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 continuous glucose monitor (CGM) devices covered by Medicare under the DME benefit
are defined in CMS Ruling 1682R as therapeutic CGMs. Refer to the Non-Medical Necessity Coverage and
Payment Rules in the LCD-related Policy Article for additional information.
Therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria
(1-6) are met:
1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for
applicable diagnoses); and,
2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and,
3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare covered
continuous subcutaneous insulin infusion (CSII) pump; and,
4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis
of BGM or CGM testing results; and,
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the
beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and,
6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person
visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822).
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 to report a Guardant360 service, please submit the following claim information: 
 Enter 1 unit of service (UOS) 
 Enter the appropriate DEX Z-Code identifier adjacent to the Current Procedural Terminology (CPT) 
code 81479 in the comment/narrative field for the following Part B claim field/types: 
 Loop 2400 or SV101-7 for the 5010A1 837P 
 Item 19 for paper claim 
 Enter the appropriate DEX Z-Code? identifier adjacent to the Current Procedural Terminology (CPT) 
 code 81479 in the comment/narrative field for the following Part A claim field/types: 
Line SV202-7 for 837I electronic claim 
 Block 80 for the UB04 claim form 
 Select the appropriate ICD-10-CM code 
 
You can find these rules in Local Coverage Article (LCA) Billing and Coding: MolDX: Guardant360 Plasma-
Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) (A57425).
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 before submitting a claim to the DME MAC the supplier must have on file a dispensing 
order, the detailed written order, the CMN (if applicable), the DIF (if applicable),information from the treating 
physician concerning the patient's diagnosis, and any information required for the use of specific modifiers or 
attestation statements as defined in certain DMEMAC policies. The supplier should also obtain as much 
documentation from the patient's medical record as they determine they need to assure themselves that 
coverage criteria for an item have been met. If the information in the patient's medical record does not 
adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved 
unless a properly executed ABN of possible denial has been obtained. You can find this information in the 
Medicare Program Integrity Manual, Chapter 5 - Items and Services Having Special DME Review 
Considerations, Section 5.7  Documentation in the Patient's Medical Record and Section 5.8 - Supplier 
Documentation.
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). 
 
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 there is a $750 deductible for your plan deductible. You can find this information on 
page 57 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 ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Medicare National Coverage Determinations Manual, 
Chapter 1, Section 280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device is made 
based upon the specifics of each person?s medical condition. There must be enough detailed information in the 
medical record to justify the treatment selected. You can find this rule in the Local Coverage Determination 
(LCD): Respiratory Assist Devices (L33800), effective for services performed on or after January 1, 2017.
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 effective for services performed on or after January 9, 2014, PILD will be covered by 
Medicare through CED for beneficiaries with LSS who are enrolled in an approved clinical study that meets the 
following criteria. CMS has a particular interest in improved beneficiary function and quality of life, specific 
characteristics that identify patients who may benefit from the procedure, and the duration of benefit. A clinical 
study seeking Medicare payment for PILD for LSS must address one or more aspects of the following 
questions in a prospective, randomized, controlled design using current validated and reliable measurement 
instruments and clinically appropriate comparator treatments, including appropriate medical or surgical 
interventions or a sham controlled arm, for patients randomized to the non-PILD group. You can find this rule 
in the Medicare National Coverage Determination for Percutaneous Image-Guided Lumbar Decompression for 
Lumbar Spinal Stenosis, 150.13. 
 
The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Medicare also pays 
for reasonable and necessary items and services used to diagnose and treat complications arising from 
participation in all clinical trials. The rules also say that Medicare plans must cover these services even if they 
are not available through in-network providers. Medicare plans may require reporting when enrollees 
participate in clinical trials but cannot require prior authorization or approval. You can find these rules in the 
Medicare National Coverage Determinations Manual, Chapter 1, Section 310.1.
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).
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. to us. The contract also 
includes a list of the covered supplemental dental benefits. The upper partial denture (D5213) is not on this list 
and is not a covered supplemental benefit. You can find this information on pages 4-73 to 4-76 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 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 crowns, one of codes D2740, D2750, D2751, D2752, D2790, D2791, or D2792, once per tooth per 60 months. You can find this information on page 23 of the Plan's 2020 Preventive & Comprehensive Dental Coverage Customer 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 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. Biologic materials to aid in soft and osseous tissue regeneration (D4265), surgical placement of implant body: endosteal implant (D6010), interim abutment (D6051), abutment supported porcelain/ceramic crown (D6058), custom fabricated abutment (D6057), and bone graft at time of implant placement (D6104) are not included on this list and are not covered supplemental benefits. You can find this information on pages 4-59 to 4-72 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 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 $250 copayment for each Medicare-covered ambulatory surgical center 
visit. You can find this information on page 82 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 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. Alveoloplasty in conjunction with extractions, therapeutic parenteral drugs, first 15 minutes of deep sedation/general anesthesia, and each subsequent 15 minute increment of deep sedation/general anesthesia are not included on this list and are not covered supplemental benefits. You can find this information on pages 58 and 59 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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments). You can find this rule at 42 CFR Section 422.111.  
 
The rules say that a copayment is a fixed amount 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 $265 copayment for each ambulance trip. You can find this information 
on page 50 of the Plan's 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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Medicare Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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 43 to 44 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 
maxillary dentures and are limited to, one of codes D5110, D5130, D5211, or D5213, once per 60 months. You 
can find this information on page 25 of the Plan?s 2020 Preventive & Comprehensive Dental Coverage 
Customer 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 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). 
 
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 there is a $1,000 deductible for all items and services, except those specifically excluded 
by the plan?s contract. Outpatient physician surgical services are not excluded from the deductible. You can 
find this information on pages 53 to 54 of the Plan?s 2020 Evidence of Coverage (EOC). 
 
The Plan contract also says that enrollees must pay a $350 copayment after you pay your $1,000 deductible. 
Covered services include medically-necessary medical care or surgery services furnished in a physician?s 
office, certified ambulatory surgical center, hospital outpatient department, or any other location. You can find 
this information on pages 86 to 88 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 comprehensive genomic profile (CGP) testing is not defined as a targeted panel by MolDX,
and it is a test not currently satisfactorily described by any existing Current Procedural Terminology (CPT)
code. Therefore, to report a CGP service, test providers should use CPT code 81479 for date of service
February 25, 2020, in addition to the approved DEX Z-Code for the test. You can find these rules in Local
Coverage Article (LCA) Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next-
Generation Sequencing Testing in Cancer (A55624).
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. Surgical placement of mini implant is not included on this list and is not a 
covered supplemental benefit. The Plan contract also says that charges for any type of implant and all related 
services are excluded from coverage. You can find this information on pages 97 to 99 and on page 101 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b). 
 
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 the only covered chiropractic service is manual manipulation of the spine to correct a 
subluxation. You can find this information on page 66 of the Plan's 2020 EOC.