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).  
 
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 You have been asked to pay $11.81, which is 30% coinsurance of the allowed 
amount for the chiropractic services provided from October 29, 2020, to November 12, 2020, and from 
November 19, 2020, to December 3, 2020 ($39.37 allowed amount x 30% coinsurance = $11.81). You have 
also been asked to pay $21.41, which is 30% coinsurance of the allowed amount for the chiropractic services 
provided on November 16, 2020 ($71.39 allowed amount x 30% coinsurance = $21.41). which applies to 
certain items and services. The Plan deductible applies to chiropractic services. You can find this information 
on pages 63 and 73 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for specific dental items/services stated in the Plans contract. Dental services must be rendered by an 
in-network provider. You can find this information on pages 56-58 of the Plan's 2023 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 effective January 1, 2002, sacral nerve stimulation is covered for the treatment of urinary 
urge incontinence, urgency-frequency syndrome, and urinary retention. Sacral nerve stimulation involves both 
a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent 
implantation in appropriate candidates. Both the test and the permanent implantation are covered. 
 
The following limitations for coverage apply to all three indications: 
 
    - Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical 
corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur. 
    - Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with 
peripheral nerve involvement) which are associated with secondary manifestations of the above three 
indications are excluded. 
    - Patient must have had a successful test stimulation in order to support subsequent implantation. Before a 
patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through 
test stimulation. Improvement is measured through voiding diaries. 
    - Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results 
of the implant procedure can be properly evaluated. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-03, National Coverage Determination (NCD) for Sacral Nerve Stimulation for Urinary 
Incontinence (230.18). 
 
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 all services billed by the skilled nursing facility (SNF) (including those furnished under 
arrangements with an outside supplier) for a resident of a SNF in a covered Part A stay are included in the 
SNF's Part A bill. If a resident is not in a covered Part A stay (Part A benefits exhausted, posthospital or level 
of care requirements not met), the SNF is required to bill for all physical therapy, occupational therapy, and/or 
speech-language pathology services provided to a SNF resident under Part B. The consolidated billing 
provision requires that effective for services and items furnished on or after July 1, 1998, payment is made 
directly to the SNF. 
 
Thus, SNFs are no longer able to "unbundle" services to an outside supplier that can then submit a separate bill 
directly to an A/B MAC (B) or DME MAC for residents in a Part A stay, or for SNF residents receiving 
physical therapy, occupational therapy, and/or speech-language pathology services paid under Part B. Instead, 
the SNF must furnish the services either directly or under an arrangement with an outside supplier or provider 
of services in which the SNF (rather than the supplier or provider of services) bills Medicare. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing 
Manual, Chapter 6, Section 10.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  
  The rules say that Medicare pays for care in a skilled nursing facility (SNF) when all of the following four 
factors are met: 
 
1. The patient requires skilled nursing or skilled rehabilitation services; 
2. The patient requires these services on a daily basis; 
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and 
4. The services are reasonable and necessary for the treatment of the patients illness or injury, or the services 
must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from 
getting worse.  
 
You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30.   
 
