Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare 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, 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 lists the specific dental services that are covered. Custom fabricated abutment is not listed and therefore is not a covered service. Overdenture is not listed and therefore is not a covered service. Surgical placement of implant body is not listed and therefore is not a covered service either. The contract also says any services not listed are not covered. You can find this information on pages 4-56 to 4-70 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 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 a Medicare plan may restrict enrollees 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 an enrollee's medical needs. You can find this rule at 42 CFR Section 422.112.

The rules say that plans must ensure continuity of care for enrollees. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 4, Section 110.6.

The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The rules say plans may require prior authorization for most in-network services if the plan ensures that all covered services are available and accessible under the plan. The plan must arrange for specialty care outside of the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through arrangements with contracted providers. This includes services available through contracting or non-contracting providers in the area serviced by the health plan including nursing home and community-based services. You can find this rule at 42 CFR Section 422.112.

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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are covered only when they are medically reasonable and necessary. Therapy services are considered reasonable and necessary when:

1. The services are specific and effective treatment for the patient's condition, 

2. The services require the skills or direct supervision of a therapist, 

3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and 

4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, or carry out a maintenance program.

Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 220.2.

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 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, Medicare Benefit Policy Manual, Chapter 15, Section 150.

The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information
to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances,
Organization/Coverage Determinations, and Appeals Grievance Manual, Section 50.12.1.

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. The Plan
contract says to see the Plan's Dental Directory for a complete list of covered dental services for which benefits
are payable under this Plan. Procedures not listed in the Plan's dental directory are not covered. This benefit
includes one oral exam every six months. You can find this information on page 65 of the Plan's 2021
Evidence of Coverage (EOC).

The Plan contract includes a list of covered supplemental dental services. The contract specifically says that
any procedure not listed is not covered. 2D oral/facial photographic image (D0350) is not included on this list
and is not a covered supplemental benefit. The Plan contract includes comprehensive oral evaluation (D0150)
and is limited to one of either codes D0120, D0140, D0150, D0160, D0170, D0171, or D0180 once every 6
months. You can find this information in the Plan's dental directory.
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 417.414.

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 contract says that the Plan covers items and services in accordance with Medicare rules. The Plan offers a supplemental benefit which provides some coverage for vision services. The contract does not list an Onyx OCR video magnifier with speech as a covered benefit. You can find this information on page 25 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 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, 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 dental implants to hold complete dentures. The dental benefit does not list the surgical placement of implant body: endosteal implant (D6010) on the list of covered services. You can find this information on pages 75-77 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 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 $60 copayment for radiation therapy. You can find this information in Chapter 4 on page 38 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 tests that include more than 5 viral pathogens are non-covered. You can find this rule at Local Coverage Article: Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels (A56851) (eff. 10/1/20).

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 when a physician/practitioner furnishes services to a registered inpatient, payment is made
under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient
who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the
setting where the patient actually receives the face-to-face encounter. You can find this rule at Medicare Claims
Processing Manual, Chapter 26, Section 10.5.

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 say that Medicare Part B generally does not pay for drugs that are usually self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are:

1. blood-clotting factors; 
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients; 
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs; 
6. oral anti-emetics used in certain situations; 
7. drugs treated as supplies during an outpatient hospital procedure; and 
8. drugs required for the effective use of durable medical equipment. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.

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 also says that covered drugs include drugs that usually aren't self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services You can find this information on page 4-33 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 list the dental services that are covered. Implant related services are not listed and therefore are not covered services. The contract says that the benefit for crowns applies for tooth structure, not for implant supported crown. You can find this information on pages 62 to 68 of the Plan's 2020 Evidence of Coverage (EOC). 

The contract also says that covered, non-routine dental care is limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. You can find that information on page 87 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services,
Internet Only Manual, 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. Guided tissue regeneration (D4266), surgical
placement of implant body: endosteal implant (D6010), bone graft at time of implant placement (D6104), sinus
augmentation with bone or bone substitutes (D7951), and consultation (D9310) are not included on this list and
are not covered supplemental benefits.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that facet joint 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. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional
deficit measured on pain or disability scale; and
2. Pain that has been present for a minimum of 3 months with documented failure to respond to
noninvasive conservative care management (as tolerated); and
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by
facet joint synovial cyst); and
4. 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 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 state that claims for A9279 (MONITORING FEATURE/DEVICE, STAND-ALONE OR INTEGRATED, ANY TYPE, INCLUDES ALL ACCESSORIES, COMPONENTS AND ELECTRONICS, NOT OTHERWISE CLASSIFIED) are denied as statutorily non-covered. You can find this rule at Local Coverage Article: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea - Policy Article (A52467).

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.

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) or subacute (6-12 weeks) osteoporotic VCF (T5 - L5) based on symptom onset and
documented by advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake) 1-3,10,25,27
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. Continuum of care10 (Both)
i. All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis education for
subsequent treatment as indicated.
ii. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program.
You can find this information in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L34106).

Provisions in this article and the LCD only address Vertebral Augmentation for Osteoporotic Vertebral
Compression Fracture (VCF). Coverage will remain available for medically necessary procedures for other
conditions not included in this article/LCD.
You can find this information in Local Coverage Article: Billing and Coding: PERCUTANEOUS
VERTEBRAL AUGMENTATION (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (A56573).

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 coverage of Botox will only be allowed for patients with chronic daily headaches (headache disorders occurring greater than 15 days a month - in many cases daily with a duration of four or more hours - for a period of at least 3 months) who have significant disability due to the headaches, and have been refractory to standard and usual conventional therapy. The etiology of the chronic daily headache may be chronic tension-type headache or chronic migraine (CM). CM is characterized by headache on at least 15 days per month, of which at least 8 headache days per month meet criteria for migraine without aura or respond to migraine-specific treatment. For continuing Botulism toxin therapy the patients must demonstrate a significant decrease in the number and frequency of headaches and an improvement in function upon receiving Botulinum toxin. You can find these rules in Local Coverage Determination (LCD): Botulinum Toxins (L33949).

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.