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 enteral nutrition is covered for a beneficiary who requires feedings via an enteral access 
device to provide sufficient nutrients to maintain weight and strength commensurate with the beneficiary's 
overall health status and has a permanent: 
A. full or partial non-function or disease of the structures that normally permit food to reach the small bowel; 
OR, 
B. disease that impairs digestion and/or absorption of an oral diet, directly or indirectly, by the small bowel. 
 
Adequate nutrition must not be possible by dietary adjustment and/or oral supplements. You can find this 
information in the Local Coverage Determination (LCD): Enteral Nutrition (L38955). 
 
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 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 the Plan offers a Point-of-Service (POS) option to use either network or out-of-network 
providers. Certain covered services may only be received from network providers. You can find this 
information on pages 3-3 and 3-4 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that out-of-network breast cancer screening services are not covered. You can find 
this information on pages 4-17 and 4-18 of the Plans 2022 EOC. 
 
The Plan contract also says that out-of-network outpatient diagnostic tests and therapeutic services are not 
covered. You can find this information on pages 4-49 and 4-54 of the Plans 2022 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 $30 copayment for in-network x-rays provided at a specialist office. 
You can find this information 64 of the Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $30 copayment for in-network provider professional 
services at a specialist office. You can find this information on pages 73 to 74 of the Plan's 2023 EOC.  
 The Plan contract also says that enrollees must pay a $150 copayment for in-network advanced imaging 
services provided in a specialist office. You can find this information on pages 73 to 74 of the Plan's 2023 
EOC.  
 
The Plan contract also says that enrollees must pay a $40 copayment for in-network wound care at an 
outpatient hospital. You can find this information on pages 68 to 69 of the Plan's 2023 EOC.  
 
The Plan contract also says that enrollees must pay a $250 copayment for surgery services provided in an 
outpatient hospital. You can find this information on pages 68 to 69 of the Plan's 2023 EOC. 
 
The Plan contract also says that enrollees must pay 50% coinsurance for out-of-network diagnostic procedures 
and tests provided in an outpatient hospital. You can find this information on pages 68 to 70 of the Plan's 2023 
EOC. 
 
The Plan contract also says that enrollees must pay 20% coinsurance for in-network Medicare Part B covered 
drugs. You can find this information on page 63 of the Plan's 2023 EOC. 
 
The Plan contract also says that enrollees must pay 25% coinsurance for out-of-network durable medical 
equipment. You can find this information on page 54 of the Plan's 2023 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 $195 copayment per day, for days 1-7, and a $0 copayment per day, for 
days 8-90, for inpatient hospital care. You can find this information on page 66 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 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 $196 copayment each day for Medicare-covered days 21 to 45 for 
Skilled Nursing Facility (SNF) Care. The Plan contract also says that a benefit period begins on the first day 
you go to a Medicare-covered inpatient hospital or a skilled nursing facility. The benefit period ends when you 
havent been an inpatient at any hospital or SNF for 60 days in a row. You can find this information on pages 
85 and 86 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 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 Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, 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 Sections 422.2 and 422.136. 
 
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 184 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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that claims lines for A4649, A6010, A6011, A6021, A6022, A6023, A6024, A6154, A6196, 
A6197, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212, 
A6213, A6214, A6215, A6217, A6218, A6219, A6220, A6221, A6222, A6223, A6224, A6228, A6229, 
A6230, A6231, A6232, A6233, A6234, A6235, A6236, A6237, A6238, A6239, A6240, A6241, A6242, 
A6243, A6244, A6245, A6246, A6247, A6248, A6251, A6252, A6253, A6254, A6255, A6256, A6257, 
A6258, A6259, A6261, A6262, A6266, A6402, A6403, A6404, A6441, A6442, A6443, A6444, A6445, 
A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456, A6457 billed without 
A1-A9 modifiers will be rejected as missing information. You can find this rule in the Local Coverage Article 
for Surgical Dressings - Policy Article, A54563 
 
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 does not include 
extractions or placement of intra-socket biological dressings. You can find this information on pages 72-73 and 
76-81 of the Plans 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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
 
2. The services require the skills or direct supervision of a therapist,  
 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2. 
 
