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 the Centers for Medicare & Medicaid Coverage (CMS) conducted a National Coverage 
Analysis that focused on the topic of gender reassignment surgery. Effective August 30, 2016, after examining 
the medical evidence, CMS determined that no national coverage determination (NCD) is appropriate at this 
time for gender reassignment surgery for Medicare beneficiaries with gender dysphoria. In the absence of an 
NCD, coverage determinations for gender reassignment surgery, under section 1862(a)(1)(A) of the Social 
Security Act (the Act) and any other relevant statutory requirements, will continue to be made by the local 
Medicare Administrative Contractors (MACs) on a case-by-case basis. You can find this rule in the National 
Coverage Determination (NCD) - Gender Dysphoria and Gender Reassignment Surgery (140.9) - Effective 
April 4, 2017. 
 
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 
coverage only for bitewing, panoramic, or complete series dental x-rays. You can find this information on page 
68 of the Plans 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 $35 copayment for a specialist office visit. You can find this 
information on page 79 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 custom fabricated orthosis is covered when there is a documented physical characteristic which 
requires the use of a custom fabricated orthosis instead of a prefabricated orthosis. Examples of situations 
which meet the criterion for a custom fabricated orthosis include, but are not limited to: 
1. Deformity of the leg or knee; 
2. Size of thigh and calf; 
3. Minimal muscle mass upon which to suspend an orthosis. 
 
If a custom fabricated orthosis is provided but the medical record does not document why that item is 
medically necessary instead of a prefabricated orthosis, the custom fabricated orthosis will be denied as not 
reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD) - Knee Orthoses 
(L33318) - Effective January 1, 2020. 
 
The rules say that a custom fabricated knee orthosis with an adjustable flexion and extension joint (L1846) is 
covered if criteria 1 and 2 are met: 
 
1. The coverage criteria for the prefabricated orthosis codes L1843, L1845, L1851 and L1852 are met; and 
2. The general criterion defined above for a custom fabricated orthosis is met. 
 
You can find this rule in the Local Coverage Determination (LCD) - Knee Orthoses (L33318) - Effective 
January 1, 2020. 
 
The rules say that a standard knee orthosis is covered if the beneficiary has had recent injury to or a surgical 
procedure on the knee(s). These orthoses are also covered for a beneficiary who is ambulatory and has knee 
instability. Knee instability must be documented by examination of the beneficiary and objective description of 
joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). Claims will be denied as not 
reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they 
will be denied if only pain or a subjective description of joint instability is documented. You can find this rule 
in Local Coverage Determination (LCD): Knee Orthoses (L33318) - Effective January 1, 2020. 
 
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 also says that there is a $750 deductible which applies to certain items and services. The Plan 
deductible applies to the TTE with doppler. You can find this information on pages 67-68 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 $250 copayment per one-way trip for ambulance services and non-
emergency ambulance services. You can find this information on page 75 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 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 one 
D2750 every five years per tooth. You can find this information on page 4-67 of the Plans 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 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 does not list 
fixed partial denture sectioning as a covered service. You can find this information on pages 4-59 to 4-74 of the 
Plans 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 that epidural steroid injections (ESI) will be considered medically reasonable and necessary when 
the following three requirements are met: 
 
1. History, physical examination, and concordant radiological image-based diagnostic testing supporting one of 
the following 
 
-Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to disc 
herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis 
-Post-laminectomy syndrome 
-Acute herpes zoster associated pain 
 
2. Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality of 
life or function. An objective pain scale or functional assessment must be performed at baseline (prior to 
interventions). The same scale must be repeated at each follow-up for assessment of response. 
3. Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or medical 
documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes zoster 
refractory to conservative management where a four (4) week wait is not required. 
 
You can find this rule in the Local Coverage Determination (LCD) - Epidural Steroid Injections for Pain 
Management (L39036) - Effective December 5, 2021.  
 
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 implanted infusion pump for chronic pain is covered by Medicare when used to 1) 
administer opioid drugs, singly or in combination with other opioid or non-opioid drugs, 2) intrathecal or 
epidural route; 3) for treatment of severe chronic intractable pain of malignant or nonmalignant origin in 
patients who have a life expectancy of at least three (3) months, and 4) the pain has been proven to be 
unresponsive to less invasive medical therapy. In order to be considered medically reasonable and necessary, 
all of the following criteria must be met and clearly documented in the beneficiarys medical record: 
 
1. The administration of the medication must require the intrathecal or epidural route and be effective on a 
long-term basis and 
2. Oral or subcutaneous medication treatment are ineffective or complicated by unacceptable side effects and 
3. The patient's medical condition must require the use of an infusion pump for pain relief due to failure of 
other treatment modalities and 
4. The type and dosage of the medication must reasonably be expected to alleviate or reduce the pain effects. 
 
You can find this rule in the Local Coverage Article (LCA) - Billing and Coding: Implantable Infusion Pumps 
for Chronic Pain (A55323) - Effective April 1, 2022. 
 
The rules say that in addition, an evaluation by an orthopedic surgeon, neurologist, neurosurgeon, oncologist or 
other specialist familiar with the underlying disease is required to validate that other treatments have failed to 
alleviate the pain and no other reasonable options are available at the time of the evaluation. Documentation 
that the patient is unresponsive to less invasive medical therapy shall be kept in the patient's medical record and 
made available upon Medical Review request. You can find this rule in the Local Coverage Article (LCA) - 
Billing and Coding: Implantable Infusion Pumps for Chronic Pain (A55323) - Effective April 1, 2022. 
 
The rules say that if the above criteria have been met, a preliminary trial of intraspinal opioid or non-opioid 
drug administration must be undertaken with a temporary intrathecal/epidural catheter to substantiate 
acceptable pain relief, degree of side effects including effects on the activities of daily living, and patient 
acceptance and compliance. You can find this rule in the Local Coverage Article (LCA) - Billing and Coding: 
Implantable Infusion Pumps for Chronic Pain (A55323) - Effective April 1, 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 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 (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5) based on symptom onset, and 
documented by 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 
greater than or equal to 8) 
           ii. Non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) despite 
optimal non-surgical management (NSM) (ONE): 
               1. Worsening pain 
               2. Stable to improved pain (but NRS or VAS still greater than or equal to 5) (with greater than or 
equal to 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 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 or 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 rule in the Local Coverage Determination (LCD) for Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L34106). 
 
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 a knee orthosis with adjustable knee joints (L1851) is covered if the beneficiary has had 
recent injury to or a surgical procedure on the knee(s). L1851 is also covered for a beneficiary who is 
ambulatory and has knee instability. For code L1851, knee instability must be documented by examination of 
the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer 
test). Claims for L1833 will be denied as not reasonable and necessary when the beneficiary does not meet the 
above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint 
instability is documented. You can find this rule in Local Coverage Determination (LCD): Knee Orthoses 
(L33318) - Effective January 1, 2020. 
 
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 Plan 
contract says that enrollees must pay $325 copayment for each in network Medicare covered outpatient hospital 
facility visit. You can find this information in Chapter 4 on page 106 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 a 20% coinsurance for durable medical equipment (DME), including 
CGM supplies for any device other that the Freestyle Libre. You can find this information on pages 77-78 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 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 options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that 
meets Medicare coverage criteria and the option/accessory itself is medically necessary. Coverage criteria for 
specific items are described below. If these criteria are not met, the item will be denied as not reasonable and 
necessary. You can find this rule in Local Coverage Determination (LCD) Wheelchair Options/Accessories 
L33792. 
 
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.