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 if payment for a drug could be available under Part A or Part B to the individual for such 
drug, then it will not be covered under Part D. You can find this rule in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual, Publication 100-18, Medicare Prescription Drug Benefit Manual, 
Chapter 6, Section 20.2. 
 
The rules say that if a plan utilizes a tiered cost-sharing structure to manage its Part D drug benefits, it must 
establish and maintain reasonable and complete exceptions procedures that permit enrollees to obtain a non-
preferred drug in a higher cost-sharing tier at the more favorable cost-sharing terms applicable to drugs in a 
lower cost-sharing tier. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), 
Internet-Only Manual, Publication 100-18, Medicare Prescription Drug Benefit Manual, Chapter 18, Section 
30.2.1. 
 
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 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 Plan 
contract includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. Treatment simulation using 3D image volume (D0393), surgical placement 
of implant body: endosteal implant (D6010), prefabricated abutment (D6056), and sinus augmentation (D7952) 
are not included on this list and are not covered supplemental benefits. You can find this information on pages 
116 to 129 of the Plan's 2021 Evidence of Coverage (EOC), and on pages 118 to 130 of the Plans 2022 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 specific 
dental services/items stated in the Plans contract. Any service not listed is not covered. The removal of an 
impacted tooth-completely bony (D7240) is not covered. You can find this information on pages 4-58 to 4-71 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 34 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 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 under some circumstances, medical visits on the same date as a procedure result in additional 
payments. Modifier 25 reported with an Evaluation and Management (E&M) code, status indicator V, is used 
to report a medical visit that takes place on the same date that a procedure with status indicator S or T is 
performed, but that is significant and separately identifiable from the procedure. However, if any E&M code 
that occurs on a day with a type T or S procedure does not have a modifier of 25, then edit 21 applies and 
the claim is returned to the provider. You can find this rule in the Integrated OCE Centers for Medicare and 
Medicaid Services (CMS) Specifications, Volume 23.0, Section 5.1.1. 
 
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 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.   
 
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). 
 
The rules say that MUEs for HCPCS codes with an MAI of 3 are date of service edits. These are per day edits 
based on clinical benchmarks. If claim denials based on these edits are appealed, MACs may pay UOS in excess of 
the MUE value if there is adequate documentation of medical necessity of correctly reported units. If MACs have 
pre-payment evidence (e.g. medical review) that UOS in excess of the MUE value were actually provided, were 
correctly coded, and were medically necessary, the MACs may bypass the MUE for a HCPCS code with an MAI of 
3 during claim processing, reopening, or redetermination, or in response to effectuation instructions from a 
reconsideration or higher level appeal. 
 
You can find these rules in the Medicare Claims Processing Manual Chapter 23, Section 20.9.3.2- Medically 
Unlikely Edits (MUEs) 
 
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 38 of the Plan's 2022 
Evidence of Coverage.  
 
The Plan contract also states that you are responsible for paying the full cost of services that are not covered by 
the Plan, either because they are not plan covered services, or they are obtained out-of-network and were not 
authorized. You can find this information on page 42 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 a Medicare plan may not pay for services given by a physician or other practitioner who has 
opted out of Medicare. This rule does not apply to emergency or urgently needed services. A Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 6, Section 60.2. 
 
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 while enrollees can get care from an out-of-network provider, the provider must be eligible to 
participate in Medicare. Except for emergency care, the Plan cannot pay a provider who is not eligible to 
participate in Medicare. You can find this information on pages 48 to 49 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 high frequency chest wall oscillation devices (HFCWODs) are covered when they are 
medically necessary for enrollees who have: 
 cystic fibrosis; or 
 bronchiectasis that has been confirmed by CT scan; or  
 one of these neuromuscular diseases: post-polio, acid maltase deficiency, anterior horn cell diseases, 
multiple sclerosis, quadriplegia, hereditary muscular dystrophy, myotonic disorders, other myopathies, or 
paralysis of the diaphragm.  
 
