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. You can find this information on pages 93-94 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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2.  
 
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 you receive your care from a provider who is eligible to provide services under 
Original Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be 
responsible for the full cost of the services you receive. You can find this information on page 60 of the Plans 
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 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 says that supplemental coverage is provided for hearing aids. This benefit includes coverage 
for hearing aids only when purchased from the Plans select hearing aid provider. You can find this information 
on page 51 of the Plans 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $40 copayment for in-network outpatient diagnostic tests, including x-
rays. You can find this information on page(s) 78-79 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 electrical nerve stimulation is an accepted modality for assessing a patient's suitability for 
ongoing treatment with a transcutaneous or an implanted nerve stimulator. 
 
Accordingly, program payment may be made for the following techniques when used to determine the potential 
therapeutic usefulness of an electrical nerve stimulator: 
 
Percutaneous Electrical Nerve Stimulation (PENS) 
 
This diagnostic procedure which involves stimulation of peripheral nerves by a needle electrode inserted 
through the skin is performed only in a physician's office, clinic, or hospital outpatient department. Therefore, 
it is covered only when performed by a physician or incident to physician's service. If pain is effectively 
controlled by percutaneous stimulation, implantation of electrodes is warranted. 
 
NOTE: Electrical nerve stimulators do not prevent pain but only alleviate pain as it occurs. A patient can be 
taught how to employ the stimulator, and once this is done, can use it safely and effectively without direct 
physician supervision. Consequently, it is inappropriate for a patient to visit his/her physician, physical 
therapist, or an outpatient clinic on a continuing basis for treatment of pain with electrical nerve stimulation. 
Electrical nerve stimulation treatments furnished by a physician in his/her office, by a physical therapist or 
outpatient clinic are excluded from coverage by 1862(a)(1) of the Act. (See 160.7 for an explanation of 
coverage of the therapeutic use of implanted peripheral nerve stimulators under the prosthetic devices benefit.) 
 
You can find these rules in the National Coverage Determination (NCD) Assessing Patient's Suitability for 
Electrical Nerve Stimulation Therapy 160.7.1. 
 
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 a 20% coinsurance for covered Part B drugs. You can find this 
information on page 71 of the Plan's 2023 Evidence of Coverage (EOC).  
 
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 $35 copayment for an office visit with a specialist. You can find this 
information on page 80 of the Plan's 2023 EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a custom fabricated mandibular advancement oral appliance (E0486) used to treat obstructive 
sleep apnea (OSA) is covered if criteria A - D are met. 
 
The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to assess 
the beneficiary for obstructive sleep apnea testing. Refer to the ICD-10 code list in the LCD-related Policy 
Article for applicable diagnoses. 
The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 - 3): 
The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events 
per hour with a minimum of 30 events; or, 
The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 
events and documentation of: 
Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
Hypertension, ischemic heart disease, or history of stroke; or, 
If the AHI> 30 or the RDI> 30 and meets either of the following(a or b): 
The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or, 
The treating practitioner determines that the use of a PAP device is contraindicated. 
The device is ordered by the treating practitioner following a review of the report of the sleep test. (The 
practitioner who provides the order for the oral appliance could be different from the one who performed the 
clinical evaluation in criterion A.) 
The device is provided and billed for by a licensed dentist (DDS or DMD). 
If all of these criteria (A-D) are not met, the custom fabricated oral appliance (E0486) will be denied as not 
reasonable and necessary. 
 You can find these rules in the Local Coverage Determination (LCD) Oral Appliances for Obstructive Sleep 
Apnea L33611. 
 
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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for painful, debilitating, 
osteoporotic vertebral collapse/compression fractures, defined as those that have not responded to non-surgical 
medical management (e.g. narcotic and/or non- narcotic medication, physical therapy modalities) with and 
without methods of immobility (e.g. rest, bracing). You can find these rules in Local Coverage Determination 
(LCD) Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L35130). 
 
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. 
 
The rules say that Medicare will pay for normally excluded dental services or related services in limited cases. 
Medicare will pay for this non-routine dental care: 
 An excluded dental service if it is performed by a dentist as incident to and as an integral part of a 
covered service performed by the same dentist on the same day. This exception does not apply if the excluded 
service is the primary service performed by the dentist.   
 Services for wiring of the teeth if done in connection with a jaw fracture. 
 A dental examination done in the hospital if it is part of a work-up prior to kidney transplant surgery. 
 Services for extraction of the teeth if done to prepare the jaw for radiation treatment needed as a result 
of cancer. 
 
You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 150 and Chapter 16, 
Section 140 and in the National Coverage Determinations Manual, Chapter 1, Section 260.6. 
 
