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 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. Crown (D2740) and core buildup, including 
any pins when required (D2950) are not included on this list and are not covered supplemental benefits. You 
can find this information on pages 77 and 78 of the Plans 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 Plan 
contract includes a list of covered supplemental dental services. First intraoral periapical x-ray (D0220) is not 
included on this list and is not a covered supplemental benefit. This benefit includes one oral examination per 
calendar year, and one routine cleaning per calendar year. You can find this information on page 68 of the 
Plans 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 knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a 
beneficiary who is ambulatory and has knee instability. 
 
For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by 
examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, 
anterior/posterior Drawer test). 
 
Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and 
necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied 
if only pain or a subjective description of joint instability is documented. 
 
You can find this rule in Local Coverage Determination (LCD): Knee Orthoses (L33318). 
 
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 two 
routine cleanings annually. You can find this information on page 71 of the Plans 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 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 (CMS), Medicare National Correct Coding Initiative Policy 
Manual for Medicare Services, Chapter I(A). 
 
For purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code 
is generally used to reflect the actual setting where the beneficiary receives the face-to-face service. For 
example, if the physicians face-to-face encounter with a patient occurs in the office, the correct POS code on 
the claim, in general, reflects the 2-digit POS code 11 for office. In these instances, the 2-digit POS code (Item 
24B on the claim Form CMS-1500) will match the address and ZIP entered in the service location (Item 32 
on the 1500 Form)  the physical/geographical location of the physician. However, there are two exceptions to 
this general rule  these are for a service rendered to a patient who is a registered inpatient or an outpatient of a 
hospital. In these cases, the correct POS code -- regardless of where the face-to-face service occurs -- is that of 
the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital 
POS code (at a minimum POS code 19 or 22, for outpatient services performed off campus or on campus) as 
discussed in section 10.5 of this chapter. So, if in the above example, the patient seen in the physicians office 
is actually an inpatient of the hospital, POS code 21, for inpatient hospital, is correct. In this example, the POS 
code reflects a different setting than the address and ZIP code of the practice location (the physicians 
office). You can find this information in the CMS 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 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 that PGx testing is considered reasonable and necessary in limited circumstances as described 
below as an adjunctive personalized medical decision-making tool once a treating clinician has narrowed 
treatment possibilities to specific medications under consideration for use, or is already using a specified 
medication, based on other clinical considerations including the patients diagnosis, the patients other medical 
conditions, other medications, professional judgment, clinical science and basic science pertinent to the drug, 
and the patients preferences and values. You can find this information in the Local Coverage Determination 
(LCD) MolDX: Pharmacogenomics Testing L38394. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, 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 in Chapter 6 on pages 76 to 78 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 Plan 
contract includes a list of covered supplemental dental services. Dentures are not included on this list and is not 
a covered supplemental benefit. You can find this information on pages 75 and 76 of the Plans 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 under the circumstances specified below, payment may be made for repair, maintenance, 
and replacement of medically required DME, including equipment which had been in use before the user 
enrolled in Part B of the program. However, do not pay for repair, maintenance, or replacement of equipment 
in the frequent and substantial servicing or oxygen equipment payment categories. In addition, payments for 
repair and maintenance may not include payment for parts and labor covered under a manufacturer's or 
supplier's warranty. You can find this information in the Centers for Medicare and Medicaid Services (CMS), 
Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual Chapter 15, Section 110.2. 
 
Payment may be made for the replacement of a prosthetic device that is an artificial limb, or replacement part 
of a device if the ordering physician determines that the replacement device or part is necessary because of any 
of the following: 
1. A change in the physiological condition of the patient; 
2. An irreparable change in the condition of the device, or in a part of the device; or 
3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be 
more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced. 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual Chapter 15, Section 120(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. 
 
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 that ConfirmMDx is covered under the following conditions: 
1. Males aged 40 to 85 years old that have undergone a previous cancer-negative prostate biopsy within 24 
months and are being considered for a repeat biopsy due to persistent or elevated cancer-risk factors,  
2. The previous negative prostate biopsy must have collected a minimum of 8 tissue cores (but not have 
received a saturation biopsy of > 24 tissue cores) and remaining FFPE tissue from all cores is available 
for testing,  
3. Minimum tissue volume criteria of 20 microns of prostate biopsy core tissue is available (40 microns 
preferable),  
4. Previous biopsy histology does not include a prior diagnosis of prostate cancer or cellular atypia 
suspicious for cancer (but may include the presence of high-grade prostatic intraepithelial neoplasia 
(HGPIN), proliferative inflammatory atrophy (PIA), or glandular inflammation),  
5. Patient is not being managed by active surveillance for low stage prostate cancer,  
6. Tissue was extracted using standard patterned biopsy core extraction (and not transurethral resection of 
the prostate (TURP)),  
7. Patient has not been previously tested by ConfirmMDx from the same biopsy samples or similar 
molecular test. 
 
You can find these rules in the Local Coverage Determination (LCD) MolDX: ConfirmMDx Epigenetic 
Molecular Assay L36327. 
 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 an expandable controller can be covered when one or more of the following features are 
medically necessary: 
 
1. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head 
control, etc.) other than a standard proportional joystick. 
2. Non-proportional input devices (e.g., sip and puff, head array, etc.) 
3. The ability to operate 3 or more powered seating actuators through the drive control. 
4. A separate display (i.e., for alternate control devices) 
5. Other electronic devices (e.g., control of an augmentative speech device or computer through the chairs 
drive control) 
6. An attendant control 
 
These rules can be found in Local Coverage Article: Wheelchair Options/Accessories - Policy Article 
(A52504). 
 
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 
intraoral x-rays and are limited to 1 procedure code per calendar year. 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 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.  
 
The rules say that payment under the fee schedule for ambulance services: 
 
Includes a base rate payment plus a payment for mileage; 
Covers both the transport of the beneficiary to the nearest appropriate facility and all items and services 
associated with such transport; and 
Precludes a separate payment for items and services furnished under the ambulance benefit. 
Payment for items and services is included in the fee schedule payment. Such items and services include but 
are not limited to oxygen, drugs, extra attendants, and EKG testing - but only when such items and services are 
both medically necessary and covered by Medicare under the ambulance benefit. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 15, 30.1. 
 
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. The Plan 
contract says that enrollees must pay a $265 copayment for Ambulance services. You can find this information 
on pages 60 and 61 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 MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands 
and manufacturers, as long as the following conditions are met (42 CFR 422.100(l)): 
 
 The MA plan provides all categories of DME covered under original Medicare Part B; 
 The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
 The MA plans contracted suppliers provide access to all preferred DME brands; 
 During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 
90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year; 
 Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
 The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
 The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the Evidence of Coverage and Annual Notice of Change and on its website; and 
 The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by CMS to require full coverage. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS) Medicare Managed 
Care Manual Chapter 4, Section 10.12.2- Specifying Brands or Manufacturers of DME. 
 
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 Abbott and Lifescan glucometers, diabetic test strips, lancets, control solutions and a 
continuous glucose monitoring device are available for dispense via a retail or mail order pharmacy. All other 
desired brands will need to be obtained from a Durable Medical Equipment (DME) supplier (or via an 
exception process). You can find this information on page 70 of the Plan's 2022 Evidence of Coverage.