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 up to 24 one-way trips per year for medical appointments. You can find this information in Chapter 4 on 
page 84 of the Plans 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 that Medicare Advantage (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 they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. 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 diabetic test strips and blood glucose monitors must be purchased from a preferred 
manufacturer (FreeStyle, OneTouch, Precision, and Prodigy). Test strips monitors from non-preferred 
manufacturers are not covered unless there is prior authorization from the Plan. You can find this information 
on page 60 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 endovenous stents may be placed for patients with severely symptomatic venous 
obstructions due to any of the following: 
1. Iliac vein compression syndrome also known as May-Thurner or Cockett syndrome. 
2. Iliocaval obstruction. 
3. Iliofemoral obstruction for patients with venous leg ulceration(s) not relieved by conservative therapies 
and compression. Progression of symptoms may lead to Phlegmasia Cerulea Dolens (PCD), acute 
inferior vena cava (IVC) thrombosis, and rapid thrombus extension despite anticoagulation as well as 
anatomically extensive DVT affecting the common femoral and/or iliac vein, or post-thrombotic 
stenosis with ankle edema of venous origin (i.e., minimum CEAP score 3). 
4. Superior or Inferior Vena Caval Thrombosis including Superior Vena Cava syndrome. 
5. Post-thrombotic syndrome (PTS). 
6. As an adjunct to catheter-directed thrombolysis for acute femoroiliocaval deep vein thrombosis when 
post thrombolysis imaging identifies symptomatic residual stenosis. 
7. Post radiation venous stenosis. 
8. Symptomatic post-traumatic venous stenosis including those resulting from central venous catheters or 
transvenous device (e.g., pacemakers, defibrillators,) pacemaker leads or a history of abdominal and/or 
pelvic surgery. 
9. Salvage of thrombosed or stenotic symptomatic or limited function arteriovenous dialysis access 
fistulae or grafts with compromised venous outflow, failed angioplasty rapid restenosis, or vessel 
perforation. This may include treatment of trapping a life threatening thrombus, an aneurysm or 
pseudoaneurysm that threatens the viability of the AV fistula or graft, or the treatment of a hemodialysis 
vascular access rupture that cannot be controlled through balloon tamponade. 
10. Thrombotic obstruction of major hepatic veins (Budd-Chiari syndrome). 
11. Transvenous decompression of portosystemic shunts. 
12. Post-operative stenosis or venous narrowing due to repair of congenital cardiac disease, e.g. sinus 
venosus Atrial Septal Defect (ASD), discordant atrioventricular connection status post Mustard or 
Senning repair of Transposition of the Great Arteries (TGA). 13. Pulmonary vein stenosis resulting from congenital malformation, extrinsic compression, sequelae of 
radiofrequency ablation (RFA), lung transplantation, or status post repair of Total Anomalous 
Pulmonary Vein Return (TAPVR). 
 
You can find these rules in Local Coverage Determination (LCD) Endovenous Stenting (L37893). 
 
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 Coverage Criteria for Monoclonal Antibodies Directed Against Amyloid for the Treatment 
of Alzheimer's Disease (AD): 
1) Monoclonal antibodies directed against amyloid that are approved by the FDA for the treatment of AD based 
upon evidence of efficacy from a change in a surrogate endpoint (e.g., amyloid reduction) considered as 
reasonably likely to predict clinical benefit may be covered in a randomized controlled trial conducted under an 
investigational new drug (IND) application. 
2) Monoclonal antibodies directed against amyloid that are approved by the FDA for the treatment of AD based 
upon evidence of efficacy from a direct measure of clinical benefit may be covered in CMS-approved 
prospective comparative studies. Study data for CMS-approved prospective comparative studies may be 
collected in a registry. 
3) For CMS-approved studies, the protocol, including the analysis plan, must include: 
 
    A study population whose diversity of patients are representative of the national population with MCI due to 
AD or mild AD dementia. 
    A neurocognitive evaluation and a description of the instruments used to assess cognition and function for 
the clinical diagnosis of MCI due to AD or mild AD dementia for study enrollment and outcomes assessment. 
    A description of: 
        The multidisciplinary dementia team and optimal medical management. 
        Study sites with clinical expertise and infrastructure to provide treatments consistent with the safety 
monitoring outlined in the FDA-approved label. 
 
4) CMS-approved studies of a monoclonal antibody directed against amyloid (antiamyloid mAb) approved by 
the FDA for the treatment of AD based upon evidence of efficacy from a direct measure of clinical benefit 
must address all of the questions below: 
a. Does the antiamyloid mAb meaningfully improve health outcomes (i.e., slow the decline of cognition and 
function) for patients in broad community practice? 
b. Do benefits, and harms such as brain hemorrhage and edema, associated with use of the antiamyloid mAb, 
depend on characteristics of patients, treating clinicians, and settings? 
c. How do the benefits and harms change over time?  
5) CMS-approved studies must adhere to the following standards of scientific integrity that have been 
identified by the Agency for Healthcare Research and Quality (AHRQ) 
 
You can find this information in the National Coverage Determination (NCD) Monoclonal Antibodies Directed 
Against Amyloid for the Treatment of Alzheimer's Disease (AD) 200.3. 
 
