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 effective for dates of service specified below, the Centers for Medicare & Medicaid Services 
(CMS) has determined that PILD will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E)of the Social Security Act (the Act) through Coverage with Evidence Development (CED) for 
beneficiaries with LSS who are enrolled in an approved clinical study that meets specific criteria. You can find 
this rule in the National Coverage Determination Manual, Section 150.13. 
 
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 therapeutic continuous glucose monitors (CGMs) and related supplies are covered by 
Medicare when all of the following coverage criteria are met: 
  1. The beneficiary has diabetes mellitus, 
  2. The beneficiary has been using a blood glucose monitor (BGM) and performing frequent (four or more 
 times a day) testing, 
  3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
 covered continuous subcutaneous insulin infusion (CSII) pump, 
  4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
 BGM or CGM testing results. 
 
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 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 $155 copayment for each Medicare-covered radiological diagnostic 
service, not including x-rays performed in a physician's office or at a free-standing facility. Examples include, 
but are not limited to, specialized scans, CT, SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic 
mammograms and interventional radiological procedures. You can find this information on page 4-32 of the 
Plan's 2020 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 a 
complete maxillary denture and a complete mandibular denture, once per 60 months. You can find this 
information in the Plan's 2020 Preventive and Comprehensive Dental Coverage Handbook.
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 tumor treatment field therapy (E0766) is covered for the treatment of newly diagnosed 
Glioblastoma Multiforme (GBM) only when all of the following criteria are met: 
 
    1. The beneficiary has histologically confirmed (World Health Organization (WHO) grade IV astrocytoma), 
newly diagnosed, supratentorial GBM; and, 
 
    2. The beneficiary has received initial treatment with maximal debulking surgery (when feasible), followed 
by chemotherapy and radiotherapy; and, 
 
    3. Tumor treatment field therapy is initiated within 7 weeks from the last dose of concomitant chemotherapy 
or radiotherapy, whichever is later; and, 
 
    4. The beneficiary has no evidence of progression by Response Assessment in Neuro-Oncology (RANO) 
criteria; and, 
 
    5. The beneficiary has a Karnofsky Performance Score (KPS) of at least 70; and, 
 
    6. The beneficiary will use TTFT for an average of 18 hours per day. 
 
If all of the coverage criteria above are not met, claims for code E0766 will be denied as not reasonable and 
necessary. 
 
Continued coverage of TTFT (E0766) beyond the first three months of therapy requires that no sooner than the 
60th day but no later than the 91st day after initiating therapy, the treating practitioner must conduct a clinical 
re-evaluation and document that the beneficiary is continuing to use and is benefiting from TTFT. 
 
Documentation of clinical benefit is demonstrated by: 
 
    1. In-person clinical re-evaluation by the treating practitioner; and, 
 
    2. Objective evidence of adherence to therapy, reviewed by the treating practitioner. 
 
Tumor treatment field therapy (E0766) will be denied as not reasonable and necessary for the treatment of 
recurrent GBM. 
 
The use of TTFT for any indications other than newly diagnosed GBM will be denied as not reasonable and 
necessary. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Tumor Treatment Field 
Therapy (TTFT) (L34823). 
 
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 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 excludes 
coverage of crowns, bridges and implants. You can find this information on page 57 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. 
 
The rules say that Medicare will allow payment for one injection per site regardless of the number of injections 
made into the site. A site is defined as one eye (including all muscles surrounding the eye including both upper 
and lower lids); one side of the face; the neck; or extremity and/or trunk muscle(s). 
 
Failure of two definitive, consecutive, treatment sessions involving a muscle or group of muscles could 
preclude further coverage of the serotype used in the treatment for a period of one year after the second session. 
It may be reasonable, however, to attempt treatment with a different serotype. 
 
You can find this in the Local Coverage Determination (LCD): Botulinum Toxins (L33646). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract lists the specific 
dental services that are covered. Core build up is not listed and therefore is not a covered service. Occlusal 
guard is not listed and therefore is not a covered item. The contract also says any items or services not listed are 
not covered. You can find this information on pages 22 to 29 of the Dental Plan's 2020 Customer Handbook.
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 oral 
exams, cleanings (prophylaxis), scaling, fluoride treatment and bitewing x-rays every 6 months. You can find 
this information on pages 63-69 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 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 exams, 
cleanings, bitewing x-rays, fillings and anesthesia. You can find this information on pages 87 and 88 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 page 74-75 of the Plan's 2020 EOC
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that indications for surgical treatment (for example - venous ligation, vein stripping and/or 
sclerotherapy): 
 
1. A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive 
therapy, and avoidance of prolonged immobility where appropriate, has failed, AND 
 
2. The patient is symptomatic and has one, or more, of the following: 
 
a. Pain or burning in the extremity severe enough to impair mobility 
b. Recurrent episodes of superficial phlebitis  
c. Non-healing skin ulceration  
d. Bleeding from a varicosity  
e. Stasis dermatitis  
 f. Refractory dependent edema 
 
You can find this rule in Local Coverage Determination (LCD): Treatment of Varicose Veins of the Lower 
Extremities (L34209) - Effective December 1, 2019. 
 
The rules say that in addition to the above, in terms of endovenous ablation, the patient's anatomy and clinical 
condition are amenable to the proposed treatment including ALL of the following: 
 
1. Absence of aneurysm in the target segment. 
2. Maximum vein diameter of 12 mm for ERFA or 20 mm for laser ablation 
3. Absence of thrombosis or vein tortuosity, which would impair catheter advancement. 4. The absence of 
significant peripheral arterial diseases. 
 
You can find this rule in Local Coverage Determination (LCD): Treatment of Varicose Veins of the Lower 
Extremities (L34209) - Effective December 1, 2019. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare does not pay for gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 
30.3. 
 
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 also says that the Plan offers a benefit that exceeds Medicare coverage. The Plan reimburses up to $40 
per month for qualifying fitness expenses, such as general access to public sports facilities. You can find this 
information on pages 64-66 of the Plan's 2020 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the 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 41 of the Plan's 2020 
Evidence of Coverage.  
 
The Plan contract also says that when you choose your PCP, you are also choosing the hospital and specialty 
network associated with your PCP. If there are specific specialists you want to use, find out whether your PCP 
sends patients to these specialists. Each network PCP has certain Plan specialists they use for referrals. This 
means that the PCP you select may determine the specialists you may see. You may generally change your PCP 
at any time if you want to see a Plan specialist that your current PCP can't refer you to. You can find this 
information on page 42 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 plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances, 
Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules also say in a hospital inpatient situation involving one physician covering for another, if physician A 
sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, 
contractors do not pay physician B for the second visit. The hospital visit descriptors include the phrase per 
day meaning care for the day.  
 
If the physicians are each responsible for a different aspect of the patient's care, pay both visits if the physicians 
are in different specialties and the visits are billed with different diagnoses. There are circumstances where 
concurrent care may be billed by physicians of the same specialty. You can find this information in the 
Medicare Claims Processing Manual, Chapter 12, Section 30.6.9. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Medicare Managed Care Manual, Chapter 1, Section 20.2. 
 
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 49 53 of the Plan's 2020 
Evidence of Coverage.