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 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 periodontal scaling and root planing once per quadrant every 3 years. You can find this information on page 103 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).

The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $325 per day copayment for days 1-5 of inpatient care. You can find this
information on page 47 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 12 of the 2021 Evidence of Coverage. The health plan contract says dental services must be provided by in-network dentists. You can find this information on page 121 of the 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that 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 Medicarecovered
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).
There is no Medicare benefit for supplies and accessories used with equipment that is not classified as DME.
Coverage of a CGM system supply allowance (K0553) is available for those therapeutic CGM systems where
the beneficiary uses a receiver classified as DME to display glucose data. In addition, Medicare coverage is
available for a CGM system supply allowance if a non-DME device (watch, smartphone, tablet, laptop
computer, etc.) is used in conjunction with the durable CGM receiver (K0554). The following are examples of
this provision:
1. Medicare coverage of a CGM supply allowance is available where a beneficiary uses a durable CGM
receiver to display their glucose data and also transmits that data to a caregiver through a smart phone or other
non-DME receiver.
2. Medicare coverage of a CGM system supply allowance is available where a beneficiary uses a durable
CGM receiver on some days to review their glucose data but may also use a non-DME device on other days.
If a beneficiary never uses a DME receiver for a therapeutic CGM, the supply allowance is not covered by
Medicare. You can find this information in Local Coverage Article: Glucose Monitor - Policy Article
(A52464).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 2 crowns (either D2750, D2751, D2752 or D2753) per calendar year. You can find this information on page 93 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that enrollees must pay a $0 copayment for an annual diabetic eye exam. You can find this
information on pages 88-89 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 medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 

The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 pays only for ambulance transport. Ambulance vehicles must be designed and
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens,
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other lifesaving
equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You
can find this rule at 42 CFR Section 410.41.
The rules say that plans may offer a supplemental benefit to provide transport not covered by original
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the
doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid
Services, Internet Only Manual, 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 contract
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit
covers 50 miles of driving distance for each one-way trip. You can find this information on page 4-52 of the
Plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that a heavy-duty walker (E0148, E0149) is covered for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds. If an E0148 or E0149 walker is provided and if the beneficiary weighs 300 pounds or less, it will be denied as not reasonable and necessary. You can find this information in the Local Coverage Determination (LCD): Walkers (L33791).

