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. The contract also says that 
enrollees may be billed by the out-of-network provider for any charged amount greater than the payment made 
by the Plan. You can find this information on page 98 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. You can find 
this information on page 71 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs and a $250 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. You can find this information 
on pages 101 and 97 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 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 45 to 55 of the Plan's 
(2022) Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that GeneSight testing is covered when the clinician has made an initial personalized decision 
for the patient based on the patients diagnosis, the patients other medical conditions, other medications the 
patient is taking, professional judgement, clinical science and basic science pertinent to the drug (e.g. 
mechanism of action, side effects), the patients past medical history and when pertinent family history and the 
patient's preferences and values. You can find these rules in the Local Coverage Determination (LCD) for 
MolDX: Pharmacogenomics Testing, L38394. 
 
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 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 certain conditions have both an underlying etiology and multiple body system manifestations 
due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the 
underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a 
combination exists, there is a use additional code note at the etiology code, and a code first note at the 
manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology 
followed by manifestation. You can find this information in the ICD-10-CM Official Guidelines for Coding 
and Reporting FY2022. 
 
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. 
 
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. Without the 
correct Evidence of Coverage (EOC), there is no way of knowing whether the copayment being charged is 
correct.
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 only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is 
statutorily non-covered. You can find this rule at Center for Medicare and Medicaid Services, Local Coverage 
Article A52514 entitled "Oxygen and Oxygen Equipment- Policy Article." 
 
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 the Plan  provides supplemental (extra) coverage for hearing aids/services.  
Hearing aids ordered through providers other than the Plans select hearing aid provider are not covered. You 
can find this information on pages 4-27 to 4-28 of the Plans 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 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 rule say that The PLA is indicated only for use on pigmented skin lesions, for which a diagnosis of 
melanoma is being considered. The test may only be ordered by clinicians who evaluate pigmented skin lesions 
and perform biopsies. The test is covered for use as a source of information on whether or not to perform a 
biopsy. 
The specific characteristics that the lesion must have are as follows: 
 The lesion must meet one or more ABCDE criteria (Asymmetry, Border, Color, Diameter, Evolving) 
 Primary melanocytic skin lesions between 5mm and 19mm 
 Lesions where the skin is intact (i.e. non-ulcerated or non-bleeding lesions) 
 Lesions that do not contain a scar or were previously biopsied 
 Lesions not located in areas of psoriasis, eczema or similar skin conditions 
 Lesions not already clinically diagnosed as melanoma or for which the clinical suspicion is sufficiently 
high that the treating clinician believes melanoma is a more likely diagnosis than not 
 Lesions in areas other than palms of hands, soles of feet, nails, mucous membranes and hair covered areas 
that cannot be trimmed 
You can find these rules in Local Coverage Determination (LCD) MolDX: Pigmented Lesion Assay L38151.  
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 copayment for Outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information on pages 79 and 80 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 when used for the treatment of chronic, intractable pain described in section II, the TENS 
unit must be used by the beneficiary on a trial basis for a minimum of one month (30 days), but not to exceed 
two months. The trial period will be paid as a rental. The trial period must be monitored by the treating 
practitioner to determine the effectiveness of the TENS unit in modulating the pain. For coverage of a 
purchase, the treating practitioner must determine that the beneficiary is likely to derive significant therapeutic 
benefit from continuous use of the unit over a long period of time. 
 
A 4-lead TENS unit may be used with either 2 leads or 4 leads, depending on the characteristics of the 
beneficiary's pain. If it is ordered for use with 4 leads, the medical record must document why 2 leads are 
insufficient to meet the beneficiarys needs. 
 
TENS used for CLBP as described in section III does not require a trial rental period or an assessment of 
effectiveness by the treating practitioner. Upon the beneficiarys enrollment into an approved study, the TENS 
is eligible for purchase. 
 
