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 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. Dentures are not covered by the Plan's dental benefits. You can find this information on pages 63 
to 65 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 a partial 
or full set of dentures but is limited to 1 complete set every 5 years. You can find this information on page 62 
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 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 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 the National Correct Coding Initiative (NCCI) was developed to prevent inappropriate 
payment of services that should not be reported together. NCCI edits are organized in a Column One/Column 
Two table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of 
an edit pair, only the Column One code is payable. For edits with a modifier indicator of 0, the Column Two 
code cannot be paid regardless of whether a modifier is used. You can find this in the NCCI Manual, Chapter I. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that reduction mammaplasty will be considered medically reasonable and necessary when 
performed: 
 
To reduce the size of the breasts and help ameliorate symptoms caused by hypertrophy when: 
The surgeon's estimate of breast size/weight/volume to be removed is proportional to the body surface area 
(BSA) per the Schnur scale per breast to relieve symptoms. 
There are signs or symptoms resulting from the enlarged breasts (macromastia) that have not responded 
adequately to non-surgical interventions. 
Symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, 
persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast. 
Dermatologic signs or symptoms are refractory to or recurrent following a completed course of medical 
management. 
Intertriginous maceration, discoloration, chronic or recurrent infection of the inframammary skin refractory to 
dermatologic treatment measures. 
 
There is back pain from macromastia, unrelieved by: 
Conservative analgesia. 
Supportive measures. 
Physical therapy. 
 
   
There is shoulder grooving to a depth greater than 1 cm with skin irritation or darkening by supporting garment 
(bra strap). 
 
There are optimally managed significant arthritic changes in the cervical or upper thoracic spine, with 
persistent symptoms or significant restriction of activity. 
 
The macromastia is not due to an active endocrine, pharmaceutical or metabolic process. 
      
OR 
 
To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery. 
Note: either the involved breast or contralateral breast may be treated to achieve symmetry. 
 
Reduction mammaplasty will be considered cosmetic (which is not a covered Medicare benefit) or not 
medically reasonable and necessary when performed to reshape the breasts to improve appearance or self-
image. 
 
You can find this information in the Local Coverage Determination (LCD): Cosmetic and Reconstructive 
Surgery (L35090). 
 
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 pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). You can find these rules in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D). 
 
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. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 38, 47-49 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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 31 to 33 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 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 page 143 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 the Centers for Medicare & Medicaid Services (CMS) covers transcatheter aortic valve 
replacement (TAVR) under Coverage with Evidence Development (CED) with the following conditions: 
 
A. TAVR is covered for the treatment of symptomatic aortic valve stenosis when furnished according to a Food 
and Drug Administration (FDA)-approved indication and when all of the following conditions are met: 
 
The procedure is furnished with a complete aortic valve and implantation system that has received FDA 
premarket approval (PMA) for that system's FDA approved indication. 
 
The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-
disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication 
across medical specialties to offer optimal patient-centered care. The heart team includes the following: 
Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis who 
have: 
independently examined the patient face-to-face, evaluated the patients suitability for surgical aortic valve 
replacement (SAVR), TAVR or medical or palliative therapy; 
documented and made available to the other heart team members the rationale for their clinical judgment. 
Providers from other physician groups as well as advanced patient practitioners, nurses, research personnel and 
administrators. 
 
The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-
operative technical aspects of TAVR. 
 
TAVR must be furnished in a hospital with the appropriate infrastructure that includes but is not limited to: 
On-site heart valve surgery and interventional cardiology programs, 
Post-procedure intensive care facility with personnel experienced in managing patients who have undergone 
open-heart valve procedures, 
Appropriate volume requirements per the applicable qualifications below: 
There are two sets of qualifications; the first set outlined below is for hospital programs and heart teams without previous TAVR experience and the second set is for those with TAVR experience. 
 
You can find this information in the National Coverage Determination (NCD) Transcatheter Aortic Valve 
Replacement (TAVR) 20.32. 
 
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 there is no further payment for oxygen equipment during the 5-year reasonable useful 
lifetime (RUL) of the equipment after 36 rental payments have been made. If use of portable equipment 
(E0431, E0433, E0434, E1392, K0738) begins after the use of stationary equipment begins, payment for the 
portable equipment can continue after payment for the stationary equipment ends until 36 rental payments have 
been made for the portable equipment. The supplier who provided the equipment during the 36th rental month 
is required to continue to provide the equipment, accessories, contents (if applicable), maintenance, and repair 
of the oxygen equipment during the 5 year reasonable useful lifetime of the equipment.  
 
You can find these rules in Local Coverage Article (LCA) Oxygen and Oxygen Equipment Policy Article 
(A52514). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 33-43 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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 34 to 35 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 Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) are 
methods of delivering ionizing radiation using highly focused convergent beams to target a lesion while 
limiting exposure of adjacent structures. 
 
Stereotactic describes target lesion localization relative to a known three-dimensional reference system that 
allows for a high degree of anatomic accuracy and precision. Devices used for stereotactic guidance may 
include a body frame with external reference markers in which a patient is positioned securely, a system of 
implanted fiducial markers that can be visualized with low-energy (kV) x-rays, and computed tomography 
(CT)-imaging-based systems used to confirm the location of a tumor immediately prior to treatment. 
 
SBRT is used to treat extra-cranial sites as opposed to stereotactic radiosurgery (SRS) which is used to treat 
intra-cranial and spinal targets. Treatment of extra-cranial sites excluding the spinal cord and related spinal 
structures requires accounting for internal organ motion as well as for patient motion. Thus, reliable 
immobilization or repositioning systems must often be combined with devices capable of decreasing organ 
motion or accounting for organ motion e.g., respiratory gating. Additionally, all SBRT is performed with at 
least one form of image guidance to confirm proper patient positioning and tumor localization prior to delivery 
of each fraction. 
 
SBRT is only indicated as primary treatment for tumor types or locations where the available published 
literature supports an outcome advantage over other conventional radiation modalities. 
 
SBRT may be delivered in one to five sessions (fractions). Each fraction requires an identical degree of 
precision, localization and image guidance. 
 
SRS is typically performed in a single session, using a rigidly attached stereotactic guiding device, other 
immobilization technology and/or a stereotactic-guidance system. 
 
The higher a Karnofsky Performance Status, the better a patient is doing. 
 The lower an Eastern Cooperative Oncology Group (ECOG) Performance Status is, the better a patient is 
doing. This is the opposite of the Karnofsky Performance scores where a lower score reflects a poorer status. 
 
You can find these rules in the Local Coverage Determination (LCD) Stereotactic Radiation Therapy: 
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) L35076. 
 
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.