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 testing which is intended to diagnose and characterize the neurocognitive effects of medical 
disorders that impinge directly or indirectly on the brain. Examples of problems that might lead to 
neuropsychological testing are: 
 
1.  Detection of neurologic diseases based on quantitative assessment of neurocognitive abilities (e.g., mild 
head injury, anoxic injuries, AIDS dementia) 
2.  Differential diagnosis between psychogenic and neurogenic syndromes 
3.  Delineation of the neurocognitive effects of central nervous system disorders 
4.  Neurocognitive monitoring of recovery or progression of central nervous system disorders; or 
5.  Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies 
among individuals with neuropsychiatric disorders. 
 
Comments: The content of neuropsychological testing procedures differs from that of psychological testing in 
that neuropsychological testing consists primarily of individually administered ability tests that 
comprehensively sample cognitive and performance domains that are known to be sensitive to the functional 
integrity of the brain (e.g., abstraction, memory and learning, attention, language, problem solving, 
sensorimotor functions, constructional praxis, etc.). These procedures are objective and quantitative in nature 
and require the patient to directly demonstrate his/her level of competence in a particular cognitive domain. 
Neuropsychological testing does not rely on self-report questionnaires such as the Minnesota Multiphasic 
Personality Inventory 2 (MMPI-2), rating scales such as the Hamilton Depression Rating Scale, or projective 
techniques such as the Rorschach or Thematic Apperception Test (TAT) when questions of how brain damage 
or degenerative disease processes (e.g. right hemisphere CVA) may be affecting emotional expression or how 
significant emotional distress or mood impairment might be affecting cognitive function (e.g. question of 
presence of "pseudodementia") arise. 
 
Typically, psychological testing will require from four (4) to six (6) hours to perform, including administration, 
scoring and interpretation. Supporting documentation in the medical record must be present to justify greater 
than 8 hours per patient per evaluation. If the testing is done over several days, the testing time should be 
combined and reported all on the last date of service. If the testing time exceeds eight (8) hours, medical 
necessity for extended time should be documented. Medical records may be requested. You can find this rule in 
the Medicare Local Coverage Determination (LCD)- L33632, Psychiatry and Psychology 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 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). 
 
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 
says that COVID-19 testing conducted to test for general workplace safety or public health surveillance, or for 
any purpose not primarily intended for the individualized diagnosis or treatment of COVID-19 or another 
health condition is not a covered benefit. This includes (but is not limited to) screenings for travel or vacation. 
You can find this information on the COVID-19-coronavirus page of your Plan's website.
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 once every five years. You can find this information on page 73 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 state that a plan is legally responsible under its contract and the regulations to authorize, provide, or 
pay for all Medicare covered services or prescription drugs that are denied and upon appeal are found to be 
services the plan should have authorized, provided, or paid for its enrollees. CMS policy is that an enrollee is 
entitled to receive a service and/or payment of a service or prescription drug from a plan from which the 
enrollee either voluntarily or involuntarily disenrolled prior to a final decision on appeal. The plan must follow 
the requirements found at 42 CFR 422.100, 423.104 422.504, and 423.505 as they relate to individual 
disenrollment or contract termination/service area reduction. 
 
You can find this information in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, 
and Appeals Guidance 90.2  Effectuation Requirements for Former Plans. 
 
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). 
 
 
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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
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 Plan 
contract says that you pay a $0 copay for one routine vision exam per calendar year for the purpose of 
obtaining eyeglasses or contact lenses. Your plan includes routine eyeglasses or contacts every calendar year. 
You can find this information on page 96 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 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 specific 
preventative and comprehensive services which are listed in the Plan's contract with identifying procedure 
codes. Services and codes not listed are not covered. You can find this information on pages 4-57 to 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 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 0% coinsurance for durable medical equipment (DME) items other than 
wheelchairs, walkers, scooters, hospital beds, spinal stimulators, and osteogenesis devices. You can find this 
information on pages 79-8 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $250 copayment for each visit to an ambulatory surgical 
center or outpatient hospital facility. You can find this information on page 103 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 a contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
  
  provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
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 160. 
 
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.
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 low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL: and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
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 Plan 
contract says that the Plan covers certain vision care services as a supplemental (extra) benefit. This includes a 
$200 allowance every year for routine prescription eyewear. The Plan contract also says that the enrollee is 
responsible for any amount above the coverage limit. You can find this information on page 112 of the 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 lower limb prosthesis is covered when the beneficiary: 
 
    Will reach or maintain a defined functional state within a reasonable period of time; and 
 
    Is motivated to ambulate. 
 
FUNCTIONAL LEVELS: 
 
A determination of the medical necessity for certain components/additions to the prosthesis is based on the 
beneficiarys potential functional abilities. Potential functional ability is based on the reasonable expectations 
of the prosthetist, and treating practitioner, considering factors including, but not limited to: 
 
    The beneficiarys past history (including prior prosthetic use if applicable); and 
 
    The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
 
    The beneficiarys desire to ambulate. 
 
Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels: 
 
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a 
prosthesis does not enhance their quality of life or mobility. 
Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed 
cadence. Typical of the limited and unlimited household ambulator. 
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers 
such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator 
who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. 
Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting 
high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. 
 
The records must document the beneficiarys current functional capabilities and his/her expected functional 
potential, including an explanation for the difference, if that is the case. It is recognized, within the functional 
classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level 
classifications. A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic 
response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or 
shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 
or above. You can find this information in Medicare's Local Coverage Determination (LCD): Lower Limb 
Prostheses (L33787). 
 
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 if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible 
for the difference in cost between the A-C IOL and a conventional IOL. The astigmatism-correcting feature of 
an IOL is not covered by Medicare. You can find this rule in the CMS Ruling, No. CMS-1536-R, 
Astigmatism-Correcting IOLs, January 22, 2007. 
 
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. 
If the bladeless, computer-controlled laser cataract surgery includes implantation of a PC-IOL or AC-IOL, only 
charges for those non-covered services may be charged to the beneficiary. You can find this information in the 
Centers for Medicare and Medicaid Services (CMS) announcement entitled Laser-Assisted Cataract Surgery 
and CMS Rulings 05-01 and 1536-R, published on November 16, 2012. 
 
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. 
 
Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of 
chronic pain in patients who meet ALL of the following criteria: 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional 
deficit measured on pain or disability scale
11
; AND* 
2. Pain that has been present for a minimum of 3 months with documented failure to respond to 
noninvasive conservative care management (as tolerated)
4,12
; AND 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused 
by facet joint synovial cyst)
4,7
; AND 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain 
the source of the patients pain, including but not limited to fracture, tumor, infection, or 
significant deformity.
11
 
If there is an extended period of time, two years or more, since the last RFA and/or there is a question as to the 
source of the recurrent pain then diagnostic procedures must be repeated. 
You can find this rule in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L34892). 
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 $500 deductible which applies to certain items and services. The Plan 
deductible applies to a medical vision exam with imaging. You can find this information on page 4-2 section 
1.2 of the Plan's 2022 Evidence of Coverage (EOC).