Medical records must show failure of standard treatments to clear secretions. The rules also say that chronic 
bronchitis and chronic obstructive pulmonary disease (COPD) do not meet criteria for coverage when there is 
no diagnosis of bronchiectasis.  
 
You can find these rules in the Medicare Local Coverage Determination (LCD) L33785, High Frequency Chest 
Wall Oscillation Devices.  
 
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 Medicare approved amount for these procedures includes payment for the following 
services related to the surgery when furnished by the physician who performs the surgery. 
 
   - Preoperative Visits 
   - Intra-operative Services 
   - Complications Following Surgery 
   - Postoperative Visits 
   - Postsurgical Pain Management 
   - Supplies 
   - Miscellaneous Services 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Claims Processing Manual, Chapter 12, Section 40.1. 
 
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 that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say that all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patients medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patients 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
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 primary indication of a diagnostic facet joint procedure is to diagnose whether the 
patient has facet syndrome. Intraarticular (IA) facet block(s) are considered reasonable and necessary as a 
diagnostic test only if medial branch blocks (MMB) cannot be performed due to specific documented anatomic 
restrictions or there is an indication to proceed with therapeutic intraarticular injections. These restrictions must 
be clearly documented in the medical record and made available upon request. 
 
Diagnostic procedures should be performed with the intent that if successful, radiofrequency ablation (RFA) 
procedure would be considered the primary treatment goal at the diagnosed level(s). 
 
A second diagnostic facet procedure is considered medically necessary to confirm validity of the initial 
diagnostic facet procedure when administered at the same level. The second diagnostic procedure may only be 
performed a minimum of 2 weeks after the initial diagnostic procedure. Clinical circumstances that necessitate 
an exception to the two-week duration may be considered on an individual basis and must be clearly 
documented in the medical record. For the first diagnostic facet joint procedure:  
 
a.  For the first diagnostic facet joint procedure to be considered medically reasonable and necessary, the 
patient must meet the criteria outlined under indications for facet joint interventions. 
b. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and 
necessary in patients who meet ALL the following criteria: 
i.  The patient meets the criteria for the first diagnostic procedure; AND 
ii.  After the first diagnostic facet joint procedure, there must be a consistent positive response of 
at least 80% relief of primary (index) pain (with the duration of relief being consistent with the 
agent used)  
 
Frequency limitation: For each covered spinal region no more than four (4) diagnostic joint sessions will be 
reimbursed per rolling 12 months, in recognition that the pain generator cannot always be identified with the 
initial and confirmatory diagnostic procedure. You can find this rule in the Local Coverage Determination 
(LCD) - L38765, Epidural Steroid Injections for Pain Management. 
 
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 Medicare guidelines say that the route of administration must be reasonable and necessary 
as well as the drug. (Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.2 - Determining 
Self-Administration of Drug or Biological (Rev. 91; Issued: 06-20-08; Effective/Implementation  
Date: 07-21-08)). National Government Services will use evidence-based clinical guidelines to determine 
medical necessity. 
 
The following drugs will be covered for their FDA approved uses as well as their approved compendia uses. 
 
Bevacizumab and biosimilars 
 
Bortezomib  
 
Denosumab (Prolia TM, Xgeva TM) 
 
Filgrastim, Pegfilgrastim, Tbo-filgrastim and biosimilars 
 
Hyaluronans Intra-articular Injections of 
 
Nivolumab 
 
Omalizumab  
 
Ranibizumab and Aflibercept  
 
You can find this rule in the Local Coverage Determination (LCD) - L33394, Drugs and Biologicals, Coverage 
of, for Label and Off-Label Use.  
 
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 Plan 
contract says that you are responsible for a $35 copayment for a specialist's office visit. You can find this 
information on page 89 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 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 $184 copayment for each day for days 21 to 57 of Skilled Nursing 
Facility (SNF) Care. You can find this information in Chapter 4 on pages 4-48 to 4-49 of the Plan's 2021 
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. 
 
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 Plan 
contract says that refraction is only covered when billed as part of the routine eye exam. You can find this 
information on page 87 of the Plan's 2022 Evidence of Coverage.