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 an initial thermal radiofrequency ablation (RFA) of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients who have had at least two medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used). Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six months or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale. You can fid this rule in the Local Coverage Determination for Facet Joint Interventions for Pain Management, L34892 (eff 04/25/21).
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, Publication 100-02, 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 does not include
services rendered by an out-of-network provider. You can find this information in the Plan's dental handbook.
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. The Plan
contract also says that enrollees must meet the criteria in section 2.1 of this chapter, as per CMS guidelines.
These conditions may benefit from the services provided by trained service dog as described under the
Americans with Disabilities Act (ADA). The Plan is using the ADA definition of a service dog that is
individually trained to do work or perform tasks for people with disabilities. The work or task a service dog has
been trained to provide must be directly related to the person's disability. Dogs whose sole function is to
provide comfort or emotional support do not qualify as service animals under the ADA. For more information
refer to the Americans with Disabilities Act (ADA).
Enrollee's must provide supporting documentation from your physician identifying you (the member), as the
owner and recipient who requires the use of a service dog and the services being rendered as defined under the
Americans with Disabilities Act (ADA).
Be in compliance with all local and state laws for dog ownership and be able to supply documentation, upon
request. Note: We are unable to initiate your benefit without speaking to you. By requesting this benefit you are
expressly authorizing us to contact you by telephone.
You can find this information on pages 107-108 of the Plan's 2010 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 the Medicare approved amount for procedures with the appropriate entry in Field 16 of the Medicare Fee Schedule Data Base (MFSDB) includes payment for the following services related to the surgery when furnished by the physician who performs the surgery: Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery. You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.1.
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 providers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A). 

The rules say that critical care is a time- based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided. You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, 30.6.12 (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.

Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. This rule does not apply to: 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed; 

2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL; and 

3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with an IOL. 
You can find this rule at 42 CFR Section 411.15(b). 

Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR Section 411.15(c).

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 offers a supplemental (extra) benefit to cover routine vision services that are not covered by Original Medicare. This benefit includes a $150 allowance every calendar year that you can use to pay for eyewear to correct vision. The allowance can be used to pay for the following items: eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames when a provider puts two lenses (at least one of which must have refractive value) into the frame) and contact lenses, including fitting and dispensing. If your eyewear purchase costs more than the Plan's allowance, you pay the difference. You can find this information on pages 92-94 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.
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. Food and Drug Administration (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 Centers for Medicare and Medicaid
Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections
50.4.1 and 50.4.2.
The rules also stat that Botulinum toxins (Botox, Dysport, Xeomin and Myobloc), will be considered
medically reasonable and necessary when administered for treatment of FDA-labeled indications and Off-label
indications (as applicable) below:
1. FDA indications for onabotulinumtoxinA (Botox) as noted on the FDA website:
https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=103000
2. Off-Label indications for onabotulinumtoxinA (Botox) may be considered medically reasonable and
necessary in patients for the following conditions:
-Esophageal achalasia in adults who are considered poor surgical candidates
-Chronic anal fissure for patients with inadequate response to conservative or pharmacologic treatment
-Essential hand tremor for patients with a high amplitude tremor that disrupts activities of daily living and
have had inadequate response to oral pharmacotherapy such as propranolol and primidone
-Focal limb dystonia
-Hemifacial spasm in adults (cranial nerve VII disorder)
-Isolated oromandibular dystonia in adults
-Laryngeal dystonia (spastic dysphonia) for adductor type (ADSD)
-Bothersome simple motor tics in adolescents and adults when the benefits of treatment outweigh the risks
-Severely disabling or aggressive vocal tics in older adolescents and adults when the benefits of treatment
outweigh the risks.
Limitations
1. Localization procedures would not be expected for easily targeted muscles and, therefore, would not be
considered medically reasonable and necessary.7
2.Cosmetic procedures are not a covered benefit under Medicare.
-Treatment of wrinkles, also referred to as glabellar lines, smoker's lines, crow's feet, laugh lines and
aging neck, using botulinum toxins is considered to be a cosmetic procedure, and is not covered under
Medicare
You can find this in the Local Coverage Determination (LCD): Botulinum Toxins (L38809).
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(a). 

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, Publication 100-16, 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 routine transportation for up to 24 one-way trips per calendar year. You can find this information on pages 4-52 to 4-53 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 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, Publication 100-02, 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. Gingival irrigation (D4921) and drugs or medicaments dispensed in the office for home use (D9630) are not included on this list and are not covered supplemental benefits. You can find this information on pages 4-78 to 4-88 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.

Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. This rule does not apply to: 

1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed; 

2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL; and 

3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with an IOL. 
You can find this rule at 42 CFR Section 411.15(b).
 
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR Section 411.15(c).

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 only covers one pair of eyeglasses or contact lenses after each cataract surgery. You can find this information on page 4-68 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 does not pay for gym benefits. Gym benefits include exercise classes, such as Tai Chi, yoga, and dance classes. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, 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 Plan offers a supplemental (extra) benefit to cover some health and wellness education programs and services through the Plan's specified health and fitness program. This benefit includes fitness facility membership, in-network classes, on-demand videos, and home-based programs. Out of network, the Plan will cover up to 50% coinsurance for fitness membership outside the specified program's service area. Members must use a network fitness facility and can select from the nationwide network of 17,000 locations. You can find this information on page 86 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 say that home blood pressure monitors and home blood pressure cuffs are considered home dialysis supplies. These items are only covered for patients on home dialysis. You can find this rule in the Centers for Medicare and Medicaid Services, Publication 100-04, Internet Only Manual, Medicare Claims Processing Manual, Chapter 8, Section 90.3.2(A). The rules also say that ambulatory blood pressure monitoring (ABPM) may be covered in some instances. This service involves the use of a non-invasive device which is used to measure blood pressure in 24-hour cycles. These 24-hour measurements are stored in the device and are later interpreted by the physician. ABPM is only covered for those patients with suspected white coat hypertension. Suspected white coat hypertension is defined as 1. Office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit; 2. At least two documented blood pressure measurements taken outside the office which are <140/90 mm Hg; and 3. No evidence of end-organ damage. You can find this information at National Coverage Determination (NCD) for Ambulatory Blood Pressure Monitoring (20.19).
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 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, Publication 100-02, 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 for services obtained out of network, the plan only pays up to a certain amount. If you choose to see an out of network dentist, you might be billed for any amount greater than what the plan pays. You can find this information on page 4-74 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 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, Publication 100-02, 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. Topical application of fluoride varnish (D1206) is not included on this list and is not a covered supplemental benefit. The contract also says that you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. You can find this information on pages 89 and 90 of the Plan's 2021 Evidence of Coverage (EOC).