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 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 a wearable defibrillator (K0606) is covered for beneficiaries if they meet one of the criteria 
described below: 
 
A documented episode of ventricular fibrillation or a sustained, lasting 30 seconds or longer, ventricular 
tachyarrhythmia. These dysrhythmias may be either spontaneous or induced during an electrophysiologic (EP) 
study, but may not be due to a transient or reversible cause and not occur during the first 48 hours of an acute 
myocardial infarction; or 
 
Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrhythmia such as long 
QT syndrome or hypertrophic cardiomyopathy; or 
 
Either documented prior myocardial infarction or dilated cardiomyopathy and a measured left ventricular 
ejection fraction less than or equal to 0.35; or 
 
A previously implanted defibrillator now requires explantation 
 
You can find this information in the Local Coverage Determination (LCD): Automatic External Defibrillators 
(L33690) 
 
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 of intraoral x-rays (D0210) once every 3 years. You can find this information in the Plan?s 2020 
Dental Benefits Addendum.
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 you have a $500 allowance for supplemental eyewear every year. Members are responsible 
for all costs over and above the allowance amount. You can find this information on page 64 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 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 additional cost sharing applies for lab tests performed or ordered during your annual wellness 
visit. The Plan contract says that enrollees must pay a $20 copayment for Tier 2 laboratory services. In order to 
have lab services covered under Tier 1 cost sharing (which is $0), you must have a Tier 1 Primary Care 
Provider (PCP) assigned to as your PCP and receive services in a Tier 1 facility. You can find this information 
on pages 61 and 79 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 LS tumor screening with IHC or MSI is considered medically necessary and covered by 
Medicare for the following indications: 
All individuals with colorectal cancer regardless of age OR 
Individuals with endometrial cancer 
*Hereditary nonpolyposis colorectal cancer (HNPCC)-related tumors include colorectal, endometrial, gastric, 
ovarian, pancreas, ureter and renal pelvis, biliary tract, brain (usually glioblastomas as seen in Turcot 
syndrome), small intestinal cancers, and sebaceous gland adenomas and keratoacanthomas as seen in Muir-
Torre syndrome. 
For patients with unresectable or metastatic solid tumors, either MSI or IHC or a multigene NGS or other 
multi-analyte methodology panel inclusive of MSI microsatellite loci, and MLH1, MSH2, MSH6 and PMS2 
genes is medically reasonable and necessary. 
For coverage, the treating physician/pathologist is expected to follow the stepped approach outlined for LS 
screening and targeted MMR testing in this policy. Germ-line testing includes sequence and duplication-
deletion analysis for a given gene. 
Testing for Known Familial Variant 
Testing for a specific known familial variant is considered medically necessary and covered only when the 
individual being tested has signs and symptoms of a Lynch-associated cancer AND has a blood relative with 
the specific disease-causing mutation for LS. 
Note: This LCD does not imply that testing family members of a known familial variant is not medically 
warranted. The scope of the Medicare benefit requires the beneficiary to have signs and symptoms of disease. 
Coverage of molecular testing for LS for carrier status or family studies is considered screening and is 
statutorily excluded from coverage. 
Limitations 
Molecular testing for LS to identify carrier status or family studies is not a Medicare benefit. 
You can find this rule in the Local Coverage Determination (LCD): MoIDX: Genetic Testing for Lynch 
Syndrome (L36793) effective December 26, 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 $125 copayment for Medicare covered diagnostic radiology services and 
a 20% coinsurance for Medicare Part B drugs. You can find this information on pages 89-91 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 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 $30 copayment for lab services performed in an outpatient hospital 
facility. You can find this information on page 78 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 1 set of 
complete or partial dentures every five years. You can find this information on page 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 indications for facet joint blocks include: 
&#61623; 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). 
&#61623; Pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with 
radiculopathy or neurogenic claudication. 
&#61623; There is no non-facet pathology that could explain the source of the patient?s pain, such as fracture, 
tumor, infection, or significant deformity. 
&#61623; Clinical assessment implicates the facet joint as the putative source of pain. 
Diagnostic Facet Joint Injections 
&#61623; Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably high 
false positive rate of single MBB injections. 
o A second confirmatory MBB is allowed if documentation indicates the first MBB produced 
greater than or equal to 80% relief of primary (index) pain and duration of relief is consistent 
with the agent employed. 
  
