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 state that the following Breath Test is Covered: 
 
-Lactose breath hydrogen to detect lactose malabsorption. 
 
The rules also state that the following Breath Tests are Excluded from Coverage: 
 
- Lactulose breath hydrogen for diagnosing small bowel bacterial overgrowth and measuring small bowel 
transit time. 
- CO2 for diagnosing bile acid malabsorption. 
- CO2 for diagnosing fat malabsorption. 
 
You can find this information in the National Coverage Determination (NCD) for Diagnostic Breath Analyses 
(100.5). 
 
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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with 
BOTH the following: 
 
    1. Inclusion criteria (ALL are required): 
        a. Acute* (< 6 weeks) osteoporotic VCF (T5  L5) by recent (within 30 days) advanced imaging (bone 
marrow edema on MRI or bone-scan/SPECT/CT uptake) 1-3,10,25 
        b. Symptomatic (ONE): 
            i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
= 8) 4-7 
            ii. Non-hospitalized with moderate to severe pain (NRS or VAS =5) despite optimal non-surgical 
management (NSM) (10)** (ONE): 
                1. Worsening pain 
                2. Stable to improved pain (but NRS or VAS still =5) (with = 2 of the following): 
                    A. Progression of vertebral body height loss 
                    B. > 25% vertebral body height reduction 
                    C. Kyphotic deformity 
                    D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
>17 
        c. Multidisciplinary team consensus 2 (ALL are required) 
            i. Referring physician (e.g., rheumatologist, endocrinologist) 
            ii. Treating physician (i.e., performing the PVA) 
            iii. Radiologist 
            iv. Neurologist 
 
You can find this information in the Local Coverage Determination (LCD):  Percutaneous Vertebral 
Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L34106). 
 
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 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 When the high probability or occurrence of medical complications (e.g., delirium, confusion, 
trauma, or unconsciousness) during detoxification for acute alcoholism or alcohol withdrawal necessitates the 
constant availability of physicians and/or complex medical equipment found only in the hospital setting, 
inpatient hospital care during this period is considered reasonable and necessary and is therefore covered under 
the program. Generally, detoxification can be accomplished within two to three days with an occasional need 
for up to five days where the patient?s condition dictates. This limit (five days) may be extended in an 
individual case where there is a need for a longer period for detoxification for a particular patient. Inpatient 
hospital care for receipt of an alcohol rehabilitation program would generally be medically necessary where 
either (l) there is documentation by the physician that recent alcohol rehabilitation services in a less intensive 
setting or on an outpatient basis have proven unsuccessful and, as a consequence, the patient requires the 
supervision and intensity of services which can only be found in the controlled environment of the hospital, or 
(2) only the hospital environment can assure the medical management or control of the patient?s concomitant 
conditions during the course of alcohol rehabilitation. In addition, the ?active treatment? criteria (see the 
Medicare Benefit Policy Manual, Chapter 2, ?Inpatient Psychiatric Hospital Services,? ?20) should be applied 
to psychiatric care in the general hospital as well as to psychiatric care in a psychiatric hospital. Since 
alcoholism is classifiable as a psychiatric condition the ?active treatment? criteria must also be met in order for 
alcohol rehabilitation services to be covered under Medicare. You can find this rule in the Medicare National 
Coverage Determination for Inpatient Hospital Stays for Treatment of Alcoholism, 130.1. 
 
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 state that transthoracic echocardiography is indicated for the evaluation of certain conditions, 
including: 
&#61623; Ventricular Function, Cardiomyopathies, and Heart Failure 
&#61623; Hypertensive Cardiovascular Disease 
&#61623; Acute Myocardial Infarction and Coronary Insufficiency 
&#61623; Exposure to Cardiotoxic Agents 
&#61623; Cardiac Transplant and Rejection Monitoring 
&#61623; Native Valvular Heart Disease 
&#61623; Prosthetic Heart Valves 
&#61623; Acute Endocarditis 
&#61623; Pericardial Disease 
&#61623; Abnormalities of the Great Vessels 
&#61623; Congenital Heart Disease 
&#61623; Suspected Cardiac Thrombi and Embolic Sources 
&#61623; Cardiac Tumors and Masses 
&#61623; Critically Ill and Trauma Patients 
&#61623; Arrhythmias and Palpitations 
&#61623; Syncope 
&#61623; Pulmonary Hypertension 
 
You can find these rules in Local Coverage Determination (LCD) Transthoracic Echocardiography (TTE) 
(L33577). 
 
