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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for the limited oral evaluation - problem focused (D0140) but is limited to one procedure per plan 
year, and the panoramic radiographic image (D0330) is limited to one procedure every three plan years. You 
can find this information in Chapter 4 on pages 4-91 and 4-92 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 special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The rules define a chronically ill enrollee as one who has one or more 
comorbid and medically complex chronic conditions that meet all of the following: 
1. Is life threatening or significantly limits the overall health or function of the enrollee; 
2. Has a high risk of hospitalization or other adverse health outcomes; and  
3. Requires intensive care coordination. 
The rules also say that the Plan must have written policies for determining enrollee eligibility and must 
document its determination that an enrollee is a chronically ill enrollee. You can find this information in 42 
CFR 422.102. 
 
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 if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. You can find this information on pages 44 to 
47 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 special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The rules define a chronically ill enrollee as one who has one or more 
comorbid and medically complex chronic conditions that meet all of the following: 
1. Is life threatening or significantly limits the overall health or function of the enrollee; 
2. Has a high risk of hospitalization or other adverse health outcomes; and  
3. Requires intensive care coordination. 
The rules also say that the Plan must have written policies for determining enrollee eligibility and must 
document its determination that an enrollee is a chronically ill enrollee. You can find this information in 42 
CFR 422.102. 
 
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 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 pages 77-78 of 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 state that flow cytometry for cell surface, cytoplasmic, or nuclear marker will be considered 
medically reasonable and necessary when performed for the following indications: 
 
    -Cytopenias and Hypercellular Hematolymphoid Disorder 
    -Lymphomas 
    -Acute Leukemia 
    -Chronic Lymphocytic Leukemia (CLL) & Other Chronic Lymphoproliferative Diseases (CLPD) 
    -Plasma Cell Disorders 
    -Myelodysplastic Syndromes (MDS) 
    -Chronic Myeloproliferative Disorders (CMPD) 
    -Mast Cell Neoplasms 
    -Paroxysmal Nocturnal Hemoglobinuria (PNH) 
    -Minimal Residual Disease (MRD) 
    -HIV Infection 
    -Organ Transplants 
    -DNA Analysis 
    -Carcinoma, Non-hematolymphoid Tumors 
    -Molar Pregnancy 
    -Primary Immunodeficiencies (PDS) 
    -Primary Platelet Disorders, non-neoplastic 
    -Red Cell and White Cell Disorders, non-neoplastic 
 
You can find this information in Local Coverage Determination (LCD): Flow Cytometry (L33661) and Local 
Coverage Article (LCA): Billing and Coding: Flow Cytometry (A57716). 
 
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 special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The rules define a chronically ill enrollee as one who has one or more 
comorbid and medically complex chronic conditions that meet all of the following: 
1. Is life threatening or significantly limits the overall health or function of the enrollee; 
2. Has a high risk of hospitalization or other adverse health outcomes; and  
3. Requires intensive care coordination. 
The rules also say that the Plan must have written policies for determining enrollee eligibility and must 
document its determination that an enrollee is a chronically ill enrollee. You can find this information in 42 
CFR 422.102. 
 
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 if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. You can find this information on pages 55 to 
57 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 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 15% coinsurance for in-network outpatient laboratory services. You can 
find this information on pages 4-36 to 4-39 of the Plan's 2021 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay 15% coinsurance for in-network outpatient diagnostic 
radiology services. You can find this information on pages 4-36 to 4-39 of the Plan's 2021 EOC. 
 
The Plan contract also says that enrollees have a $1,300 out-of-pocket maximum each year. This is the most 
you pay during the plan year for covered Medicare Part A and Part B services received from both in-network 
and out-of-network providers. You can find this information on page 4-4 of the Plans 2021 EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
The rules say that the codes describing bundled payments made to OTPs are Healthcare Common Procedure 
Coding System (HCPCS) codes G2067-G2075. There are add-on codes described by HCPCS codes G2076-
G2080, HCPCS codes G2215, G2216, and G1028. Only an entity enrolled with Medicare as an Opioid 
Treatment Program (OTP) can bill these codes. Additionally, OTPs are limited to billing only these codes 
describing bundled payments, and may not bill for other codes, such as those paid under the Physician Fee 
Schedule. You can find this rule in Medicare Claims Processing Manual Chapter 39  Opioid Treatment 
Programs (OTPs), Section 30.6. 
 
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. 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 41 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). 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 enrollees must pay a $50 copayment for outpatient diagnostic services. You can see this on page 88 of the Plans 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 pages 84 to 85 of 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 stress testing with cardiac imaging will be considered medically reasonable and necessary for 
patients experiencing new, recurrent, or worsening cardiac symptoms, including otherwise unexplained angina 
equivalent symptoms and a physical inability to perform a maximum exercise workload, a new or previously 
unrecognized uninterpretable Electrocardiogram (ECG) or an ECG which is uninterpretable for ischemia. You 
can find these rules in Local Coverage Determination (LCD) Cardiology Non-emergent Outpatient Stress 
Testing (L38396). 
 
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 semi-electric hospital is covered if the beneficiary meets one of the criteria for a fixed 
height bed and requires frequent changes in body position and/or has an immediate need for a change in body 
position. You can find this information in Local Coverage Determination (LCD): Hospital Beds and 
Accessories (L33820). 
 
The rules say that a Group 1 mattress overlay or mattress is covered if one of the following three criteria are 
met: 
1. The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position 
without assistance, or 
2. The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body 
position significant enough to alleviate pressure and at least one of conditions A-D below, or 
3. The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D 
below. 
 
Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition 
sufficiently to demonstrate the medical necessity for a pressure reducing support surface): 
A. Impaired nutritional status 
B. Fecal or urinary incontinence 
C. Altered sensory perception 
D. Compromised circulatory status 
 
You can find this information in Local Coverage Determination (LCD): Pressure Reducing Support Surfaces - 
Group 1 (L33830). 
 
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 reduction mammaplasty is considered medically necessary when the patient has significant 
symptoms that have interfered with normal daily activities, despite conservative management, for at least 6 
months, including at least one of the following criteria: 
 
1. History of back and/or shoulder pain which adversely affects activities of daily living (ADLs) unrelieved by, 
e.g. 
 
a. conservative analgesia (e.g., such as NSAID, compresses, massage, etc.) 
b. supportive measures (e.g., such as garments, back brace, etc.), 
c. physical therapy 
d. correction of obesity 
 
2. History of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with 
persistent symptoms and/or significant restriction of activity, e.g.: 
 
a. Signs and symptoms of ulnar paresthesias 
b. Cervicalgia 
c. Torticollis 
d. Acquired kyphosis 
 
3. Signs and symptoms of: 
 
a. intertrigonous maceration or infection of the inframammary skin (e.g., hyperpigmentation, bleeding, chronic 
moisture, and evidence of skin breakdown), refractory to dermatologic measures, or 
b. shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by appropriate supporting 
garment 
 
You can find this rule in the Local Coverage Determination (LCD) - Reduction Mammaplasty (L35001) - 
Effective November 17, 2019. 
 
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 the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet 
joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet ALL the 
following criteria: 
 
    Initial thermal RFA: 
        After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with each 
one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used) AND 
        Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and 
necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) 
months or at least 50% consistent improvement in the ability to perform previously painful movements and 
ADLs as compared to baseline measurement using the same scale; 
 
Frequency Limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be 
reimbursed per rolling 12 months. 
 
You can find this information in the Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management L38841. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.