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 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 $30 copayment for each visit to a specialty physician office. You can find 
this information in Chapter 4 on page 88 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 $300 copayment per day for complex imaging, including CT scans. You 
can find this information on pages 77-79 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 effective for claims with dates of service on and after March 3, 2009, the Centers for 
Medicare & Medicaid Services finds that the evidence is sufficient to determine that the results of the sleep 
tests identified below can be used by a beneficiarys treating physician to diagnose OSA, that the use of such 
sleep testing technologies demonstrates improved health outcomes in Medicare beneficiaries who have OSA 
and receive the appropriate treatment, and that these tests are thus reasonable and necessary under section 
1862(a)(1)(A) of the Social Security Act. 
 
1. Type I PSG is covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and 
symptoms indicative of OSA if performed attended in a sleep lab facility. 
 
2. Type II or Type III sleep testing devices are covered when used to aid the diagnosis of OSA in beneficiaries 
who have clinical signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab 
facility or attended in a sleep lab facility. 
 
3. Type IV sleep testing devices measuring three or more channels, one of which is airflow, are covered when 
used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if 
performed unattended in or out of a sleep lab facility or attended in a sleep lab facility. 
 
4. Sleep testing devices measuring three or more channels that include actigraphy, oximetry, and peripheral 
arterial tone, are covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms 
indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility. 
 
You can find this rule in the Center for Medicare Services (CMS) Publication 100-03, Medicare National 
Coverage Determination (NCD) Manual, Section 240.4.1. 
 
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 $300 copayment per day, for days 1 through 5, and $0 copay for days 6 
and beyond. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctors 
order. The day before you are discharged is your last inpatient day. You can find this information in Chapter 4 
on page 75 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 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 Covered Routine Dental Benefits chart. A panoramic x-ray is covered but is 
limited to one procedure every three years. Scaling in presence of generalized moderate or severe gingival 
inflammation (D4346) is not covered by the Plan's routine dental benefits. You can find this information on 
pages 4-79 to 4-89 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 Medicare does not pay for gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. 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. 
 
Medicare rules say that the health plan must provide you with a clear and accurate description of the Original 
Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including 
applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. 
You can find these rules at Medicare Regulation 42, Section 422.111. 
 
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 the plan reimburses you up to $250 per calendar year towards your cost for membership in a qualified 
health club or fitness facility, covered instructional fitness classes, participation in wellness programs such as 
Matter of Balance, Chronic Disease self-management, diabetes workshop, Healthy Eating for Successful 
Living, Healthy IDEAS, Powerful Tools for Caregivers, Arthritis Foundation Exercise,  Enhance Wellness, Fit 
For Your Life, AAA Senior Driving, memory fitness activities, acupuncture, and/or covered nutritional 
counseling sessions with a licensed nutritional counselor or registered dietician. You pay all charges over $250 
per calendar year. You can find this information on pages 79 and 80 of the Plan's 2021 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 ambulatory EEG monitoring is a diagnostic procedure for patients in whom a seizure 
diathesis is suspected but not defined by history, physical or resting EEG. Ambulatory EEG can be utilized in 
the differential diagnosis of syncope and transient ischemic attacks if not elucidated by conventional studies. 
Ambulatory EEG should always be preceded by a resting EEG. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet-Only Manual, Publication 100-3, National Coverage Determinations 
Manual (NCD): Ambulatory EEG Monitoring (160.22). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the plan must state the type, amount, frequency, and duration of the services to be furnished 
and indicate the diagnoses and anticipated goals. (A plan is not required if only a few brief services will be 
furnished.)  
 
Reasonable Expectation of Improvement. 
 
Services must be for the purpose of diagnostic study or reasonably be expected to improve the patient's 
condition. The treatment must, at a minimum, be designed to reduce or control the patient's psychiatric 
symptoms so as to prevent relapse or hospitalization and improve or maintain the patient's level of functioning. 
 
When stability can be maintained without further treatment or with less intensive treatment, the psychological 
services are no longer medically necessary. 
 
Frequency and Duration of Services. 
 
There are no specific limits on the length of time that services may be covered. There are many factors that 
affect the outcome of treatment; among them are the nature of the illness, prior history, the goals of treatment, 
and the patient's response. As long as the evidence shows that the patient continues to show improvement in 
accordance with his/her individualized treatment plan, and the frequency of services is within accepted norms 
of medical practice, coverage may be continued. When a patient reaches a point in his/her treatment where 
further improvement does not appear to be indicated and there is no reasonable expectation of improvement, 
the outpatient psychiatric services are no longer considered reasonable or medically necessary. You can find 
this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD) L33632, 
Psychiatry and Psychology Services. 
 
