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, if you choose to see an Out-of-Network dentist you might be billed for charges above what the plan pays, even for services listed as $0 copayment. You can find this guidance in your 2021 Evidence of Coverage Chapter 4, pages 4-79 to 4-81.
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 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 oral exams and intraoral x-rays once per calendar year. You can find this information on page 86 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 state that Medicare covers Screening Pap Smear. 
 
A screening pap smear and related medically necessary services provided to a woman for the early detection of 
cervical cancer (including collection of the sample of cells and a physicians interpretation of the test results) 
and pelvic examination (including clinical breast examination) are covered under Medicare Part B when 
ordered by a physician (or authorized practitioner) under one of the following conditions: 
 
She has not had such a test during the preceding two years or is a woman of childbearing age (1861(nn) of the 
Social Security Act (the Act). 
There is evidence (on the basis of her medical history or other findings) that she is at high risk of developing 
cervical cancer and her physician (or authorized practitioner) recommends that she have the test performed 
more frequently than every two years. 
High risk factors for cervical and vaginal cancer are: 
 
Early onset of sexual activity (under 16 years of age) 
Multiple sexual partners (five or more in a lifetime) 
History of sexually transmitted disease (including HIV infection) 
Fewer than three negative or any pap smears within the previous seven years; and 
DES (diethylstilbestrol) - exposed daughters of women who took DES during pregnancy. 
 
You can read this rule at the Medicare National Coverage Determination (NCD)-210.2, Screening Pap Smears 
and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer. 
 
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 Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules state that the date of service (DOS) for laboratory tests generally must be the date the specimen was 
collected; however, an exception is made for molecular pathology tests performed by a laboratory other than a 
blood bank. This requires that the DOS be reported as the date the testing was performed when: the test was 
performed following a hospital outpatient's discharge from the hospital outpatient department; the specimen 
was collected from a hospital outpatient during an encounter; and, it was medically appropriate to have 
collected the sample from the hospital outpatient during the hospital outpatient encounter. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 16, Section 40.8. 
 
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 all of the following must be present for coverage eligibility for lab-developed tests for 
inherited cancer syndromes in patients with cancer: 
  
   
1. The patient must have: 
 
-Any cancer diagnosis 
-AND a clinical indication for germline (inherited) testing for hereditary cancer 
-AND a risk factor for germline (inherited) cancer 
-AND has not been previously tested with the same germline genetic content. 
 
2. The test has satisfactorily completed a Technical Assessment (TA) by Molecular Diagnostic Services 
Program (MolDX) for the stated indications of the test. 
3. The test performed includes at least the minimum genetic content (genes or genetic variants) with definitive 
or well-established guidelines-based evidence required for clinical decision making for its intended use that can 
be reasonably detected by the test. 
 
-Because these genes and variants will change as the literature and drug indications evolve, they are listed 
separately in associated documents, such as the MolDX TA forms. 
-A single gene or variant may be tested if it is the only gene or variant considered to be reasonable and 
necessary for a cancer type. 
 
4. If a previous test was performed with a similar/duplicative intended use, a subsequent test is only reasonable 
and necessary if the non-duplicative genetic content of the second test is reasonable and necessary. 
 
5. If the test is an Next Generation Sequencing test, it must abide by all conditions listed in the NCD 90.2. 
 
You can find this rule in the Local Coverage Determination (LCD) - MolDX: Lab-Developed Tests for 
Inherited Cancer Syndromes in Patients with Cancer (L8972) - Effective August 8, 2022. 
 
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 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 says that the only covered chiropractic service is manual manipulation of the spine to correct 
a subluxation. Additionally, enrollees must pay a 50% coinsurance for Medicare-covered chiropractic services 
rendered by an out-of-network provider. You can find this information on page 72 of the Plans 2022 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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
 
The rules say that a group 4 power wheelchair (PWC) (K0868, K0869, K0870, K0871, K0877, K0878, K0879, 
K0880, K0884, K0885, K0886) have added capabilities that are not needed for use in the home. Therefore, if 
these wheelchairs are provided, they will be denied as not reasonable and necessary. You can find this rule in 
the Local Coverage Determination (LCD) Power Mobility Devices L33789. 
 
