Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $100 copayment for outpatient hospital services. You can find this 
information on page(s) 94 and 95 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 also say that prolotherapy is not covered by Medicare. If prolotherapy is billed using trigger point 
therapy codes it will be considered not reasonable and necessary. You can find this rule in the Local Coverage 
Determination (LCD) for Trigger Point Injections (L37635). 
 
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 Implantable (or Insertable Loop) Recorder (ILR) is a type of pre-symptom Memory Loop 
Recorder (MLR) that is implanted subcutaneously in a patients upper left chest and may remain implanted for 
many months. An ILR is used when syncope is thought to be cardiac-related but is too infrequent to be detected 
by either a HolterTM monitor or a traditional pre-symptom MLR. You can find this information in the Centers 
for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-03, Medicare National 
Coverage Determinations (NCD) Manual, Section 20.15. 
 
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 beneficiaries covered for the first three months of an E0470 or an E0471 device must be re-
evaluated to establish the medical necessity of continued coverage by Medicare beyond the first three months. 
While the beneficiary may certainly need to be evaluated at earlier intervals after this therapy is initiated, the 
re-evaluation upon which Medicare will base a decision to continue coverage beyond this time must occur no 
sooner than 61 days after initiating therapy by the treating practitioner. Medicare will not continue coverage for 
the fourth and succeeding months of therapy until this re-evaluation has been completed. 
 
There must be documentation in the beneficiarys medical record about the progress of relevant symptoms and 
beneficiary usage of the device up to that time. Failure of the beneficiary to be consistently using the E0470 or 
E0471 device for an average of 4 hours per 24 hour period by the time of the re-evaluation (on or after 61 days 
after initiation of therapy) would represent non-compliant utilization for the intended purposes and expectations 
of benefit of this therapy. This would constitute reason for Medicare to deny continued coverage as not 
reasonable and necessary. 
 
A signed and dated statement completed by the treating practitioner no sooner than 61 days after initiating use 
of the device, declaring that the beneficiary is compliantly using the device (an average of 4 hours per 24 hour 
period) and that the beneficiary is benefiting from its use must be obtained by the supplier of the device for 
continued coverage beyond three months. 
 
If the above criteria are not met, continued coverage of an E0470 or an E0471 device and related accessories 
will be denied as not reasonable and necessary. 
 
Yon can find these rules in the Local Coverage Determination (LCD) for Respiratory Assist Devices, L33800. 
 
The rules say that a bi-level positive airway pressure device with back-up rate (E0471) is not reasonable and 
necessary if the primary diagnosis is OSA. If an E0471 is billed with a diagnosis of OSA, it will be denied as 
not reasonable and necessary.  
Yon can find this rule in the Local Coverage Determination (LCD) for Positive Airway Pressure (PAP) 
Devices for the Treatment of Obstructive Sleep Apnea, L33718. 
 
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 Home Health Resource Group (HHRG) used to pay home health services billed on type 
of bill (TOB) 032x are determined by the HH Grouper program. HHRGs are represented on claims in the form 
of Health Insurance Prospective Payment System (HIPPS) codes. The home health (HH) Grouper is a module 
within Medicare claims processing systems. The home health agency sends a HIPPS code on the claim, using 
revenue code 0023. Medicare systems combine claim data and Outcome and Assessment Information Set 
(OASIS) data and send the data to the HH Grouper to determine the HIPPS code used for payment. You can 
find this information in the Centers for Medicare and Medicaid Services, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 10, Section 80. 
 
The rules say that the patients primary diagnosis is defined as the chief reason the patient is receiving home 
care and the diagnosis most related to the current home health Plan of Care. The primary diagnosis may or may 
not relate to the patients most recent hospital stay but must relate to the skilled services (skilled nursing, 
physical therapy, occupational therapy, and speech language pathology) rendered by the home health agency 
(HHA). You can find this information in the OASIS-D Guidance Manual. 
 
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 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 a Medicare plan may restrict enrollees to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the plan must 
arrange for and cover any medically necessary covered benefit outside of the plan provider network, but at in-
network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollees 
medical needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community-based 
services. You can find this rule at 42 CFR Section 422.112. 
 
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 31 to 32 of the Plan's 
2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that for a diagnosis of obstructive sleep apnea (OSA) to be made, the following criteria must be 
met:  
 
Prior to sleep testing, the patient has a face-to-face clinical evaluation by the treating physician to assess the 
patient for OSA which must include, at a minimum, the following: 
 
    - Sleep history and symptoms including, but not limited to, snoring, daytime sleepiness, observed apneas, 
choking or gasping during sleep, morning headaches; and, 
    - Epworth Sleepiness Scale; and, 
    - Physical examination that documents body mass index, neck circumference and a focused cardiopulmonary 
and upper airway system evaluation. 
 
You can find this information in the Local Coverage Determination (LCD) for Polysomnography and Sleep 
Testing (L33405). 
 
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 pages 67 and 68 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that diagnostic services (including clinical diagnostic laboratory tests) provided to a beneficiary 
by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by 
another entity under arrangements with the admitting hospital), within 3 days prior to and including the date of 
the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment, unless 
there is no Part A coverage. This provision does not apply to ambulance services and maintenance renal 
dialysis services (see the Medicare Benefit Policy Manual, Chapters 10 and 11, respectively). Additionally, 
Part A services furnished by skilled nursing facilities, home health agencies, and hospices are excluded from 
the payment window provisions. 
 
For outpatient nondiagnostic services furnished on or after June 25, 2010, all outpatient nondiagnostic services, 
other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly 
owned or wholly operated by the hospital) on the date of a beneficiary's inpatient admission are deemed related 
to the admission, and thus, must be billed with the inpatient stay. Also, outpatient nondiagnostic services, other 
than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or 
wholly operated by the hospital) on the first, second, and third calendar days for a subsection (d) hospital paid 
under the IPPS (first calendar day for non-subsection (d) hospitals) preceding the date of a beneficiary's 
inpatient admission are deemed related to the admission, and thus, must be billed with the inpatient stay, unless 
the hospital attests to specific nondiagnostic services as being unrelated to the hospital claim (that is, the 
preadmission nondiagnostic services are clinically distinct or independent from the reason for the beneficiary's 
admission) by adding a condition code 51 (definition "51 - Attestation of Unrelated Outpatient Non-diagnostic 
Services") to the separately billed outpatient non-diagnostic services claim. Beginning on or after April 1, 
2011, providers may submit outpatient claims with condition code 51 for outpatient claims that have a date of 
service on or after June 25, 2010. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet-Only Manual, Publication 100-104, Chapter 3, Section 40.3. 
 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.
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 
intraoral x-rays but is limited to one procedure code per plan year. You can find this information on pages 86-
89 and 93-96 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the requested item or service but is limited to only 1 of any (D4341-D4342) per quadrant every 24 months. You can find this information on page 10 of the Plan's 2023 Dental Benefits Details document.
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 services that are listed on the dental 
benefit chart. The full mouth debridement is not covered by the Plan's dental benefits. You can find this 
information on pages 77 to 80 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 
coverage for specific dental items/services stated in the Plans contract. The unspecified endodontic procedure, 
by report (D3999) is not covered. You can find this information in the 2023 Medicare quick reference guide.
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 specific dental items/services stated in the Plans contract. The treatment of a root canal 
obstruction; non-surgical access (D3331) is not covered. You can find this information on the 2023 List of 
Covered Dental codes.