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 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 Appeal Number is: 
1-9547906466 
 
To be covered under Medicare, use of a drug or biological must be safe and effective and otherwise reasonable 
and medically necessary. Drugs or biologicals approved for marketing by the Food and Drug Administration 
(FDA) are considered safe and effective for purposes of this requirement when used for approved indications as 
specified on the labeling. Medical necessity is determined by the contractor at the local level. 
 
    Goserelin acetate, leuprolide acetate, triptorelin acetate and histrelin acetate are synthetic Luteinizing 
Hormone-Releasing Hormone (LHRH) analogs whose labeled indications include palliative treatment of 
advanced carcinoma of the prostate. All offer an alternative treatment of advanced prostate cancer when 
orchiectomy and/or estrogen administration are either not indicated or are unacceptable to the patient. 
    Goserelin acetate is also indicated for treatment of breast cancer, endometriosis and for endometrial thinning 
to treat dysfunctional uterine bleeding. Leuprolide acetate is also indicated for treatment of breast cancer and 
leuprolide acetate is indicated for treatment of uterine leiomyomata and endometriosis. Histrelin acetate was 
FDA approved for treatment of Central Precocious Puberty (CPP) effective May 3, 2007. 
    Response to the implants, leuprolide acetate (Viadur?) and histrelin (Vantas?) should be monitored 
periodically throughout the 12-month period by measuring serum concentrations of prostate-specific antigen 
(PSA) and testosterone. Patients who receive a LHRH analog implant should continue to be seen by the 
managing physician in follow-up at least every 3 to 4 months. 
 
 
You can find these rules in Local Coverage Determination (LCD): Luteinizing Hormone-Releasing Hormone 
(LHRH) Analogs (L34822). 
 
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 there is a lifetime maximum of 190 days on inpatient psychiatric hospital services available 
to any beneficiary. Therefore, once an individual receives benefits for 190 days of care in a psychiatric 
hospital, no further benefits of that type are available to that individual. You can find this information in the 42 
Code of Federal Regulations (CFR), Section 409.62. 
 
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 there is a 190-day lifetime limit for inpatient services in a psychiatric hospital. The 190-day limit 
does not apply to Mental Health services provided in a psychiatric unit of a general hospital. You can find this 
information on page 72 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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information in Chapter 3 on pages 42 to 43 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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract says that 
services must be performed by a participating general dentist. You can find this information on page 64 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 raised toilet seats are not covered because they are considered hygienic equipment that is not 
primarily medical in nature. You can find this rule in the Medicare National Coverage Determinations Manual, 
Section 280.1. 
 
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 that Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
 
You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.3(B). 
 
The rules state that a power operated vehicle is covered if all of the basic coverage criteria for a power mobility 
device have been met and the following criteria are also met: 
- The beneficiary is able to: 
- Safely transfer to and from a POV, and 
- Operate the tiller steering system, and 
- Maintain postural stability and position while operating the POV in the home. 
- The beneficiary's mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) 
are sufficient for safe mobility using a POV in the home. 
- The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for 
the operation of the POV that is provided. 
- The beneficiary's weight is less than or equal to the weight capacity of the POV that is provided and 
greater than or equal to 95% of the weight capacity of the next lower weight class POV - i.e., a Heavy 
Duty POV is covered for a beneficiary weighing 285 - 450 pounds; a Very Heavy Duty POV is covered 
for a beneficiary weighing 428 - 600 pounds. 
- Use of a POV will significantly improve the beneficiary's ability to participate in MRADLs and the 
beneficiary will use it in the home. 
- The beneficiary has not expressed an unwillingness to use a POV in the home. 
 
You can find these rules in 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 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 pages 74-75 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. 
 
Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise 
reasonable and necessary for the patient. FDA approved drugs used for indications other than what is indicated 

on the official label may be covered if the use is determined to be medically accepted, taking into consideration 
the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. You 
can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50.4.1 and 50.4.2. 
 
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.
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 32 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 Plan 
contract includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. Incisional biopsy of oral tissue (D7286) is not included on this list and is 
not a covered supplemental benefit. You can find this information on pages 4-51 to 4-64 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 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 72 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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
dentures (partial, full, immediate) and are limited to one set every five (5) years. The contract also says that the 
replacement of lost, stolen, or broken dentures less than five (5) years of age does not meet criteria for pre-
authorization of a new denture. You can find this information on page 67 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 state that facet joint injections are covered when the following indications are met: 
At least 3 months of moderate to severe pain with functional impairment inadequately responsive to 
conservative care such as NSAIDs, acetaminophen, physical therapy (if tolerated). 
Predominant axial pain that is not associated with radiculopathy or neurogenic claudication. 
Absence of non-facet pathology that could explain the source of the patient?s pain, such as fracture, tumor, 
infection, or significant deformity. 
Clinical assessment that implicates the facet joint as the putative source of pain. 
You can find this rule in Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, 
and Facet Joint Radiofrequency Neurotomy (L34832). 
 
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 pay for durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers 
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment 
already available to an enrollee. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, 
Section 110.1(C). 
 
During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but not actual 
replacement) for medically necessary equipment owned by the beneficiary. Cases suggesting malicious 
damage, culpable neglect, or wrongful disposition of equipment should be investigated and denied where the 
DME MACs determines that it is unreasonable to make program payment under the circumstances. 
 
You can find this information at Medicare Benefit Policy Manual Chapter 15, Section 110.2 - Repairs, 
Maintenance, Replacement, and Delivery. 
 
Medicare pays for the least expensive option of repair vs. replacement of durable medical equipment (DME). 
The repair is covered when the DME is being purchased or is already owned by the patient and repair is 
necessary to make the equipment serviceable. Do not pay for repair of previously denied equipment or 
equipment in the frequent and substantial servicing or oxygen equipment payment categories. Routine periodic 
servicing, such as testing, cleaning, regulating, and checking of the beneficiary?s equipment, is not covered.  In 
no case can the reasonable useful lifetime of DME be less than 5 years. Replacement due to wear is not covered 
during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does 
cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment 
owned by the beneficiary. 
 
You can find this information at Medicare Benefit Policy Manual Chapter 15 ? Covered Medical and Other 
Health Services, Section 110.2 - Repairs, Maintenance, Replacement, and Delivery and Medicare Claims 
Processing Manual Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), 
Section 10.2 - Coverage Table for DME Claims. 
 
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 neuromuscular stimulators such as FES are covered for spinal cord injury (SCI) patients in 
order to assist with walking. The goal of physical therapy must be to train SCI patients on the use of 
NMES/FES devices to achieve walking, not to reverse or retard muscle atrophy. You can find this information 
in the National Coverage Determination (NCD) for Neuromuscular Electrical Stimulation (NMES) (160.12). 
 
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 CFR ?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.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contractsays that the Plan covers items and services in accordance with Medicare rules.