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 state that contractors shall consider a complete claim to have all items on the Form CMS-1490S 
completed along with an itemized bill with the following information: date of service, place of service, 
description of each surgical or medical service or supply furnished; charge for each service; treating doctors or 
suppliers name and address; diagnosis code; procedure code and the provider or suppliers NPI. The ordering 
& referring providers legal name and address and the National Provider Identifier (NPI) if known must be 
included on the itemized bill if from a Clinical laboratory for ordered tests; an independent diagnostic imaging 
center for ordered imaging procedures or a supplier of Durable Medical Equipment, Prosthetics, Orthotics and 
Supplies (DMEPOS) for ordered DMEPOS. Required information on a claim must be valid for the claim to be 
considered as complete. You can find this rule at the Medicare Claims Processing Manual, 80.3.2 - Handling 
Incomplete or Invalid Claims. 
 
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 Medicare will consider the removal of benign skin lesions as medically necessary, and not 
cosmetic, if one or more of the following conditions is present and clearly documented in the medical record: 
 
A. The lesion has one or more of the following characteristics: 
1. bleeding 
2. intense itching 
3. pain 
 
B. The lesion has physical evidence of inflammation, e.g., purulence, oozing, edema, erythema. 
 
C. The lesion obstructs an orifice or clinically restricts vision. 
 
D. The clinical diagnosis is uncertain, particularly where malignancy is a realistic consideration based on 
lesional appearance (e.g. non-response to conventional treatment, or change in appearance). However, if the 
diagnosis is uncertain, either biopsy or removal may be more prudent than destruction. 
 
E. A prior biopsy suggests or is indicative of lesion malignancy or premalignancy. 
 
F. The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that 
such trauma has in fact occurred. 
 
G. Wart removals will be covered under (a) through (f) above. In addition, wart destruction will be covered 
when the following clinical circumstance is present: 
 
        Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesional virus 
shedding         Evidence of spread from one body area to another, particularly in 
immunocompromised/immunosuppressed patients. 
 
You can find this information in the Local Coverage Determination (LCD) Benign Skin Lesion Removal 
L34233. 
 
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 replacement refers to the provision of an identical or nearly identical item. Equipment which 
the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. 
Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot 
be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful 
lifetime (RUL) of the equipment. In the absence of program instructions, Medicare contractors may determine 
the reasonable useful lifetime of equipment, but in no case can it be less than 5 years. Replacement due to wear 
is not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, 
Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary 
equipment owned by the beneficiary. You can find this information in the Centers for Medicare and Medicaid 
Service, Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 
110.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 also say that preoperative visits after the decision is made to operate beginning with the day before 
the day of surgery for major procedures and the day of surgery for minor procedures are included in the global 
package for the surgery code. You can find this information in the Centers for Medicare and Medicaid 
Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 
40.1. 
 
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. 
 
Medicare coverage and payment for cataract surgery is the same irrespective of whether the surgery is 
performed using conventional surgical techniques or a bladeless, computer controlled laser. Under either 
method, Medicare will cover and pay for the cataract removal and insertion of a conventional intraocular lens. 
You can find this information in the Laser-Assisted Cataract Surgery and Centers for Medicare & Medicaid 
Services (CMS) Rulings 05-01 and 1536-R. 
 
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 only 
those items and services specifically listed in your Plan contract but is limited to an annual maximum of 
$2,000. You can find this information on pages 82-84 and 98-100 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 state that a repeat epidural steroid injection (ESI) is indicated when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using SAME scale for at least three (3) months. If a patient 
fails to respond well to the initial ESI, a repeat ESI after 14 days can be performed, using a different approach, 
level and/or medication if appropriate, with the rationale and medical necessity for the second ESI documented 
in the medical record.  
 
