volume is concave or convex, and the critical normal tissues are within or around that convexity 
or concavity. 
4. The target volume is in close proximity to critical structures that must be protected. 
5. The volume of interest must be covered with narrow margins to adequately protect immediately adjacent 
structures. 
On the basis of the above conditions demonstrating medical necessity, disease sites that may support the use of 
IMRT include the following: 
-Primary, metastatic or benign tumors of the central nervous system including the brain, the brain stem, and 
spinal cord. 
-Primary or metastatic tumors of the spine where the spinal cord tolerance may be exceeded with conventional 
treatment or where the spinal cord has previously been irradiated. 
-Primary, metastatic, benign or recurrent head and neck malignancies, including: orbits, sinuses, skull base, 
aero-digestive tract, and salivary glands. 
-Thoracic malignancies. 
-Abdominal malignancies when dose constraints to small bowel or other normal abdominal tissue are exceeded 
and present administration of a therapeutic dose. 
-Pelvic malignancies including: prostatic, gynecological and anal carcinoma. 
-Other pelvic or retroperitoneal malignancies. 
 
You can find this rule in Local Coverage Determination (LCD):Intensity Modulated Radiation Therapy 
(IMRT) (L36711) - Effective November 14, 2019. 
 
The rules say that other malignancies not delineated in the above can be supported with submission of 
documentation for medical necessity should a denial occur. The determination of appropriateness and medical 
necessity for IMRT for any site shall be found in the documentation from the radiation oncologist and must be 
available when requested or submitted in the appeals process. You can find this rule in Local Coverage 
Determination (LCD):Intensity Modulated Radiation Therapy (IMRT) (L36711) - Effective November 14, 
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 state that the use of nerve blocks or injections for the treatment of multiple neuropathies or peripheral 
neuropathies caused by underlying systemic diseases is not considered medically necessary. The use of nerve 
blocks with or without the use of electrostimulation, and the use of electrostimulation along is not considered 
medically reasonable and necessary. At present, the literature and scientific evidence supporting the use of 
peripheral nerve blocks with or without the use of electrostimulation/electromagnetic stimulation, and the use 
of electrostimulation/ electromagnetic stimulation alone for neuropathies or peripheral neuropathies caused by 
underlying systemic diseases, is insufficient to warrant coverage. These procedures are considered 
investigational and are not eligible for coverage for the treatment of neuropathies or peripheral neuropathies 
caused by underlying systemic diseases. The use of ultrasound guidance in conjunction with these non -covered 
injections is also considered not medically necessary and will result in denial. You can find these rules in Local 
Coverage Determination (LCD) Nerve Blocks for Peripheral Neuropathy (L35249). 
 
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 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) (L34228) - Effective December 16, 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 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 $0 copayment for days 1-10, a $20 copayment per day for days 11-20, 
and a $178 copayment per day for days 21-100 for skilled nursing facility services. You can find this 
information on page 60 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 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 on page 46 of the plan's 
2020 Evidence of Coverage.  
 
The Plan contract says that when you are outside the service area and cannot get care from a network provider, 
the plan will cover urgently needed services that you get from any provider. You can find this information on 
page 50 of the plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a Continuous Glucose Monitor is covered when the beneficiary is insulin-treated with 
multiple (three or more) daily injections of insulin or a Medicare covered continuous subcutaneous insulin 
infusion (CSII) pump. This rule can be found in 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 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 if an enrollee uses an out of network provider the share of costs for covered services may be 
higher. If a provider is not available in the Plan's network the enrollee can ask to see an out of network 
provider. If the request is approved the enrollee will pay the applicable in network cost-sharing and provider 
will be reimbursed at the in network allowable charge. You can find this information on pages 50-51 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. 
 
A pneumatic compression device (PCD) coded as E0652 is covered for the treatment of lymphedema extending 
onto the chest, trunk and/or abdomen when all of the following are met: 
 
The beneficiary has lymphedema of an extremity. 
The coverage criteria for an E0650 or E0651 PCD are met. 
The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the 
limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to 
improve with a four-week trial. 
 
A four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651 
PCD is required. The four-week trial of conservative therapy must include all of the following: 
 
At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 PCD after 
careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and 
successfully uses the appliance provided 
Compliant use of an appropriate compression bandage system or compression garment to provide 
adequate graduated compression 
Elevation where appropriate 
Manual lymphatic drainage (where available) and self-manual lymphatic drainage (MLD) for at least 30 
minutes per day 
Evaluation of diet and implementation of any necessary change  Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.) 
Correction (where possible) of anemia and/or hypoproteinemia 
 
You can find this information at Local Coverage Determination (LCD): Pneumatic Compression Devices 
(L33829). 
 
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 power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered. You can find these rules in Local Coverage Article: 
Wheelchair Options/Accessories - Policy Article (A52504). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 
coverage for dentures once every 5 years. You can find this information on pages 51 and 52 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 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 on pages 1-6 of the Plan's 2020 
Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health 
plan contract says simple extraction or surgical removal of erupted tooth / one (1) procedure per year. Services 
must be performed by a participating general dentist. You can find this information in Chapter 4 on pages 63-
65 of the plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a speech generating device (SGD) (E2500, E2502, E2504, E2506, E2508, E2510, E2511) is 
covered when all of the following criteria are met:  
 
1. Prior to the delivery of the SGD, the beneficiary has had a formal evaluation of their cognitive and 
communication abilities by a speech-language pathologist (SLP).  
2. The beneficiary's medical condition is one resulting in a severe expressive speech impairment; and 
3. The beneficiary's speaking needs cannot be met using natural communication methods; and 
4. Other forms of treatment have been considered and ruled out; and 
5. The beneficiary's speech impairment will benefit from the device ordered. 
 
You can find this information in the Local Coverage Determination (LCD): Speech Generating Devices (SGD) 
(L33739). 
 
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.