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 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 20% coinsurance for outpatient diagnostic tests. You can find this 
information on page 23 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 LCD cited by the plan is not valid for this case. 
 
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 state that the Centers for Medicare & Medicaid Services has determined that there is sufficient 
evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and 
necessary under section 1862(a)(1)(A) of the Social Security Act (the Act). The use of infrared and/or near-
infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, 
including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral 
sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. You can find this rule in 
National Coverage Determination (NCD) for Infrared Therapy Devices (270.6). 
 
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 facet joint interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL of the following criteria: 
 
1. Duration of pain of at least three (3) months 
2. Pain is intermittent or continuous with average pain levels of 6 or greater on a visual-numerical analogue 
pain scale (VNAS) of 0 to 10 (primary [index] pain), or functional disability 
3. Documented failure to respond to conservative care such as nonsteroidal anti-inflammatory drugs 
(NSAIDS), acetaminophen, physical therapy for a minimum of 6 weeks (as tolerated) 
4. History of pain that is predominantly axial and, with the possible exception of facet joint cysts, not 
associated with radiculopathy or neurogenic claudication 
5. Physical examination with documented signs that the facet joint is the primary suspected source of pain  
6. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
the patient?s pain, including but not limited to fracture, tumor, infection, or significant deformity 
 
You can find this rule in Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management 
(L34892) - Effective November 21, 2019. 
 
The rules say that the thermal radiofrequency destruction of cervical, thoracic or lumbar paravertebral facet 
joint (median branch) nerves will be considered to be medically reasonable and necessary as follows: 
 
-After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one 
providing a minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with 
the agent used) or at least 50% improvement in the ability to perform previously painful movements and ADLs; 
- After the patient has had at least one (1) medically reasonable and necessary therapeutic injection that 
provided at least 50% pain relief for at least three (3) months. 
 
You can find this rule in Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management 
(L34892) - Effective November 21, 2019.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that 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 rule in Code of 
Federal Regulations (CFR) Title 42, 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 that there is a 190-day lifetime limit for inpatient services in a psychiatric hospital. You can find 
this information in Chapter 4 on page 4-23 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that initial radiofrequency ablation may be covered: 
? After the patient has had at least two (2) medically reasonable and necessary diagnostic medial branch 
blocks, with each one providing a minimum of 80% relief of primary (index) pain (with the duration of 
relief being consistent with the agent used) or at least 50% improvement in the ability to perform 
previously painful movements and activities of daily living;  or 
? After the patient has had at least one (1) medically reasonable and necessary therapeutic injection that 
provided at least 50% pain relief for at least three (3) months. 
 
You can find these rules in Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management (L34892). 
 
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 $300 copayment for each Medicare-covered outpatient hospital facility 
visit. You can find this information on page 74 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 $372 copayment per day for days 1-5 for inpatient hospital care. You 
can find this information on page 75 of the Plan's 2019 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 $110 copayment for each Medicare-covered radiological diagnostic 
service, not including x-rays. You can find this information on page 4-31 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 20% coinsurance for Medicare Part B prescription drugs. You can find 
this information on page 90 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 20% coinsurance for in-network Medicare-covered durable medical 
equipment and related supplies. You can find this information on pages 68 to 69 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 $45 copayment for each Medicare-covered visit with an in-network 
specialist. Covered services include consultation, diagnosis, and treatment by a specialist. You can find this 
information on pages 100 to 102 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 allows payment for one annual wellness visit (AWV) for enrollees who have not 
had an AWV within the past 12 months. You can find this information in the Medicare Claims Processing 
Manual, Chapter 18, Section 140. 
 
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 custom-fabricated orthosis is covered when there is a documented physical characteristic 
which requires the use of a custom fabricated orthosis instead of a prefabricated orthosis. Examples of 
situations which meet the criterion for a custom fabricated orthosis include, but are not limited to:  
 
1. Deformity of the leg or knee; 
 
2. Size of thigh and calf; 
 
3. Minimal muscle mass upon which to suspend an orthosis. 
You can find this rule in Local Coverage Determination (LCD): Knee Orthoses (L33318) - Effective January 1, 
2020. 
 
The rules say that although these are examples of potential situations where a custom fabricated orthosis may 
be appropriate, suppliers must consider prefabricated alternatives such as pediatric knee orthoses in 
beneficiaries with small limbs, straps with additional length for large limbs, etc. If a custom fabricated orthosis 
is provided but the medical record does not document why that item is medically necessary instead of a 
prefabricated orthosis, the custom fabricated orthosis will be denied as not reasonable and necessary. You can 
find this rule in Local Coverage Determination (LCD): Knee Orthoses (L33318) - Effective January 1, 2020. 
 
The rules say that custom fabricated orthoses (L1834, L1840, L1844, L1846, L1860) are not reasonable and 
necessary in the treatment of knee contractures in cases where the beneficiary is nonambulatory. A custom 
fabricated knee immobilizer without joints (L1834) is covered if criteria 1 and 2 are met:  
 
1. The coverage criteria for the prefabricated orthosis code L1830 are met; and 
2. The general criterion defined above for a custom fabricated orthosis is met. 
 
You can find this rule in Local Coverage Determination (LCD): Knee Orthoses (L33318) - Effective January 1, 
2020. 
 
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 Plan 
contract includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. Endodontic therapy (D3320) is not included on this list and is not a covered 
supplemental benefit. You can find this information on pages 4-80 to 4-89 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 continued coverage of a PAP device (E0470 or E0601) beyond the first three months of 
therapy requires that, no sooner than the 31st 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 benefiting from 
PAP therapy. For PAP devices with initial dates of service on or after November 1, 2008, documentation of 
clinical benefit is demonstrated by: 
 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved; and, 
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. 
 
You can find this rule in Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for 
the Treatment of Obstructive Sleep Apnea (L33718) - Effective January 1, 2020. 
 
The rules say that adherence to therapy is defined as use of PAP 4 or more hours per night on 70% of nights 
during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. You can 
find this rule in Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the 
Treatment of Obstructive Sleep Apnea (L33718) - Effective January 1, 2020. 
 
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 on page 67 of the 2020 Evidence of Coverage.