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 outpatient surgery performed at an outpatient hospital has a copayment of $300. You can see this on page 99 of the Plans 2022 Evidence of Coverage.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay 20% coinsurance for each Medicare covered prosthetic device, such as a pacemaker. You can see this on page 102 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 Medicare covers a lung cancer screening counseling and shared decision-making visit, and for appropriate beneficiaries, annual screening for lung cancer with LDCT, as an additional preventive service benefit under the Medicare program when certain criteria are met. For purposes of Medicare coverage of lung cancer screening with LDCT, beneficiaries must meet all of the following eligibility criteria: 1. Age of 50-77 years, 2. Absence of signs/symptoms of lung cancer, 3. Tobacco smoking history of at least 20 pack-years (one pack-year equates to smoking one pack/day for one year), 4. Current smoker or former smoker who quit within the last 15 years. 5. Receive an order for lung cancer screening with LDCT You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Lung Cancer Screening with Low Dose Computed Tomography (LDCT) (210.14).
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 noninvasive physiologic studies of the upper or lower extremity arteries performed to 
establish the level and/or degree of arterial occlusive disease, will be considered medically necessary if a) 
significant signs and/or symptoms indicate a high likelihood of limb ischemia, and b) the patient is a candidate 
for invasive therapeutic procedures under any of the following circumstances: 
 
1. Claudication of less than one block or of such severity that it interferes significantly with the patient's 
occupation or lifestyle. 
2. Rest pain of ischemic origin (typically including the forefoot), associated with absent pulses, which 
becomes increasingly severe with elevation and diminishes with placement of the leg in a dependent 
position. 
3. Tissue loss defined as gangrene or pre-gangrenous changes of the extremity, or ischemic ulceration of 
the extremity occurring in the absence of pulses. 
4. Aneurysmal disease of the extremity. 
5. Evidence of thromboembolic events in an extremity. 
6. Evidence of compression/occlusion of the vascular structures supplying the upper or lower extremities. 
7. Blunt or penetrating trauma of the extremities (including complications of diagnostic and/or therapeutic 
procedures of an extremity). 8. Follow-up studies post-operative conditions: 
- In the immediate post-operative period if re-established pulses are lost, become equivocal, or if 
the patient develops related signs and/or symptoms of ischemia with impending repeat 
intervention. 
- Following bypass surgery or post-angioplasty with or without stent placement at three months, 
six months and one year when clinically indicated. 
- Subsequent studies may be allowed if there is clinical evidence of recurrent vascular disease 
evidenced by signs (i.e. decreased ABI from previous exam) or symptoms (i.e., recurrence of 
claudication symptoms that interfere significantly with the patients occupation or lifestyle). For 
postoperative surveillance, either a limited Duplex or multi-level Doppler with pressures is 
usually sufficient, but it is not considered necessary to do both. 
You can find this information in Local Coverage Determination (LCD): Noninvasive Physiological Studies of 
Upper and Lower Extremity Arteries (L33696). 
 
