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 for services performed on or after January 21, 2020, Medicare will now provide limited 
coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, 
CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, 
such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This 
benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated 
improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may 
be provided by a physician in accordance with state requirements, or by physician assistants, nurse 
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. 
Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, 
physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determinations Manual, Section 30.3.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that 12 acupuncture visits are covered within a 90-day period. The contract also says that no more 
than 20 acupuncture treatments may be administered annually. You can find this information on pages 64-65 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     Diagnostic Facet Joint Procedures (IA or MBB): 
 
    The primary indication of a diagnostic facet joint procedure is to diagnose whether the patient has facet 
syndrome. Intraarticular (IA) facet block(s) are considered reasonable and necessary as a diagnostic test only if 
medial branch blocks (MMB) cannot be performed due to specific documented anatomic restrictions or there is 
an indication to proceed with therapeutic intraarticular injections. These restrictions must be clearly 
documented in the medical record and made available upon request. 
 
    Diagnostic procedures should be performed with the intent that if successful, radiofrequency ablation (RFA) 
procedure would be considered the primary treatment goal at the diagnosed level(s). 
 
    A second diagnostic facet procedure is considered medically necessary to confirm validity of the initial 
diagnostic facet procedure when administered at the same level. The second diagnostic procedure may only be 
performed a minimum of 2 weeks after the initial diagnostic procedure. Clinical circumstances that necessitate 
an exception to the two-week duration may be considered on an individual basis and must be clearly 
documented in the medical record.  
    For the first diagnostic facet joint procedure:  
            For the first diagnostic facet joint procedure to be considered medically reasonable and necessary, the 
patient must meet the criteria outlined under indications for facet joint interventions. 
            A second confirmatory diagnostic facet joint procedure is considered medically reasonable and 
necessary in patients who meet ALL the following criteria: 
                The patient meets the criteria for the first diagnostic procedure; AND 
                After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 
80% relief of primary (index) pain (with the duration of relief being consistent with the agent used)  
 
    Frequency limitation: For each covered spinal region no more than four (4) diagnostic joint sessions will be 
reimbursed per rolling 12 months, in recognition that the pain generator cannot always be identified with the 
initial and confirmatory diagnostic procedure. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Interventions 
for Pain Management (L38765). 
 
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 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. 
 
The rules say interpret the phrase "new patient" to mean a patient who has not received any professional 
services, i.e., evaluation and management (E/M) service or other face-to-face service (e.g., surgical procedure) 
from the physician or physician group practice (same physician specialty) within the previous 3 years. 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 30.6.7. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 only the 
items and services listed in the dental services benefit category. Core build up (D2950) is not covered by the 
Plan's dental benefits. You can find this information on pages 60-62 of the Plans 2022 Evidence of Coverage 
(EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. You can find this in the Local Coverage Article (LCA): 
Wheelchair Options/Accessories - Policy Article (A52504). 
 
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). 
 
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. 
 
Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise 
reasonable and necessary for the patient. Food and Drug Administration (FDA) approved drugs used for 
  
  indications other than what is indicated on the official label may be covered if the use is determined to be 
medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or 
accepted standards of medical practice. 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, Sections 
50.4.1 and 50.4.2. 
 
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. 
 
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion 
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the 
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. 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 290(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that orthopedic shoes are only covered by Medicare under specific conditions: If shoes are part of 
a leg brace and are included in the cost of the brace, or the shoes are for a person with diabetic foot disease. 
You can find this information in Chapter 4 on page 141 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare does not pay for over-the-counter (OTC) items, including non-prescription drugs. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 40.2. 
 
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 you have a maximum benefit limit of $100 every three (3) months for Over-the-Counter (OTC) 
items. The contract also says that Over-the-Counter Items (OTC) are not covered Out-of-Network (Point of 
Service Option). You can find this information on pages 101 and 102 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Medicare covers cytogenetic tests when they are reasonable and necessary for the diagnosis 
or treatment of the following conditions: 
 
   - Genetic disorders (e.g., mongolism) in a fetus; (See the Medicare Benefit Policy Chapter 15, "Covered 
Medical and Other Health Services," 20.1) 
   - Failure of sexual development; 
   - Chronic myelogenous leukemia; 
   - Acute leukemias lymphoid (FAB L1-L3), myeloid (FAB M0-M7), and unclassified; or 
   - Mylodysplasia 
 
You can find this rule in the National Coverage Determination (NCD) for Cytogenetic Studies (190.3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
 
The rules say that supplier-produced records, even if signed by the treating practitioner, and attestation letters 
(e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment 
purposes. Templates and forms, including CMS CMNs, are subject to corroboration with information in the 
medical record. A prescription is not considered to be part of the medical record. Medical information intended 
to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated 
by information contained in the medical record. The beneficiarys medical record must contain sufficient 
documentation of the beneficiarys medical condition to substantiate the necessity for the type and quantity of 
items ordered and for the frequency of use or replacement (if applicable). The information should include the 
beneficiarys diagnosis and other pertinent information including, but not limited to, duration of the 
beneficiarys condition, clinical course (worsening or improvement), prognosis, nature and extent of functional 
limitations, other therapeutic interventions and results, past experience with related items, etc. You can find this 
rule in Local Coverage Article (LCA) - Standard Documentation Requirements for All Claims Submitted to 
DME MACs (A55426). 
 
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 no payment may be made for the implantation of dorsal column or depth brain stimulators or 
services and supplies related to such implantation, unless all of the conditions listed below have been met: 
 
    The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic 
intractable pain; 
    With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for 
the given patient; 
    Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
    All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be available; and 
    Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find this information in Medicare's National Coverage Determination (NCD): Electrical Nerve 
Stimulators (160.7). 
 
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 the following uses of real-time, outpatient cardiac telemetry are considered medically reasonable 
and necessary: 
 
Detection, characterization and documentation of symptomatic transient or paroxysmal dysrhythmia when the 
frequency of the symptoms is limited and the use of a 24-hour ambulatory ECG is documented in the medical 
record to be unlikely to capture and record the dysrhythmia, or 
Other testing and/or monitoring/recording/telemetry has been unrevealing. The ordering physician must 
document the prior testing performed and the results. This information must be maintained in the patients 
medical record and be available upon request, or 
Prolonged monitoring is required specifically to ensure the absence of atrial fibrillation prior to the 
discontinuation of anticoagulation therapy. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Real-Time, Outpatient 
Cardiac Telemetry (L34997).] 
 
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 codes E2310 and E2311 describe electronic components that allow the patient to control two 
or more of the following motors from a single interface, e.g., proportional joystick, touchpad, or 
nonproportional interface: 
 
1. Power tilt 
2. Power recline, with or without shear reduction 
3. Combination power tilt and recline, with or without shear reduction 
4. Power leg elevation with or without articulation, power center mount elevating foot platform with or without 
articulating properties. 
 
You can find this rule in the Local Coverage Article (LCA) - Power Mobility Devices - Policy Article 
(A52498) - Effective January 1, 2020. 
 
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 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. 
 
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 10% coinsurance for Doctor and Other Health Care Provider Services. 
You can find this information on page 60 of the Plan's 2022 Evidence of Coverage (EOC). 
 
The contract also says there is an $800 annual deductible for medical services. You can find this information on 
page 41 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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. You can find this information 
on pages 4-79 through 4-89 of the Plans 2021 Evidence of Coverage (EOC).