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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of 
stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).   
 
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need 
medical care. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2. 
 
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 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 item or service but is limited to one D5213 and D5212 every five years. You can find this 
information on pages 104-107 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 facet Joint Interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL of the following criteria: 
 
Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured 
on pain or disability scale; AND 
Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive 
conservative care management (as tolerated); AND 
Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint 
synovial cyst); AND 
There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the 
patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
*Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the 
same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for 
functional assessment (if patient qualifies for treatment). 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Interventions 
for Pain Management (L34892). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 specific 
dental procedure codes included in a dental benefits chart. Retainer (D6548) is not listed as a covered dental 
benefit. You can find this information on pages 4-83 to 4-97 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 
preventive and comprehensive services. A porcelain/ceramic crown (D2740) is excluded from this benefit. You 
can find this information on pages 4-60 to 4-63 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 
D2955. You can find this information on pages 4-65 to 4-78 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 the 
requested item or service but is limited to one per Plan year. You can find this information on page 4-60 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 therapeutic continuous glucose monitors (CGMs) and related supplies are covered by 
Medicare when all of the following coverage criteria are met: 
  1. The beneficiary has diabetes mellitus, 
  2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a 
Medicare-covered continuous subcutaneous insulin infusion (CSII) pump, 
  3. The beneficiarys insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results, 
  4. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the 
beneficiary to evaluate their diabetes control and determined that criteria (1-3) above are met; and, 
  5. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
For claims with dates of service on or after July 1, 2017, through December 31, 2022, a non-adjunctive CGM 
must be billed with code K0554. For claims with dates of service on or after January 1, 2023, a non-adjunctive 
CGM must be billed with code E2103. Code E2103 or K0554 describes a non-adjunctive CGM that meets the 
requirements of the DME benefit. To be eligible for Medicare reimbursement, all CGM devices billed as 
E2103 must have received coding verification review by the Pricing, Data Analysis and Coding (PDAC) 
contractor and be listed on the Product Classification List (PCL) for HCPCS code E2103. You can find this 
information on the Local Coverage Article: Glucose Monitor - Policy Article (A52464). 
 
The rules say that a Freestyle Libre 3 is not specified as a product that may be billed using code E2103. You 
can find this information in the Product Classification List (PCL) on the Pricing Data Analysis, and Coding 
(PDAC) contractor web site. 
(https://www4.palmettogba.com/pdac_dmecs/searchProductClassificationResults.do?manufacturer=&codeDeci
sion=k0554&productName=&modelNumber=&classification=). 
 
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 accepted treatments for eliminating saphenous (great saphenous vein (GSV), anterior 
accessory GSV (AAGSV), small saphenous vein (SSV)) reflux (saphenofemoral or saphenopopliteal) are 
radiofrequency ablation (RFA), laser ablation (EVLA), polidocanol microfoam (PEM), cyanoacrylate 
embolization (CAE) ablation, and mechanochemical ablation (MOCA). Coverage is only for devices with FDA 
approval or clearance consistent with saphenous ablation and used according to its approved instructions for 
use (IFU). 
 
The treatments for symptomatic varicose tributaries are either compressive sclerotherapy or microphlebectomy. 
The treatments of the tributary veins will be considered medically necessary if saphenous reflux is not present 
or already successfully eliminated, the veins are greater than 4 mm in diameter and if the patient remains 
symptomatic after a six-week trial of conservative therapy.   
 
The conservative therapy must be documented in the medical record. Inability to tolerate compressive bandages 
or stockings and the reason for such intolerance must be documented in the medical record. 
 
The patient is considered symptomatic if any of the following signs and symptoms of significantly diseased 
vessels of the lower extremities are documented in the medical record: 
 stasis ulcer of the lower leg, 
 significant pain and significant edema that interferes with activities of daily living, 
 bleeding associated with the diseased vessels of the lower extremities, 
 recurrent episodes of superficial phlebitis, 
 stasis dermatitis, or 
 refractory dependent edema. 
Coverage of endovenous ablation therapy is limited to patients with:  
 a maximum vein diameter of 12 mm for CAE, PEM and MOCA; and 
 absence of thrombosis or vein tortuosity, which would impair catheter advancement (except for PEM). 
 
You can find this rule in the Local Coverage Determination for the Treatment of Varicose Veins of the Lower 
Extremity, L33575.  
 
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% coinsurance for Medicare Part B prescription drugs. You can find 
this information on pages 89-90 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 the practitioner ordering the Transcutaneous Electrical Nerve Stimulators (TENS) unit and 
related supplies must be the treating practitioner for the disease or condition justifying the need for the TENS 
unit. 
 
A TENS is covered for the treatment of beneficiaries with chronic, intractable pain or acute post-operative pain 
when one of the following coverage criteria, I or II, are met. 
I. Acute Post-operative Pain 
 
TENS is covered for acute post-operative pain. Coverage is limited to 30 days (one month's rental) from 
the day of surgery. Payment will be made only as a rental. 
 
A TENS unit will be denied as not reasonable and necessary for acute pain (less than three months 
duration) other than for post-operative pain. 
II. Chronic Pain Other than Low Back Pain 
 
TENS is covered for chronic, intractable pain other than chronic low back pain when all of the 
following criteria must be met: 
-The presumed etiology of the pain must be a type that is accepted as responding to TENS 
therapy. Examples of conditions for which TENS therapy is not considered to be reasonable and 
necessary are (not all-inclusive): 
-headache 
-visceral abdominal pain -pelvic pain 
-temporomandibular joint (TMJ) pain 
-The pain must have been present for at least three months. 
-Other appropriate treatment modalities must have been tried and failed. 
 
TENS therapy for chronic pain that does not meet these criteria will be denied as not reasonable and 
necessary. 
TENS therapy for Chronic Low Back Pain (CLBP) will be denied as not reasonable and necessary.  
 
General Requirements for chronic pain (II) 
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. 
 
You can find this information 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 say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. You can find this information 
on pages 62-65 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 only the 
items and services listed in the mandatory supplemental dental benefits chart. A crown (D2740) is not covered 
by the Plan's supplemental dental benefits. A periapical x-ray (D0220) is covered but is limited to one 
procedure per year. You can find this information on pages 85-87 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 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 $160 copayment per day for days 21-100 (per benefit period) for skilled 
nursing facility (SNF) care. You can find this information on page 113 of the Plan's 2022 Evidence of 
Coverage (EOC).