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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. 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 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers 100 one-way trips per calendar year (limited to ground transportation only). You can find this 
information on page 83 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 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, 3.3.2.1. 
 
The rules say that providers performing validity testing on urine specimens utilized for drug testing should not 
separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, 
creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not 
separately billed. You can find this information in the National Correct Coding Initiative (NCCI) Policy 
Manual, Chapter X, page X-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 that if equipment or a device can be replaced free of charge by the warrantor, no program
payment may be made, since there is no charge involved. You can find this in the Medicare Benefit Policy
Manual Chapter16, General Exclusions from Coverage, Section 40.4 entitled Items Covered Under Warranty.
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 extracranial-Intracranial (EC-IC) arterial bypass surgery is not a covered procedure when it
is performed as a treatment for ischemic cerebrovascular disease of the carotid or middle cerebral arteries,
which includes the treatment or prevention of strokes. The premise that this procedure which bypasses
narrowed arterial segments improves the blood supply to the brain and reduces the risk of having a stroke has
not been demonstrated to be any more effective than no surgical intervention. Accordingly, EC-IC arterial
bypass surgery is not considered reasonable and necessary within the meaning of 1862(a)(1) of the Act when
it is performed as a treatment for ischemic cerebrovascular disease of the carotid or middle cerebral arteries.
You can find this in the National Coverage Determination (NCD) - Extracranial-Intracranial (EC-IC) Arterial
Bypass Surgery (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.
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). 
 
Another type of pre-symptom Memory Loop Recorder MLR, it is implanted subcutaneously in a patients 
upper left chest and may remain implanted for many months. An Implantable (or Insertable Loop) Recorder 
(ILR) is used when syncope is thought to be cardiac-related, but is too infrequent to be detected by either a 
HolterTM monitor or a traditional pre-symptom MLR. You can find this information in the National Coverage 
Determination (NCD) 20.15 Electrocardiographic 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 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 pages 38 to 39 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. 
 
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 mental health services are eligible for coverage when provided by a state-licensed 
psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, 
physician assistant, or other Medicare-qualified mental health care professional as allowed under 
applicable state laws. You can find this information on pages 88 to 89 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 panels with greater than 5 respiratory pathogens performed in the Part B outpatient setting 
are not considered medically reasonable and necessary. You can find this rule in the Local Coverage 
Determination (LCD) - Respiratory Pathogen Panel Testing (L38918) - Effective July 11, 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 state that Medicare covers these tests when they are reasonable and necessary for the diagnosis or 
treatment of the following conditions: 
    - Genetic disorders (e.g., mongolism) in a fetus; (See the Medicare Benefit Policy Chapter 15, "Covered 
Medical and Other Health Services," Section 20.1) 
    - Failure of sexual development; 
    - Chronic myelogenous leukemia; 
    - Acute leukemias lymphoid (FAB L1-L3), myeloid (FAB M0-M7), and unclassified; or Mylodysplasia 
 
You can find this in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
03, Medicare National Coverage Determinations Manual, Chapter 1, Section 190.3 
 
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.
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 covers medical nutrition therapy services (MNT) for certain enrollees who have 
diabetes or a renal disease. You can find this rule at 42 CFR Section 410.132(b)(4) and in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, National Coverage 
Determinations Manual, Chapter 1, Section 180.1. 
 
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 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 47 and 48 of the Plan's 
2022 Evidence of Coverage (EOC). 
 
The Plan contract also says prior authorization may be required for home health agency care, and is the 
responsibility of the provider. You can find this information on page 83 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 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.
The Medicare rules 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. 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.
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 services, but the services must be performed by a participating general dentist. You can find this information on pages 60 to 61 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 bariatric surgery is coverable for patients who meet the following criteria: 
a. the patient has a Body Mass Index of greater than or equal to 35 at the time of surgery 
b. the patient has been provided with knowledge and tools needed to achieve such lifelong lifestyle changes, 
exhibits understanding of the needed changes and has demonstrated to clinicians involved in his or her care to 
be capable and willing to undergo the changes. 
c. the patient has made a diligent effort to achieve healthy body weight with such efforts described in the 
medical record and certified by the operating surgeon 
d. the patient has failed to maintain a healthy weight despite adequate participation in a structured dietary 
program with medical oversight. 
 
Repeat bariatric surgery is generally not reasonable and necessary. Claims for more than one bariatric surgical 
procedure may be submitted for individual consideration, and potentially covered when clinical circumstances 
demonstrate reasonability and necessity (such as replacing a defective device or correcting a complication in a 
patient who had met medical necessity for the original procedure and has achieved acceptable weight loss. You 
can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination L33411 
entitled Surgical Management of Morbid Obesity. 
 
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. 
 
Repeat epidural steroid injection (ESI) 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 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 
information in the Local Coverage Determination (LCD): Epidural Injections for Pain Management (L38994) 
 
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 includes 
preventive and comprehensive dental services. Guided tissue regeneration - resorbable barrier, per site is not 
covered by the Plan's dental benefit. You can find this information on pages 68-70 of the Plans 2022 Evidence 
of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 hearing aids provided through plan specified provide are covered. Hearing aids 
ordered through providers other than plan specified provider are not covered. You can find this information 
on page 4-23 of the Plan's 2022 Evidence of Coverage.