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

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health 
plan contract says that enrollees must pay a $20 copayment for Medicare-covered non-radiological diagnostic 
services. You pay these amounts until you reach the out-of- pocket maximum. Examples include, but are not 
limited to EKG?s, pulmonary function tests, home or lab-based sleep studies, and treadmill stress tests. You can 
find this information in Chapter 4 on page 4-40 of the plan's 2020 Evidence of Coverage. 
 
The health plan contract says that enrollees must pay a $110 copayment for each Medicare-covered 
radiological diagnostic service, not including X-rays, performed in a physician?s office or at a freestanding 
facility (such as a radiology center or medical clinic). You pay these amounts until you reach the out-of- pocket 
maximum. The diagnostic radiology services require specialized equipment beyond standard X-ray equipment 
and must be performed by specially trained or certified personnel. Examples include, but are not limited to, 
specialized scans, CT, SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and 
interventional radiological procedures (myelogram, cystogram, angiogram, and barium studies). You can find 
this information in Chapter 4 on pages 4-41 to 4-42 of the plan's 2020 Evidence of Coverage. 
 
The health plan contract says that enrollees must pay a $35 copayment for services obtained from a specialist, 
or under certain circumstances, treatment by a nurse practitioner or physician?s assistant or other non-physician 
health care professionals in a specialist?s office (as permitted under Medicare rules). You can find this 
information in Chapter 4 on pages 4-52 to 4-43 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 pay for an IRF admission when the services are reasonable and medically 
necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing 
rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of 
the therapies must be physical therapy or occupational therapy. The patient must need and be expected to 
actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive 
rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per 
week. The patient does not need to be expected to achieve complete independence in self-care nor be expected 
to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation 
physician. The physician must see the patient at least three days per week throughout the stay.  
 
You can find these rules in the Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 
42 CFR Section 412.622. 
 
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 cardiovascular nuclear imaging is indicated for the following: 
61623; Assessment of the functional and prognostic importance of angina; 
61623; Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused 
by drugs, bundle branch block, or left ventricular hypertrophy; 
61623; Assessment of congenital anomalies of coronary arteries; 
61623; Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, 
with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not 
had a revascularization procedure within the past two years; 
61623; Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of 
diagnosed heart failure or left ventricular systolic dysfunction; 
61623; Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization / coronary 
angiography are not planned; 
61623; Evaluation of myocardial perfusion and/or function before and after coronary artery bypass surgery or 
other re-perfusion procedures; 
61623; Quantification and surveillance of myocardial infarction and prognostication in patients with infarction; 
61623; Assessment of congenital anomalies of coronary arteries; 
61623; Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery and/or 
perioperative management in: 
o patients with minor or intermediate clinical risk predictors and poor functional capacity; 
o patients with intermediate or high likelihood of coronary heart disease, or 
o patients with poor functional capacity undergoing high risk non-cardiac surgery; 
 
You can find these rules in Local Coverage Determination (LCD) Cardiovascular Nuclear Medicine (L33560). 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Section 423.578(b)(5)(ii). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 74 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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Section 423.578(b)(5)(ii). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 112 of the plan?s 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy 
are indicated when the following apply: 
 
The member has a 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) 
 
The 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. 
 
You can find this information in the Local Coverage Determination (LCD): 
Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L34993). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health 
plan contract says that enrollees must pay a $195 copayment each day for days 1 - 7 per admission for inpatient 
hospital care. You can find this information in Chapter 4 on page 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 $0 copayment for Medicare-covered laboratory tests. You can find this 
information on page 90 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 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 $40 copayment for a specialist office visit. Covered services include 
consultation, diagnosis, and treatment by a specialist. Additional covered services include telehealth services 
for the diagnosis, evaluation or treatment of symptoms of an acute stroke. You can find this information on 
page 93 of the Plan's 2020 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health 
plan contract says that services that are covered for you: Providers may ask you for more than one cost share 
payment if you get more than one service at an appointment. For example: Your doctor will ask for a 
copayment for the office visit and additional copayments for each x-ray that is performed while you are there.  
Your hospital may ask for separate cost sharing for certain outpatient hospital medical services for example but 
not limited to; radiological tests or Medicare Part B drugs administered while you are there.  Your pharmacist 
will ask for a separate copayment for each prescription he or she fills.  The specific cost sharing that will apply 
depends on which services you receive. You can find this information in Chapter 4 on page 4-6 of the plan's 
2020 Evidence of Coverage. 
 
The health plan contract says that enrollees must pay a $50.00 copayment for each complex procedure, test, 
and radiology except PET scans. You can find this information in Chapter 4 on page 4-28 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 an inpatient admission is generally appropriate when the admitting physician expects the 
patient to need hospital care that crosses at least two midnights. The expectation should be based on such 
complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and 
medical risk. The factors must be documented in the medical record.  
 
If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be 
considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as 
inpatient only is generally appropriate, regardless of the length of stay. An inpatient admission may be 
appropriate if the admitting physician expects a patient to require hospital care for only a limited period of 
time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be 
supported by the medical record. You can find this rule at 42 CFR Section 412.3. 
 
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.
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 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 Guidance 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 health 
plan contract says that enrollees must pay a $225 copayment for each Medicare-covered advanced imaging 
service (not including x-rays). You can find this information in Chapter 4 on page 89 of the plan's 2018 
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 if the Medicare Fee Schedule Database contains an assistant at surgery indicator of 0 for a 
surgical procedure, assistant at surgery services are generally not medically necessary. Assistant at surgery 
services will not be paid unless supporting documentation is submitted to establish medical necessity. You can 
find this rule in the Medicare Claims Processing Manual, Chapter 12, Section 40.8(D). 
 
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 Section 411.15(o). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 health 
plan contract says, "as a member of our plan, the most you will have to pay out of pocket for in-network 
covered Part A and Part B services in 2019 is $4,900. The amounts you pay for copayments and coinsurance 
for in-network covered services count toward this maximum out-of-pocket amount." You can find this 
information in Chapter 4 on page 47 of the plan's 2019 Evidence of Coverage. 
 
The health plan contract says for Days 1 - 20: $0 per day  / Days 21 - 100: $142 per day; All Other  
Participating SNF: Days 1 - 20: $0 per day / Days  21 - 100: $172 per day for SNF care. You can find this 
information in Chapter 4 on page 84 of the plan's 2019 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 routine examinations are excluded from Medicare coverage. This exclusion applies to 
examinations required by third parties such as insurance companies, business establishments, or Government 
agencies. You can find this information in the Medicare Benefit Policy Manual, Chapter 16, Section 90. 
 
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.