&#61623; Intraarticular facet block will not be reimbursed as a diagnostic test unless medial branch blocks cannot 
be performed due to specific documented anatomic restrictions. 
You can find this rule in the Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch 
Blocks, and Facet Joint Radiofrequency Neurotomy (L35936) effective December 5, 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 
 
Section 1879 of the Social Security Act says a beneficiary is not responsible for payment of the Part B 
deductible or coinsurance for items or services that are not reasonable or necessary to diagnose or treat the 
illness or injury. 
 
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 Medicare Part B prescription drugs that are injected 
or infused. You can find this information on page 71 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 TENS therapy for CLBP is only covered when all of the following criteria are met:  
The beneficiary has one of the diagnosis codes listed.  
The beneficiary is enrolled in an approved clinical study that meets all of the requirements set 
out in the National Coverage Determination 160.27. 
TENS therapy for CLBP that does not meet these criteria will be denied as not reasonable and necessary. You 
can find this rule in the Local Coverage Determination for Transcutaneous Electrical Nerve Stimulators 
(TENS), L33802 (eff 01/01/20). 
 
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 $200 copayment for diagnostic tests and procedures at an outpatient 
hospital setting. You can find this information on page 81 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 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 $275 copayment per day for days 1-6 for inpatient hospital care. You 
can find this information on page 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 payment for inpatient psychiatric hospital services is to be made only for active treatment. 
For services to be designated as active treatment they must: 
 
1. be provided under an individualized treatment or diagnostic plan; 
 
2. reasonably be expected to improve the patient?s condition, or for the purpose of diagnosis; and 
 
3. be supervised and evaluated by a physician.   
You can find these rules in the Medicare Benefit Policy Manual, Chapter 2, Sections 30.2.2 and 30.2.2.1. 
 
The rules say that Medicare will not pay any expenses for items or services which are not medically necessary 
and reasonable for the diagnosis or treatment of illness or injury. This exclusion extends to claims for services 
which are provided in inappropriate settings. You can find this rule in the Social Security Act, Section 
1862(a)(1). 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 the Annual Wellness Visit will include the establishment of, or update to, the individual?s 
medical and family history, measurement of his or her height, weight, body-mass index (BMI) or waist 
circumference, and blood pressure (BP), with the goal of health promotion and disease detection and fostering 
the coordination of the screening and preventive services that may already be covered and paid for under 
Medicare Part B. This is seen in the CMS MLN Matters article number MM7079 (effective January 1, 2011). 
 
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 you?ve had Part B for longer than 12 months, you can get an annual wellness visit to 
develop or update a personalized prevention plan based on your current health and risk factors.  This is covered 
once every 12 months.  Doesn?t include lab tests, radiological diagnostic tests or non-radiological diagnostic 
tests or diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your 
visit, as described for each separate service in this Medical Benefits Chart. You can see this on pages 4-7 and 
4-8 of the 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. 
 
The rules say that a Medicare plan may not pay for services given by a physician or other practitioner who has 
opted out of Medicare. This rule does not apply to emergency or urgently needed services. This rule applies to 
all other services, as well as to supplemental benefits. A Medicare plan must pay for emergency or urgently 
needed services given by a physician or practitioner who has not signed a private contract with the enrollee. 
You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the Medicare Managed Care Manual, 
Chapter 6, Section 60.2. 
 
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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. You must go to a 
participating dentist - a dentist who has contracted with the Plan for your dental services to be covered. You 
can find this information on page 9 of the Plan?s 2019 Preventative and Comprehensive Dental Coverage 
Customer Handbook.