Separate allowance will be made for replacement supplies when they are reasonable and necessary and are used 
with a covered TENS. Usual maximum utilization is: 
 
2 TENS leads - a maximum of one unit of A4595 per month. 
4 TENS leads - a maximum of two units of A4595 per month. 
 
If the use of the TENS unit is less than daily, the frequency of billing for the TENS supply code should be 
reduced proportionally. 
 
You can find this rule in the Local Coverage Determination (LCD): Transcutaneous Electrical Nerve 
Stimulators (TENS) L33802. 
 
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 a fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or 
more of the following criteria (1-4) are met: 
 
    The beneficiary has a medical condition which requires positioning of the body in ways not feasible with an 
ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a 
hospital bed, or 
    The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to 
alleviate pain, or 
    The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration, or 
    The beneficiary requires traction equipment, which can only be attached to a hospital bed. 
 
A heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one of the criteria for 
a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 
pounds. 
 
You can find this information in the Local Coverage Determination (LCD) Hospital Beds And Accessories 
L33820. 
 
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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments). You can find this rule at 42 CFR Section 422.111.  
 
The rules say that a copayment is a fixed amount 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 $275 copayment for each ambulance trip. You can find this information 
on page 64 of the Plans 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 invasive procedures for the treatment of varicose veins are considered medically reasonable 
and necessary when ALL of the following criteria have been met: 
 
1. An evaluation of the patient has been performed including a history and physical examination, the CEAP 
clinical classification and the revised Venous Clinical Severity Score (VCSS), AND 
2. A duplex scan of the deep and superficial venous systems supports the examination findings,3 AND 
3. A duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers in the 
saphenous, or perforator veins is 500 milliseconds or greater3 and absence of deep venous obstruction, AND 
4. The documentation supports signs and/or symptoms that interfere with activities of daily living and/or 
quality of life, AND 
5. The CEAP clinical classification is C1 to C6 with the following criteria: 
 
a. Treatment of C1 disease (telangiectasia and their feeding reticular veins) is considered medically reasonable 
and necessary for patients with spontaneous and/or traumatic venous hemorrhage. 
b. For patients with C2 or C3 disease and VCSS less than 6, the plan of care shall include documentation of a 
period of conservative therapy (2 to 4 weeks) including graduated compression 20-30 mmHg or greater, 
ambulation, elevation, and avoiding prolonged sitting and standing. 
c. For patients who meet any one of the following criteria, the mandatory conservative therapy prior to the 
invasive procedure may be waived. 
 
-VCSS 6 or more 
-C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, and active venous leg 
ulceration) 
-Hemorrhage 
-Recurrent superficial thrombophlebitis 
 
You can find this rule in the Local Coverage Determination (LCD) - Treatment of Chronic Venous 
Insufficiency of the Lower Extremities (L38720) - Effective December 27, 2020. 
 
The rules say that incompetent perforator vein (IPV) management by foam sclerotherapy or thermal ablation, 
will be considered medically reasonable and necessary when: 
 
1. An active venous ulcer is in close proximity to the IPV, OR 2. The proximal significant reflux has been treated and an IPV persists under or adjacent to a healed venous 
ulcer, OR 
3. The proximal and regional venous reflux has been treated and there is persisting focal pain and tenderness or 
stasis dermatitis overlying an IPV, OR 
4. The incompetent perforator demonstrates reflux more than 500 ms and diameter more than 3.5 mm. 
 
You can find this rule in the Local Coverage Determination (LCD) - Treatment of Chronic Venous 
Insufficiency of the Lower Extremities (L38720) - Effective December 27, 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 state that abdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the 
abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally, 
chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, and the above symptoms 
have been present for at least three months and are refractory to usual standard medical therapy, such surgery 
may be considered reconstructive. Preoperative photographs may be required to support justification and 
should be supplied upon request. 
 
You can find this information in the Local Coverage Determination (LCD) Plastic Surgery L35163. 
 
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 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 $50 copayment for a Medicare-covered urgent care facility visit. You 
can find this information in Chapter 4 on page 118 of the Plan's 2022 Evidence of Coverage (EOC).