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 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). 
 
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 MRIs are covered when medically necessary and reasonable for the diagnosis or treatment of the specific patient involved. You can find this rule in the Medicare National Coverage Determinations Manual, Section 220.2(B).
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 if medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG) 
Positron Emission Tomography (PET) scan to determine the initial level of cancer treatment needed for an 
enrollee. After the completion of the initial anti-cancer therapy, additional FDG PET scans may be covered at 
the discretion of Medicare. You can find this rule in the National Coverage Determinations Manual, Section 
220.6.17. 
 
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 in Chapter 5 - Section 4.2 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. 
 
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. Covered dental services are 
listed on page 44 of the plan?s 2020 Evidence of Coverage. Any service not listed is not a covered benefit.
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 botulinum toxin is indicated for disorders associated with spastic conditions and 
dystonia. The wide range of botulinum toxin dosages used in a treatment session is determined by patient age, 
degree of spasticity, number of injections made into each muscle and number of muscles treated. You can find 
this rule at Local Coverage Determination (LCD): Botulinum Toxins (L33949) (eff. 11/28/19). 
 
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 payment for seat lift units which incorporate a recliner feature along with the seat lift are 
limited to the amount payable for a seat lift without the chair. This rule can be found in National Coverage 
Determination (NCD) for Seat Lift (280.4). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The Plan contract does not 
list D3999 (unspecified endodontic procedure) as a covered benefit. You can find this information on pages 90-
102 of the 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 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 3-4 of the 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 coverage for the use of a functional neuromuscular stimulator is limited to Spinal Cord 
injury patients for walking, who have completed a training program which consists of at least 32 physical 
therapy sessions with the device over a period of three months. The trial period of physical therapy will enable 
the physician treating the patient for his or her spinal cord injury to properly evaluate the person?s ability to use 
these devices frequently and for the long term. Physical therapy necessary to perform this training must be 
directly performed by the physical therapist as part of a one-on-one training program. This rule can be found in 
National Coverage Determination (NCD): Neuromuscular Electrical Stimulator (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 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that indication for facet joint injections include: 
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).  
Pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with 
radiculopathy or neurogenic claudication.   There is no non-facet pathology that could explain the source of the patient?s pain, such as fracture, 
tumor, infection, or significant deformity.  Clinical assessment implicates the facet joint as the putative source of pain. 
Therapeutic Injections  Either intraarticular injections or medial branch blocks may provide temporary or long-lasting or 
permanent relief of facet-mediated pain. Injections may be repeated if the first injection results in 
significant pain relief (> 50%) for at least 3 months. (See Limitations section for total number of 
injections that may be performed in one year.)  
? Recurrent pain at the site of previously treated facet joint may be treated without additional diagnostic 
blocks if > 50% pain relief from the previous block(s) lasted at least 3 months. 
You can find this rule in the Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch 
Blocks, and Facet Joint Radiofrequency Neurotomy (L35996) effective November 1, 2019. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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: 
Preventive services: 
&#61623; Oral Exam: 2 every year 
&#61623; Cleaning: 2 every year 
&#61623; Dental X-ray: 1 every year 
&#61623; Fluoride Treatment: 1 every year 
Additional comprehensive dental services: 
&#61623; Periodontics 
&#61623; Restorative Services: 2 bridges or crowns covered per year. 
&#61623; Extractions 
&#61623; Prosthodontics: 1 upper and 1 lower denture is covered once every 3 years. 
You can find this information on pages 83-84 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 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). 
 
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 for 2 oral exams, 2 cleanings, 1 dental X-ray, and 1 fluoride treatment every year. You can find this 
information on page 57 of the Plan's 2020 Evidence of Coverage (EOC). A full list of covered dental codes is 
provided on pages 109 to 118. Codes not listed are not covered services.