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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. The extractions, alveoloplasty, and anesthesia are not covered by the Plan's dental benefits. You 
can find this information on pages 61 to 62 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 state that ambulatory electrocardiograph (AECG) monitoring, when performed with a device that has 
Food and Drug Administration (FDA) clearance, will be considered medically reasonable and necessary in the 
following situations: 
1. A standard 12-lead electrocardiograph (ECG), complete cardiac history and cardiac exam has not 
satisfactorily explained the patient's cardiac complaints and AECG testing will provide diagnostic information 
that will assist in developing a treatment plan or changing a treatment plan for patients that are at risk for 
cardiac arrythmias. OR 
2. For patients experiencing unexplained syncope, near syncope, episodic dizziness, chest pain, palpitations, 
and/or shortness of breath. OR 
3. To assess documented or suspected bradycardia. OR 
4. For patients experiencing nocturnal arrhythmias. OR 
5. To assess the average heart rate and adequacy of rate control in a patient with atrial fibrillation. OR 
6. To aid in the regulation of anti-arrhythmic drug dosage. OR 
7. To assess the effectiveness of arrhythmia therapy. OR 
8. To evaluate prognosis following acute coronary syndrome. OR 
9. Pre/Post implantable cardiac defibrillator reprogramming. OR 
10. To assess for silent myocardial ischemia in a patient with known or suspected coronary heart disease. OR 
11. To assess for asymptomatic ventricular premature beats or non-sustained ventricular tachycardia in patients 
with hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, 
dilated or restrictive cardiomyopathy, congenital heart disease, or Brugada syndrome. OR 
12. To evaluate for occult atrial fibrillation (A-Fib) as a potential cause of cardio-embolism in patients with 
cryptogenic stroke. 
 
Limitations 
The following are considered not medically reasonable and necessary: 
1. Devices that do not have FDA clearance, including non-physician prescribed; hand/wrist held  smart phone-
based devices. 
2. AECG monitoring of potentially harmful ventricular arrhythmias requiring inpatient level of care. 
3. Any 24-hour monitoring station that does not meet the definition in the definition section.  
You can find this information in the Local Coverage Determination (LCD): Ambulatory Electrocardiograph 
(AECG) Monitoring (L39492). 
 
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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 28-34 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 that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that non-impregnated gauze dressing change is up to 3 times per day for a dressing without a 
border and once per day for a dressing with a border. It is usually not reasonable and necessary to stack more 
than 2 gauze pads on top of each other in any one area. When surgical dressings are billed, the appropriate 
modifier (A1  A9, AW, EY, or GY) must be added to the code when applicable. If modifier A9 (DRESSING 
FOR NINE OR MORE WOUNDS) is used, information must be submitted with the claim indicating the 
number of wounds. If GY is used, a brief description of the reason for non-coverage (e.g., "A6216GY - used 
for wound cleansing") must be entered in the narrative field of the electronic claim. 
 
Solutions used to moisten gauze, and wound cleansers or irrigating solutions are wound care items which are 
non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing.  
 
 You can find this rule in the Local Coverage Determination and Article for Surgical Dressings, L33831 and 
A54563. 
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 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 says that supplemental coverage is provided for hearing aids. This benefit includes coverage 
for hearing aids only when purchased from the Plans select hearing aid provider. You can find this information 
on pages 61-62 of the Plans 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 percutaneous vertebral augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients with both of the following: 
1. Inclusion criteria (all are required): 
a. Acute (less than 6 weeks) or subacute (6 to 12 weeks) osteoporotic vertebral compression 
fracture (VCF) (T1  L5), based on symptom onset, and documented by advanced imaging 
b. Symptomatic (one of the following): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score 8 or greater) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS 5 or greater) despite 
optimal non-surgical management (NSM)(one of the following): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still 5 or greater) (with 2 or more of 
the following): 
A. Progression of vertebral body height loss 
B. Greater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) greater than 17 
c. Continuum of care (10) (Both of the following): 
i. All patients presenting with VCF should be referred for evaluation of bone mineral 
density (BMD) and osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program. 
2. Exclusion criteria (Can have none of the following):   
a. Absolute contraindication 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
ii. Osteomyelitis, discitis, active systemic or surgical site infection 
iii. Pregnancy b. Relative contraindication 
i. Greater than three vertebral fractures per procedure 
ii. Allergy to bone cement or opacification agents 
iii. Uncorrected coagulopathy 
iv. Spinal instability 
v. Myelopathy from the fracture 
vi. Neurologic deficit 
vii. Neural impingement 
viii. Fracture retropulsion/canal compromise 
 
You can find these rules in Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L33569). 
 
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.