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

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that you must pay a $210 copayment per day for days 1-6 per admission for inpatient mental
health care. The Plan contract also says that you must pay a $40 copayment for each individual/group therapy
session. You can find this information on pages 84 and 95 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 that the quantity of test strips (code A4253) and lancets (code A4259) that are covered depends
on the usual medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin,
regardless of their diagnostic classification as having Type 1 or Type 2 diabetes mellitus. You can find this rule
in the Local Coverage Determination (LCD) - Glucose Monitors (L33822) - Effective July 18, 2021.
The rules say that the usual utilization for glucose monitor supplies is:
1. for a beneficiary who is not currently being treated with insulin administrations, up to 100 test strips and up
to 100 lancets every 3 months are covered if the basic coverage criteria are met.
2. For a beneficiary who is currently being treated with insulin administrations, up to 300 test strips and up to
300 lancets every 3 months are covered if basic coverage criteria are met.
You can find this rule in the Local Coverage Determination (LCD) - Glucose Monitors (L33822) - Effective
July 18, 2021.
The rules say that high utilization for glucose monitor supplies is:
1. For a beneficiary who is not currently being treated with insulin administrations, more than 100 test strips
and more than 100 lancets every 3 months are covered if criteria (a) - (c) below are met.
2. For a beneficiary who is currently being treated with insulin administrations, more than 300 test strips and
more than 300 lancets every 3 months are covered if criteria (a) - (c) below are met.
a. Basic coverage criteria for all home glucose monitors and related accessories and supplies are met; and,
b. Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization
guidelines, the treating practitioner has had an in-person visit with the beneficiary to evaluate their diabetes
control and their need for the specific quantity of supplies that exceeds the usual utilization amounts described
above; and,
c. Every six (6) months, for continued dispensing of quantities of testing supplies that exceed the usual
utilization amounts, the treating practitioner must verify adherence to the high utilization testing regimen.
You can find this rule in the Local Coverage Determination (LCD) - Glucose Monitors (L33822) - Effective
July 18, 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 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 74 of the Plan's 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 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 an initial thermal radiofrequency ablation (RFA) of cervical, thoracic, or lumbar paravertebral
facet joint (medial branch) nerves is considered medically reasonable and necessary for patients who have had
at least two (2) medically reasonable and necessary diagnostic Medial Branch Blocks (MBBs), with each one
providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief
being consistent with the agent used). You can find this information in the Local Coverage Determination
(LCD): Facet Joint Interventions for Pain Management (L33930).
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 list
cone beam CT scans, bone replacement grafts or guided tissue regeneration as covered services. You can find
this information on pages 4-56 to 4-69 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 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 crowns
and core buildup only for permanent teeth needing multi-surface restorations where other restorative materials
have a poor prognosis. Permanent molar teeth must have pathologic destruction to the tooth by caries or trauma
and should involve four or more surfaces and at least one cusp. Permanent bicuspid teeth must have pathologic
destruction to the tooth by caries or trauma and should involve three or more surfaces and at least one cusp.
You can find this information in the Clinical Criteria for Crowns in the Plan's dental vendor's 2021 Office
Reference Manual.
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 NGS considers one iStent, iStent inject, or Hydrus device per eye medically reasonable and
necessary for the treatment of adults with mild or moderate open-angle glaucoma and a cataract when the
individual is currently being treated with an ocular hypotensive medication and the procedure is being
performed in conjunction with cataract surgery. One XEN45 device per eye is covered for the management of
refractory glaucoma, defined as prior failure of filtering/cilioablative procedure and/or uncontrolled IOP
(progressive damage and mean diurnal medicated IOP greater than or equal to 20 mm Hg) on maximally
tolerated medical therapy (i.e., greater than or equal to 4 classes of topical IOP-lowering medications, or fewer
in the case of tolerability or efficacy issues). XEN45 insertion must be performed by an ophthalmologist with
experience with trabeculectomy and bleb management.
You can find this rule in the Centers for Medicare and Medicaid Services, Local Coverage Determination
(LCD): Micro-Invasive Glaucoma Surgery (MIGS) L37244.
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 dental
services beyond Medicare coverage. This benefit covers supplemental dental services only when provided by a
participating general dentist. You can find this information on pages 70-71 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. The Plan contract says that
members who have not had regular dental visits (at least once every six months) or have been diagnosed with
gum disease may need periodontal scaling, root planing, or full-mouth debridement before routine care such as
regular cleanings can be provided. The enrollee may have to pay additional cost-sharing for these services. The
contract also says that the enrollee must pay a $125 copayment for periodontal scalings and root planings
(D4341) You can find this information on pages 126 and 133 of the Plan's 2021 Evidence of Coverage (EOC).
The Plan contract includes a list of covered supplemental dental services. The contract specifically says that
any procedure not listed is not covered. Unspecified periodontal procedure (D4999) is not included on this list
and is not a covered supplemental benefit. You can find this information on pages 123 to 143 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 no payment may be made for the implantation of dorsal column or depth brain stimulators
or services and supplies related to such implantation, unless all of the conditions listed below have been met:
- The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic
intractable pain;
- With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated
for the given patient;
- Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to
implantation. (Such screening must include psychological, as well as physical evaluation);
- All the facilities, equipment, and professional and support personnel required for the proper diagnosis,
treatment training and follow up of the patient (including that required to satisfy item c) must be available.
and
- Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation.
You can find this information in the National Coverage Determination (NCD): Electrical Nerve Stimulators
(160.7).
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 a $50 copayment for Physician/Practitioner services, including doctor's office visits. You can find this information on page 89 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 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 42-49 of the plan's 2021
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 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 state that when completing the 1500 claim form, providers must enter the correct Place of Service
(POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. If an
independent lab bills for services, the place where the sample was taken is reported as the POS. An
independent laboratory taking a sample in its laboratory shows "81" as place of service. You can find this rule
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare
Claims Processing Manual Chapter 26, Section 10.6.
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 Plan
contract includes a list of covered supplemental dental services. The contract specifically says that any
procedure not listed is not covered. Custom fabricated abutment (D6057) and abutment supported porcelain
fused to metal crown (D6061) are not included on this list and are not covered supplemental benefits. You can
find this information on pages 4-84 to 4-98 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 a $45 copayment for each Medicare-covered x-ray. You can find this
information in Chapter 4 on pages 83 to 84 of the Plan's 2021 Evidence of Coverage (EOC).