The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need 
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of 
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, 
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also 
custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
periodontal maintenance (D4910) but is limited to one procedure every six months. You can find this 
information on page 54 of the Plan's 2023 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 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 (T1  L5) by recent (within 30 days) 
advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain 
score  8) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS 5) despite optimal non-surgical 
management (NSM)* (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) 
* consider including pedicle periosteal infiltration 
c. Continuum of care (BOTH): 
1.  
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 or active systemic or surgical site infection 
iii. Pregnancy 
b. Relative contraindication 
i. Allergy to bone cement or opacification agents 
ii. Uncorrected coagulopathy 
iii. Spinal instability 
iv. Myelopathy from the fracture 
v. Neurologic deficit 
vi. Neural impingement 
vii. Fracture retropulsion/canal compromise 
viii. Greater than three vertebral fractures 
Vertebral augmentation and kyphoplasty for vertebral compression fractures with intractable spinal pain not 
relieved with medical therapy will be covered for osteolytic vertebral metastatic disease or myeloma involving 
a vertebral body. You can find this rule at Local Coverage Determination (LCD) L38737: Percutaneous 
Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (eff. 8/21/22). 
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 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 and cover any medically necessary covered benefit outside of the plan provider network, but at in-
network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollees 
medical needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 health 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. 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 page 8 of the Plans 2023 
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 endoscopy by capsule of the small intestine may be an adjunctive tool used in the 
detection of abnormalities of the small bowel, which is not accessible to standard upper endoscopy and 
colonoscopy. A small capsule is swallowed and moves through the GI tract propelled by peristalsis, 
transmitting video pictures. The video images are transmitted to sensors taped to the body and stored on a 
portable recorder. The strength of the signal is used to calculate the position of the capsule as it passes through 
the GI tract. Video images are stored on a portable recorder and later downloaded to a computer, from which 
they may be viewed. The capsule passes naturally from the body with the stool, and since it is disposable, it is 
not recovered. 
 
The rules say that the test is indicated for the diagnosis of occult gastrointestinal bleeding, the site of which has 
not been identified previously by any of the following: upper gastrointestinal endoscopy, colonoscopy, push 
enteroscopy, nuclear imaging, or radiological procedures. The test is especially helpful in the diagnosis of 
angiodysplasias of the gastrointestinal tract. 
 
The rules say that endoscopy by capsule is indicated for the diagnosis of Crohn's disease when the condition 
has not been previously confirmed or gastrointestinal capsule imaging is indicated when a diagnosis of colitis 
of an indeterminate type affecting the colon is known, and a more specific diagnosis is sought by evaluating for 
possible small bowel involvement. 
 
The rules say that evaluation of malabsorption syndrome, chronic diarrhea, or protein-losing enteropathy of 
obscure origin is reasonable when it is suspected to originate in the small intestinal mucosa. Appropriate prior 
negative or non-diagnostic evaluations of the esophagus, stomach, duodenum/small intestine, and colon by 
flexible endoscopy, and complementary radiologic procedures and/or microbiologic studies must be 
documented. 
 
The rules also say that evaluation of extent of small bowel involvement with arteriovenous malformations or 
lymphangiectasia for patients who are contemplated for surgical resection of the small bowel to control 
recurrent bleeding or protein loss is reasonable. 
 You can find this information in the Local Coverage Determination (LCD) for Endoscopy by Capsule 
(L34081). 
 
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 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). 
 
The rules say that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and 
necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments 
(CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements 
are met: 
   a. Patient has: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
You can find this rule in National Coverage Determination (NCD) Next Generation Sequencing (NGS) 90.2 
 
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.
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). 
 
The rules say that biofeedback therapy is covered under Medicare only when it is reasonable and necessary for 
the individual patient for muscle re-education of specific muscle groups or for treating pathological muscle 
abnormalities of spasticity, incapacitating muscle spasm, or weakness, and more conventional treatments (heat, 
cold, massage, exercise, support) have not been successful. This therapy is not covered for treatment of 
ordinary muscle tension states or for psychosomatic conditions.  You can find this information in National 
Coverage Determination (NCD): Biofeedback Therapy (30.1). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that 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 also say that when a continuous glucose monitor (CGM) is covered, the related supply allowance 
(code A4238 or A4239) is also covered. The supply allowance (code A4238 or A4239) is billed as one (1) unit 
of service (UOS) per thirty (30) days. 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. 
 
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 Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care 
(MAC) is usually unnecessary or rarely indicated for these procedures and therefore not considered medically 
reasonable and necessary.16 Even in patients with a needle phobia and anxiety, typically oral anxiolytics 
suffice. In exceptional and unique cases, documentation must clearly establish the need for such sedation in the 
specific patient. 
 
You can find this information in the Local Coverage Determination (LCD) Epidural Steroid Injections for Pain 
Management L39036. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.