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 
preventive and comprehensive dental services along with specific dental codes that are listed on the dental 
benefit chart. The pulp vitality test, the delivery of antimicrobial agents, gingival irrigation, a diagnostic 
consult, medications, and an unspecified procedure are not covered by the Plan's dental benefits. You can find 
this information on pages 122 to 134 of the Plans Evidence of Coverage (EOC) and pages 107 to 121 of the 
Plans 2023 EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 does not include 
gingival irrigation. You can find this information in Chapter 4 on pages 85 through 87 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 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 does not include 
intraoral x-rays. You can find this information on pages 84-85 and 99-104 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 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 
coverage for only those items and services specifically listed in your Plan contract. There is no coverage for 
adjunctive pre-diagnostic (D0431), localized delivery of antimicrobial agents via a controlled release vehicle 
into diseased crevicular tissue per tooth by report (D4381), gingival irrigation per quadrant (D4921), or other 
drugs and/or medicaments by report (D9630). You can find this information pages 83-86 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 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 this contractor provides limited coverage for molecular Deoxyribonucleic acid/ribonucleic 
acid (DNA/RNA) biomarker tests for the diagnosis of prostate cancer that help differentiate men who may or 
may not benefit from a prostate biopsy when ALL of the following conditions are met:  
1. The patient must not have an established diagnosis of prostate cancer. 
2. The beneficiary is a candidate for prostate biopsy or repeat prostate biopsy, according to a consensus 
guideline [(i.e., National Comprehensive Cancer Network (NCCN), American Society of Clinical 
Oncology (ASCO), American Urological Association (AUA)]. 
a. For men  75 years of age - Prostate Specific Antigen (PSA) (or adjusted PSA in special 
populations, i.e., patients taking 5alpha-reductase inhibitors) OR repeat PSA are >3 and 
<10ng/mL AND/OR Digital Rectal Exam (DRE) findings are very suspicious for cancer 
b. For men > 75 years of age - PSA (or adjusted PSA in special populations, i.e., patients taking 5-
alpha-reductase inhibitors) OR repeat PSA are 4 and <10ng/mL AND/OR DRE findings are 
very suspicious for cancer. 

You can find this rule in Local Coverage Determination (LCD) MolDX: Molecular Biomarkers to Risk-Stratify 
Patients at Increased Risk for Prostate Cancer L39005. 
 
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 the 
requested panoramic radiographic image (D0330) but is limited to one procedure code every five calendar 
years, extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) and extraction erupted tooth or exposed root (D7140) but is limited to 
two procedure codes per calendar year. This benefit includes only those items and services specifically listed in 
your Plan contract. Consultation (D9310) and therapeutic parenteral drug, single administration (D9610) are 
not covered under the Plans dental benefits. You can find this information on pages 86-88 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 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 code L5999 (lower extremity prosthesis, not otherwise specified) must not be used to bill for 
any features or functions included in the socket or addition codes. Use of L5999 is incorrect coding 
(unbundling). You can find this information in Local Coverage Article Lower Limb Prostheses - Policy Article 
A52496. 
 
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 the 
requested intraoral - periapical each additional radiographic image (D0230) but is limited to one procedure 
code per calendar year. This benefit includes only those items and services specifically listed in your Plan 
contract. Core buildup, including any pins when required (D2950) and pontic - porcelain fused to high noble 
metal (D6240) are not covered under the Plan's dental benefit. This benefit includes an annual maximum of 
$2,000 for covered dental benefits. You can find this information on pages 84-87 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 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 following Part B suppliers are eligible to furnish diagnostic and therapeutic mental health 
services, perform diagnostic tests, and provide Behavioral Health Integration (BHI) and Screening, Brief 
Intervention and Referral to Treatment (SBIRT) services are permitted under state law: 
 
1. Physicians (Medical Doctors [MDs] and Doctors of Osteopathy [DOs]), particularly 
Psychiatrists 
2. Clinical Psychologists (CPs) 
3. Clinical Social Workers (CSWs) 
4. Clinical Nurse Specialists (CNSs) 
5. Nurse Practitioners (NPs) 
5. Physician Assistants (PAs) 
6. Certified Nurse Midwives (CNMs) 
7. Independently Practicing Psychologists (IPPs) 
8. Certified Registered Nurse Anesthetists (CRNAs) (supervision of diagnostic psychological and 
neuropsychological tests) 
 
You can find this rule in the Medicare Learning Network - Medicare Mental Health (MLN1986542, March 
2022). 
 
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 the Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. MUEs for codes with an MAI of 3 are per day edits based on clinical 
benchmarks. Codes with an MAI of 3 are based on criteria combined with data such that it would be 
possible, but medically unlikely, that higher values would represent correctly reported medically necessary 
services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, 
were correctly coded, and were medically necessary. 
 
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(V). 
 
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 page 36 of the Plan's 2022 
Evidence of Coverage (EOC).