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 Epidural Injections (EIs) are generally performed to treat pain arising from spinal nerve roots. EIs can be performed via an interlaminar or caudal approach or a transforaminal approach. An epidural injection is considered medically reasonable and necessary with the following conditions: Each patient must be thoroughly evaluated by a physician or non-physician practitioner whose license and state scope of practice allow evaluation and treatment outlined in this LCD. A central or systemic source of pain or neurologic deficit shall be determined prior to epidural injection. If a central or systemic process is present, but the pain or neurologic deficit is clearly unrelated, injection therapy or EI may still be indicated when at least one of the indications listed below is present. 1. Pain from Herpes Zoster or suspected radicular pain based on radiation of pain along the dermatome of a nerve. 2. Pain from Neurogenic claudication that includes any of the following: -Pain severe enough to cause some degree of functional deficit; -Failure of at least four weeks of noninvasive care*; -Imaging demonstrating a correlative region of nerve/cord impingement. 3. Pain from CervicoThoracic or Lumbar radicular pain with any of the following: -Pain severe enough to cause some degree of functional deficit; -Failure of at least four weeks of non-invasive care*; -Imaging demonstrating a correlative region of nerve impingement. 4. Back pain without lower extremities symptoms and failure of four weeks of non-surgical, non-injection care* with either: -documented VAS for pain or NPRS greater than or equal to 3/10 (moderate to severe pain), OR functional impairment in ADLs;AND -the pain or functional impairment is associated with any of the following: substantial imaging abnormality, such as a central disc herniation or high intensity zone; documented severe degenerative disc disease or central spinal stenosis; discogenic pain, not attributable to facet joint or sacroiliac joint pain. You can find these rules in Local Coverage Determination (LCD): Epidural Injections for Pain Management (L36920).
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 pays only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41. The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers 60 one-way transportation trips. You can find this information on page 4-81 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.
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 290(3).
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 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 lists the specific dental services that are covered. Periodontal scaling and root planing is not listed as a covered service. You can find this information on pages 92 and 93 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 coverage of proton beam therapy in Group 2 is limited to providers who have demonstrated
experience in data collection and analysis with a history of publication in the peer-reviewed medical literature.
- Unresectable lung cancers and upper abdominal/peri-diaphragmatic cancers
- Advanced stage, unresectable pelvic tumors including those with peri-aortic nodes or malignant lesions
of the cervix
- Breast cancers
- Unresectable pancreatic and adrenal tumors
- Skin cancer with macroscopic perineural/cranial nerve invasion of skull base
- Unresectable malignant lesions of the liver, biliary tract, anal canal and rectum
- Prostate cancer, without distant metastases
- Hodgkin or Non-Hodgkin Lymphoma involving the mediastinum or in non-mediastinal sites where
PBT has the potential to reduce the risk of pneumonitis or late effects of radiation therapy (secondary
malignancy, cardiovascular disease, or other chronic health conditions)
- Re-irradiation where prior radiation therapy to the site is the governing factor necessitating PBT in lieu
of other radiotherapy.
Prostate Cancer
Coverage and payments of proton beam therapy for prostate cancer will require:
a. Physician documentation of patient selection criteria (stage and other factors as represented in the
NCCN guidelines);
b. Documentation and verification that the patient was informed of the range of therapy choices, including
risks and benefits.
You can find this rule at Local Coverage Determination (LCD): Proton Beam Therapy (L35075) (eff. 11/7/19).
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 state that dorsal column stimulators may be covered as therapies for the relief of chronic intractable
pain under the following circumstances:
1. To treat chronic pain caused by lumbosacral arachnoiditis that has not responded to medical
management including physical therapy.
2. To treat intractable pain caused by nerve root injuries, post-surgical or post-traumatic including that
of post-laminectomy syndrome (failed back syndrome).
3. To treat intractable pain caused by complex regional pain syndrome I & II.
4. To treat intractable pain caused by phantom limb syndrome that has not responded to medical
management.
5. To treat intractable pain caused by end-stage peripheral vascular disease, when the patient cannot
undergo revascularization or when revascularization has failed to relieve painful symptoms and the
pain has not responded to medical management.
6. To treat intractable pain caused by post-herpetic neuralgia.
7. To treat intractable pain caused by plexopathy.
8. To treat intractable pain caused by intercostal neuralgia that did not respond to medical management
and nerve blocks.
9. To treat intractable pain caused by cauda equina injury.
10. To treat intractable pain caused by incomplete spinal cord injury.
You can find these rules in Local Coverage Determination (LCD) Spinal Cord Stimulation (Dorsal Column
Stimulation) (L35450).
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 reimbursement for oxygen equipment is limited to 36 monthly rental payments. Payment
for accessories (e.g., cannula, tubing, etc.), delivery, back-up equipment, maintenance, and repairs is included
in the rental allowance. Payment for oxygen contents (stationary and/or portable) is included in the allowance
for stationary equipment (E0424, E0439, E1390, E1391).

The rules also state that there is no further payment for oxygen equipment during the 5-year reasonable useful
lifetime (RUL) of the equipment after 36 rental payments have been made. If use of portable equipment
(E0431, E0433, E0434, E1392, K0738) begins after the use of stationary equipment begins, payment for the
portable equipment can continue after payment for the stationary equipment ends until 36 rental payments have
been made for the portable equipment.

You can find more information at Local Coverage Article: Oxygen and Oxygen Equipment - Policy Article
(A52514).

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.