You can find this rule at the Medicare Local Coverage Determination (LCD) L39242: Epidural Steroid 
Injections for Pain Management. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 must make services geographically accessible and consistent with local community 
patterns of care. Commonly used services should be available within a reasonable distance and travel time. 
Longer distances and travel times are permissible when they are based on location (such as a rural area) and/or 
established and based on routine patterns of care. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, 
Section 110.1. 
 
The rules say that a Medicare plan may restrict members 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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
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 4 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 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 71-72 in the Plan's 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 L5781 describes a complete device that is an addition to a lower limb prosthesis. The 
primary function of the vacuum pump is to suspend the prosthetic limb. Additionally, products coded L5781 
provide residual limb volume management and moisture evacuation. The pump mechanism evacuates air and 
accumulated moisture between the limb and socket walls. The pump mechanism can be actuated by either 
external power and/or mechanical system(s). You can find this rule in the Local Coverage Article (LCA) - 
Lower Limb Prostheses - Policy Article (A52496). 
 
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 to report home health visits, the home health agency (HHA) reports one of the following 
codes to represent a visit by each home health care discipline: 
- Physical Therapy: G0151, G0157, G0159, G2168 
- Occupational Therapy: G0152, G0158, G0160, G2169 
- Speech-Language Pathology: G0153, G0161 
- Skilled Nursing: G0299, G0300, G0162, G0493, G0494, G0495, G0496 
- Medical Social Services: G0155 
- Home Health Aide: G0156 
- Telecommunications: G0320, G0321, G0322 
 
You can find this rule in Medicare Claims Processing Manual Chapter 10, Section 40.2. 
 
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 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 
requested item or service but is limited to a $2,500 annual maximum. You can find this information in Chapter 
4 on pages 58-59 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). 
 
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 $233 deductible which applies to certain items and services. The Plan 
deductible applies to in-network and out-of-network physician/practitioner services. You can find this 
information on pages 56-57 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees then pay a $0 copayment after meeting the deductible for in-network 
primary care and specialist office visits. You can find this information on pages 78-79 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. 
 
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 one pair of eyeglasses or contact lenses after each cataract surgery that includes 
insertion of an intraocular lens. The Plan covers the Medicare-covered standard frames and lenses for cataracts 
up to the Medicare allowed amount. The Plan contract also says upgrades such as deluxe frames, progressive 
lenses, and additional lens upgrades (including but not limited to transition, scratch-resistant, or tinted lenses) 
are not covered for glasses/lenses after cataract surgery. You may pay for upgrades yourself if you choose. You 
can find this information on page 112 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 state that Intensity Modulated Radiation Therapy ((IMRT) is a technology in radiation oncology that 
delivers radiation more precisely to the tumor while relatively sparing the surrounding normal tissues. It is an 
advanced form of three-dimensional conformal radiation therapy (3D CRT) that allows for varying intensities 
of radiation to produce dose distributions that are more conformal than those possible with standard 3D CRT. It 
introduces inverse planning and computer-controlled radiation deposition, and normal tissue avoidance in 
contrast to the conventional trial-and-error approach. 
 
The clinical objectives are defined mathematically and the IMRT optimization process determines the beam 
parameters that will lead to the desired solution while sparing normal tissues. 
 
Examples of situations where IMRT is covered include tumors of the prostate, head and neck, brain, and 
paraspinal regions when needed to reduce the incidence and severity of the side effects of radiation, including 
compromise of visual function, mucositis, and xerostomia. 
 
An IMRT candidate includes a patient who has already received a maximum amount of radiation delivered by 
conventional means. IMRT allows these patients to receive additional radiation safely, which can result in a 
prolonged survival and an improved quality of life. 
 
You can find this rule in the Local Coverage Article (LCA) for Billing and Coding: Intensity Modulated 
Radiation Therapy (IMRT) (A58245). 
 
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. 
 
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 the Plan covers worldwide emergency and urgent care services outside of the United 
States. Pre-scheduled and/or elective procedures are not covered. You can find this information on page 50 of 
the Plan's 2022 Evidence of Coverage.