The rules also say that for outpatient therapy to be considered reasonable and necessary, the services must meet 
Medicare guidelines. The guidelines for coverage of outpatient therapies have basic requirements in common. 
In the case of rehabilitative therapy, the patients condition has the potential to improve or is improving in 
response to therapy. A therapy plan of care is developed either by the physician/ non-physician practitioner 
(NPP), or by the physical therapist who will provide the physical therapy services. All services provided are to 
be specific and effective treatments for the patients condition according to accepted standards of medical 
practice; and the amount, frequency, and duration of the services must be reasonable. The services that are 
provided must meet the description of skilled therapy. You can find this information in Local Coverage 
Determination (LCD) L33631: Outpatient Physical and Occupational Therapy Services. 
 
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 infrared therapy devices are used to treat an area of the skin and adjacent subcutaneous 
tissues of a patient with infrared therapy energy, using an array of juxtaposed infrared diodes affixed to a 
flexible pad to retain skin contact. The devices can also produce local warming, though this may be a 
secondary effect. The use of infrared therapy devices has been proposed for a variety of disorders, including 
treatment of diabetic neuropathy, other peripheral neuropathy, skin ulcers and wounds, and similar related 
conditions, including conditions such as pain arising from these conditions. A wide variety of devices are 
currently available. 
 
Effective for services performed on and after October 24, 2006, the Centers for Medicare & Medicaid Services 
has determined that there is sufficient evidence to conclude the use of infrared therapy devices and any related 
accessories is not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act (the Act). 
The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-
covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic 
and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous 
tissues. 
 
You can find these rules in the National Coverage Determination (NCD) Infrared Therapy Devices 270.6. 
 
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 for those items and services specifically listed in your Plan contract. The injection of a therapeutic 
drug (D9610) is not listed and therefore not covered by the Plans dental benefit. This benefit includes 
extractions but is limited to eight simple extractions (D7140) every calendar year and three surgical extractions 
(D7210) every calendar year. You can find this information in Chapter 4 on pages 47 to 49 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 CT scans are covered if there is literature to support its use for the patients condition and the 
scan is reasonable and necessary for the patient. 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 220.1(A). 
 
The rules say that computed tomography cerebral perfusion analysis (CTP)  (using automated post-processing 
software algorithmic analysis) is medically reasonable and necessary in patients with small acute ischemic 
stroke (AIS) caused by unilateral large vessel occlusion (LVO) in the proximal anterior circulation evaluated at 
stroke centers; CTP can be used to aid in selection for endovascular mechanical thrombectomy (EVT) if 1 of 
the following other conditions is fulfilled: 
1. Treatment (femoral puncture) can be started within 6-24 hours of the time last known to be at neurologic 
baseline and who meet the pre-CTP inclusion/exclusion criteria as defined by the DAWN trial, or 
2. Treatment (femoral puncture) can be started within 6-16 hours of the time last known to be at neurologic 
baseline and who meet the pre-CTP inclusion/exclusion criteria as defined by the DEFUSE 3 trial. 
*excluding criteria purely related to study mechanics (e.g., able to return for protocol required follow-up visits, 
etc.) 
 
You can find this rule in the Local Coverage Determination (LCD) - Computed Tomography Cerebral 
Perfusion Analysis (CTP) (L38769). 
 
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 provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
The rules say that legible documentation to support medical necessity must be present for each date of service 
billed on the claim. Documentation should include the following elements: 
- Specific botulinum toxin used 
- Dosage of toxin used (including dosage in units per site) 
- A complete description of the site(s) injected 
- A covered diagnosis (however, when a form of botulinum toxin is used for an indication that is not supported 
by Food and Drug Administration (FDA)-approval and/or compendia support, a physician statement in the 
medical record stating the reason(s) why the unsupported form was used is also required) 
- Support of the clinical effectiveness of the injections, noting date of last injection (if applicable) 
- Support for the medical necessity of electromyography or stimulation guidance procedures if performed. 
You can find this information in the Local Coverage Determination (LCD): Chemodenervation (L33458). 
 
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.