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 state that until January 1, 1995, immunosuppressive drugs were covered under Medicare Part B for a 
period of one year following discharge from a hospital for a Medicare covered organ transplant. Medicare 
interpreted the 1-year period after the date of the transplant procedure to mean 365 days from the day on which 
an inpatient is discharged from the hospital. Beneficiaries are eligible to receive additional Part B coverage 
within 18 months after the discharge date for drugs furnished in 1995; within 24 months for drugs furnished in 
1996; within 30 months for drugs furnished in 1997; and within 36 months for drugs furnished after 1997. For 
immunosuppressive drugs furnished on or after December 21, 2000, this time limit for coverage is eliminated. 
 
Covered drugs include those immunosuppressive drugs that have been specifically labeled as such and 
approved for marketing by the Food & Drug Administration (FDA). Covered drugs also include those 
prescription drugs, such as prednisone, that are used in conjunction with immunosuppressive drugs as part of a 
therapeutic regimen reflected in FDA approved labeling for immunosuppressive drugs. Therefore, antibiotics, 
hypertensives, and other drugs that are not directly related to rejection are not covered. The FDA has identified 
and approved for marketing the following specifically labeled immunosuppressive drugs. They are: 
- Sandimmune (cyclosporine), Sandoz Pharmaceutical; 
- Imuran (azathioprine), Burroughs Wellcome; 
- Atgam (antithymocyte globulin), Upjohn; 
- Orthoclone OKT3 (Muromonab-CD3), Ortho Pharmaceutical; 
- Prograf (tacrolimus), Fujisawa USA, Inc; 
- Celicept (mycophenolate mefetil, Roche Laboratories; 
- Daclizumab (Zenapax); 
- Cyclophosphamide (Cytoxan); 
- Prednisone; 
- Prednosolone. 
 
You can find these rules in Medicare Benefit Policy Manual Chapter 15, Section 50.5.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $0 copay for Medicare covered DME for Durable medical equipment 
(DME) and related supplies. You can find this information on page 21 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 cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The rules say that abdominal lipectomy/panniculectomy is considered medically reasonable and necessary 
when the pannus or panniculus hangs below the level of the symphysis pubis causing one or more of the 
following conditions: 
1. Chronic intertrigo that consistently remains refractory to appropriate medical therapy 
(e.g., topical antifungals, corticosteroids, antibiotics) over a period of three months. 
2. Difficulty walking or functional impairment in activities of daily living. 
If the procedure is being performed following significant weight loss, in addition to meeting the criteria noted 
above, there should be evidence that the patient has maintained a stable weight for at least six months. For 
patients whose weight loss is the result of bariatric surgery, abdominal lipectomy/panniculectomy should not be 
performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the 
most recent six months. 
Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L38914). 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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 certain home health services are covered. Covered services include but are not 
limited to: 
-Part-time or intermittent skilled nursing and home health aide services 
-Physical therapy, occupational therapy, and speech therapy 
-Medical and social services 
-Medical equipment and supplies 
You can find this information on page 53 of the Plans 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 that the Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
Codes with an MAI of 3 are based on criteria combined with data such that it would be possible, but 
medically unlikely, that higher values would represent correctly reported medically necessary services. To be 
paid, there must be evidence (e.g., medical review) that the excess units were actually provided, were correctly 
coded, and were medically necessary. 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(V). 
 
The rules say that physicians in the same group practice who are in the same specialty must bill and be paid as 
though they were a single physician. If more than one evaluation and management (face-to-face) service is 
provided on the same day to the same patient by the same physician or more than one physician in the same 
specialty in the same group, only one evaluation and management service may be reported unless the 
evaluation and management services are for unrelated problems. Instead of billing separately, the physicians 
should select a level of service representative of the combined visits and submit the appropriate code for that 
level. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.5. 
 
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 treatments for symptomatic varicose tributaries are either compressive sclerotherapy or 
microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are greater than 4 millimeters in diameter and 
if the patient remains symptomatic after a six-week trial of conservative therapy. You can find this information 
in the Local Coverage Determination (LCD): Treatment of Varicose Veins of the Lower Extremity (L33575). 
 
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 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 98-100 of the Plans 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 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 crowns when the clinical criteria are met. You can find this information in Chapter 4 on pages 56 
to 58 of the Plans 2023 Evidence of Coverage (EOC) and in the Office Reference Manual maintained by the 
Plan's dental benefit administrator.