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 molecular diagnostic tests used to assist in risk stratification of melanoma patients are 
covered when all of the following are true: 
1. The patient has a personal history of melanoma and: 
- Either has Stage T1b and above or has T1a with documented concern about adequacy of microstaging 
- Is undergoing workup or being evaluated for treatment, and 
- Does not have metastatic disease and 
- Presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, histological, or other 
information is >5% and 
- Has a disease stage, grade, and Breslow thickness (or other qualifying conditions) within the intended use of 
the test 
2. The test has demonstrated, as part of a Technical Assessment: 
- Clinical validity of analytes tested in predicting metastatic disease (or the absence of metastatic disease) in 
peer-reviewed scientific literature 
- Utility beyond clinical, histological, and radiographical factors in the ability to accurately stratify patients into 
risk groups to manage patient care, such by precluding unnecessary sentinel lymph node biopsies 
- Appropriate analytical validity 
- Performance characteristics equivalent or superior to other covered, similar tests 
 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD): MolDX: Melanoma Risk Stratification Molecular Testing (L37748). 
 
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 73 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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
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 also says that the Plan covers Frames  1 set of frames every calendar year. Lenses  1 set every 
calendar year includes basic single vision, lined bifocal, lined trifocal and lenticular lenses only (additional 
upgrades, extra charges and/or any customizations are not covered, e.g. tintings, coatings and/or special lens 
materials). You can find this information on page 106 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 for each Medicare-covered hospital stay, enrollees must pay a $310 copayment per day for 
days 1 to 6; $0 copayment per day for days 7 to 90. You can find this information in Chapter 4 on page 50 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 molecular diagnostic tests used to assist in risk stratification of melanoma patients are 
covered when all of the following are true: 
1. The patient has a personal history of melanoma and: 
- Either has Stage T1b and above or has T1a with documented concern about adequacy of microstaging 
- Is undergoing workup or being evaluated for treatment, and 
- Does not have metastatic disease and 
- Presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, histological, or other 
information is >5% and 
- Has a disease stage, grade, and Breslow thickness (or other qualifying conditions) within the intended use of 
the test 
2. The test has demonstrated, as part of a Technical Assessment: 
- Clinical validity of analytes tested in predicting metastatic disease (or the absence of metastatic disease) in 
peer-reviewed scientific literature 
- Utility beyond clinical, histological, and radiographical factors in the ability to accurately stratify patients into 
risk groups to manage patient care, such by precluding unnecessary sentinel lymph node biopsies 
- Appropriate analytical validity 
- Performance characteristics equivalent or superior to other covered, similar tests 
 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD): MolDX: Melanoma Risk Stratification Molecular Testing (L37748). 
 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 $75 copayment per day, days 1 to 4 for inpatient hospital care. The Plan 
contract also says that enrollees must pay a $100 copayment per day, days 21 to 100 for a skilled nursing 
facility. You can find this information on pages 66 to 67 and 80 of the Plan's 2022 Evidence of Coverage 
(EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 sent 
you a document called the Limited Hearing Services Rider which indicates that there is some coverage for 
hearing aids not listed in your contract. This document indicates that you are entitled to up to $600 every 36 
months toward the purchase of hearing aids.
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 in general, noninvasive studies of the arterial system are to be utilized when invasive 
correction is contemplated, or severity of findings dictates noninvasive study follow up. The latter may also be 
  
  followed with physical findings and/or progression or relief of signs and/or symptoms. It can be useful in pre-
operative evaluation of patients with known arteriosclerotic diseases who will be undergoing surgeries which 
put them at high risk for vascular complications (i.e. CABG, cranial surgeries etc.). It can be used for 
surveillance to ensure graft patency post-operatively. 
 
Non-invasive peripheral arterial studies performed to establish the level and/or degree of arterial occlusive 
disease are considered medically necessary if: 
 
    Signs and/or symptoms of possible limb ischemia are present; and 
    The patient can be medically managed or is a candidate for percutaneous, surgical, diagnostic, or therapeutic 
procedures. 
 
Acute ischemia is characterized by the sudden onset of severe pain, coldness, numbness, and pallor of the 
extremity. Chronic ischemia or critical limb ischemia can have intermittent claudication, pain at rest, 
diminished pulse, ulceration, and gangrene. 
 
Local Coverage Determination (LCD) Non-Invasive Peripheral Arterial Vascular Studies L35761. 
 
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. 
 
Medicare rules list addition codes which describe components or features that can be physically incorporated in 
the specified prefabricated bases orthosis but are considered to be included in the allowance for the orthosis. 
Codes on this list are not separately payable. This information can be found in Local Coverage Article: Knee 
Orthoses - Policy Article (A52465). 
 
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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. 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. 
 
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 routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 48 one-way ground transportation trips each year. trips must be to or from plan-approved locations 
and each one-way trip must not exceed 50 miles of driving distance. You can find this information on pages 4-
59 to 4-60 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 state that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing 
levels within a Part D sponsor's formulary. You can find this rule in 42 CFR 423.4. 
 
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 pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1.  
 
The rules also say that telephone alert systems will be denied because these are emergency communications 
systems and do not serve a diagnostic or therapeutic purpose. You can find this rule in National Coverage 
Determination (NCD): Durable Medical Equipment Reference List (280.1). 
 
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. 
 
Medicare rules state that the implantation of spinal cord stimulators (SCS) may be covered as therapies for the 
relief of chronic intractable pain. SCS is best suited for neuropathic pain but may have some limited value in 
other types of nociceptive severe, intractable pain. Therapy consists of a short trial with a percutaneous 
implantation of neurostimulator electrode(s) in the epidural space for assessing a patients suitability for 
ongoing treatment with a permanent surgically implanted nerve stimulator. Performance and documentation of 
an effective trial is a prerequisite for permanent nerve stimulation. In situations where the spinal cord 
stimulator has been working well but is in need of replacement for battery change, malfunction or end of 
stimulator life, a new trial is not needed to replace the stimulator. 
 
Selection of patients for implantation of spinal cord stimulators is critical to success of this therapy. SCS 
therapy should be considered as a late option after more conservative attempts such as medications, physical 
therapy, psychological therapy or other modalities have been tried. This rule is found in Local Coverage 
Determination (LCD): Spinal Cord Stimulators for Chronic Pain (L36204). 
 
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 $40 copayment for a wound visit performed at an outpatient hospital 
facility. You can find this information on page 78 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 although presbyobia-correcting (P-C) IOLs may serve the same function as eyeglasses or 
contact lenses furnished following cataract surgery, IOLs are neither eyeglasses nor contact lenses. Therefore, 
the presbyopia-correcting functionality of an IOL does not fall into the benefit category and is not covered. 
You can find this rule in the CMS Ruling, No. CMS-05-01 Presbyobia-Correcting IOLs, May 3, 2005. 
 
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 an electrical bone growth stimulator is covered only for the following indications: 
1. Nonunion of long bone fractures;  
2. Failed fusion, where a minimum of 9 months has elapsed since the last surgery;  
3. Congenital pseudarthroses.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 150.2. 
 
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 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 outpatient diagnostic tests. You can find this 
information on pages 23-24 of the Plan's 2022 Evidence of Coverage (EOC).