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 an implantable loop recorder (ILR) is a type of pre-symptom memory loop recorder (MLR) 
that is implanted subcutaneously in a patients upper left chest and may remain implanted for many months. An 
ILR is used when syncope is thought to be cardiac-related, but is too infrequent to be detected by either a 
HolterTM monitor or a traditional pre-symptom MLR. 
 
The following indications are covered nationally unless otherwise indicated: 
1. Computer analysis of EKGs when furnished in a setting and under the circumstances required for 
coverage of other EKG services. 
2. EKG services rendered by an IDTF, including physician review and interpretation. Separate physician 
services are not covered unless he/she is the patients attending or consulting physician. 
3. Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed 
as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance 
at the time the service is performed or immediately thereafter. 
4. Home EKG services with documentation of medical necessity. 
5. Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications 
described below, when performed with equipment meeting the standards described below, subject to the 
limitations and conditions specified below. Coverage is further limited to the amounts payable with 
respect to the physicians service in interpreting the results of such transmissions, including charges for 
rental of the equipment. The device used by the beneficiary is part of a total diagnostic system and is 
not considered DME separately. Covered uses are to: 
a. Detect, characterize, and document symptomatic transient arrhythmias; 
b. Initiate, revise, or discontinue arrhythmic drug therapy; or, 
c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); 
(only if 24-hour coverage is provided). 
 
Certain uses other than those specified above may be covered if, in the judgment of the local Medicare 
Administrative Contractor (MAC), such use is medically necessary. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-3, Medicare National Coverage 
Determination for Electrocardiographic Services, 20.15.  
 
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). 
 
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 does not clearly disclose how much enrollees should expect to pay for laboratory services, an 
outpatient hospital clinic visit, and an office visit.
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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, 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 on pages 47 to 48.
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 $35 copayment for specialist office visits. You can find this information 
on page 89 of the Plan's 2022 Evidence of Coverage (EOC). 
 
The Plan contract also says that enrollees must pay a $40 copayment for urgently needed services. You can find 
this information on page 98 of the Plan's 2022 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 10% coinsurance for all other Medicare covered DME for Durable 
medical equipment (DME) and related supplies. You can find this information on page 65 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 state that PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients 
with BOTH the following: 
1. Inclusion criteria (ALL are required): 
a. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5), based on 
symptom onset, and documented by advanced imaging  
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score more than or equal to 8)  
ii. Non-hospitalized with moderate to severe pain (NRS or VAS more than or equal to 5) 
despite optimal non-surgical management (NSM): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still more than or equal to 5) (with 
more than or equal to 2 of the following): 
A. Progression of vertebral body height loss 
B. More than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) more than 17 
c. Continuum of care (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. 
2. Exclusion criteria (Can have NONE of the following):   
a. Absolute contraindication 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
ii. Osteomyelitis, discitis, active systemic or surgical site infection 
iii. Pregnancy 
b. Relative contraindication 
i. Greater than three vertebral fractures per procedure 
ii. Allergy to bone cement or opacification agents 
iii. Uncorrected coagulopathy iv. Spinal instability 
v. Myelopathy from the fracture 
vi. Neurologic deficit 
vii. Neural impingement 
viii. Fracture retropulsion/canal compromise 
You can find this information in the Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L33569). 
 
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 for facet joint procedures one to two levels, either unilateral or bilateral, are allowed per 
session per spine region. The need for a three or four-level procedure bilaterally may be considered under 
unique circumstances and with sufficient documentation of medical necessity on appeal. This information is 
found in ??????Local Coverage Determination (LCD) Facet Joint Interventions for Pain Management 
(L35936). 
 
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 a second confirmatory diagnostic facet joint procedure is considered medically reasonable 
and necessary in patients who meet ALL the following criteria: The patient meets the criteria for the first 
diagnostic procedure; AND -After the first diagnostic facet joint procedure, there must be a consistent positive 
response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the 
agent used). You can find this rule at the Medicare Local Coverage Determination (LCD)- L35936, Facet Joint 
Interventions for Pain Management. 
 
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.