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 does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 there is a $350 plan coverage limit for eyeglasses, frames, lenses, or contacts every two (2) years. The 
Plan contract also says enhancements including but not limited to the following are not covered through the 
allowance but may be purchased by the member at an additional cost: Optional cosmetic processes; Anti-
reflective, mirror, color or scratch coating; Blended, cosmetic, laminated, oversize, UV protected or 
polycarbonate lenses; Photochromic lenses, tinted lenses except Pink #1 and Pink #2.; Progressive multifocal 
lenses; Certain limitations on low vision care; A frame that costs more than Plan allowance. You can find this 
information on pages 103 and 104 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 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 a routine hearing exam is covered per calendar year. Additionally, up to two 
hearing aids are covered every calendar year. A $500 allowance every 3 calendar years is provided for hearing 
aids purchased from an in-network or out-of-network provider. You can find this information on page A1-25 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 state that psychotherapy is the treatment of mental illness and behavior disturbances, in which the 
provider establishes a professional contact with the patient and through therapeutic communication and 
techniques, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of 
behavior, facilitate coping mechanisms and/or encourage personality growth and development. 
 
Insight oriented, behavior modifying, and/or supportive psychotherapy refers to the development of insight or 
affective understanding, the use of behavior modification techniques, the use of supportive interactions, and the 
use of cognitive discussion of reality, or any combination of the above to provide therapeutic change. 
 
Psychotherapy will be considered medically necessary when the patient has a psychiatric illness and/or is 
demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive 
functioning. Psychotherapy services must be performed by a person licensed by the state where practicing, and 
whose training and scope of practice allow that person to perform such services. 
 
Psychotherapy must be provided as an integral part of an active treatment plan for which it is directly related to 
the patients identified condition/diagnoses. Some patients receive psychotherapy alone, and others receive 
psychotherapy along with medical evaluation and management services. These services involve a variety of 
responsibilities unique to the medical management of psychiatric patients such as medical diagnostic evaluation 
(i.e. evaluation of co-morbid medical conditions, drug interactions, and physical examinations), drug 
management when indicated, physician orders, interpretation of laboratory or other diagnostic studies and 
observations. The patient should be amenable to allowing insight-oriented therapy such as behavioral 
modification techniques, interpersonal psychotherapy techniques, supportive therapy, and cognitive/behavioral 
techniques to be effective. 
 
Some psychiatric patients receive a medical evaluation and management service on the same day as a 
psychotherapy service by the same physician or other qualified health care professional. These services to be 
medically necessary should be significantly different and separately identifiable. You can find this rule at 
Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD) L33252, Psychiatric 
Diagnostic Evaluation and Psychotherapy Services. 
 
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 the Physician Fee Schedule Status Indicator X means that this code is a statutory exclusion. 
No payment may be made under the physician fee schedule. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, 30.2.2. 
 
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 state that epidural steroid injection (ESI) will be considered medically reasonable and necessary 
when the following three (3) requirements are met: 
- History, physical examination, and concordant radiological image-based diagnostic testing supporting 
one of the following: 
 Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic 
claudication due to disc herniation, osteophyte or osteophyte complexes, severe 
degenerative disc disease, producing foraminal or central spinal stenosis; OR 
 Post-laminectomy syndrome; OR 
 Acute herpes zoster associated pain 
- Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality 
of life or function. An objective pain scale or functional assessment must be performed at baseline 
(prior to interventions). The same scale must be repeated at each follow-up for assessment of response. 
- Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or 
acute herpes zoster refractory to conservative management where a four (4) week wait is not required 
You can find this information in the Local Coverage Determination (LCD): Epidural Steroid Injections for Pain 
Management (L39036). 
 
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 10% coinsurance for an in-network, inpatient hospital stay. You can find 
this information in Chapter 4, on page 89, of the Plan's 2021 Evidence of Coverage (EOC). The Plan contract 
also says the most you will have to pay out-of-pocket for in-network covered plan services is $2100. You can 
find this information in Chapter 4, on page 61, of the Plans 2021 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 $290 copayment per date of service regardless of the number of trips. You 
can find this information in Chapter 4 on page 61 of the Plan's 2022 Evidence of Coverage (EOC).