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 follow-up polysomnography (PSG) or home sleep study (HST) is not routinely indicated for 
patients treated with continuous positive airway pressure (CPAP), whose symptoms continue to be resolved 
with CPAP treatment. Follow-up PSG may be indicated; however, under the following circumstances: 
 
- After substantial weight loss has occurred in patients on CPAP for treatment of sleep-related breathing 
disorders to ascertain whether CPAP is still needed at the previously titrated pressure; 
- After substantial weight gain has occurred in patients previously treated with CPAP successfully, who are 
again symptomatic despite the continued use of CPAP, to ascertain whether pressure adjustments are needed; 
or 
- When clinical response is insufficient or when symptoms return despite a good initial response to treatment 
with CPAP. 
 
You can find this information in the Local Coverage Determination (LCD) for Polysomnography (L36593). 
 
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 102 of the Plans 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 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 
contract says hearing aids ordered through providers other than the Plan Hearing are not covered. You 
can find this information on pages 4-27 to 4-28 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 state that Nerve blocks cause the temporary interruption of conduction of impulses in peripheral 
nerves or nerve trunks by the injection of local anesthetic solutions. Their utility in the diagnosis and treatment 
of non-neuropathic pain and specific syndromes mediated by sympathetic nervous system overactivity has been 
established. 
- Diagnostic - to determine the source of pain e.g., to identify or pinpoint a nerve that acts as a pathway 
for pain; to determine the type of nerve that conducts the pain; to distinguish between pain that is 
central (within the brain and spinal cord) or peripheral (outside the brain and spinal cord) in origin; or to 
determine whether a neurolytic block or surgical lysis of the nerve should be performed. The type of 
diagnostic test may include injecting saline to stimulate pain or injecting an anesthetic agent to evaluate 
the patient's response, as an initial diagnostic step so that other pain relief options may be considered. 
- Therapeutic - to treat painful conditions that respond to nerve blocks (e.g., celiac block for pain of 
pancreatic cancer) and /or inappropriate sympathetic nervous system activity. An appropriate 
injection of local anesthetic induces a temporary interruption in the conduction of impulses by 
peripheral nerves or nerve trunks. Longer-lasting or permanent blockade may be induced with the 
injection of neurolytic agents and/or application of thermal (not pulsed) radiofrequency. When blockade 
has been of value in the relief of acute or chronic cancer related pain, somatic or epidural blockade may 
be maintained through the infusion of local anesthetics via indwelling catheter. 
 
Prior to blockade, all patients with pain complaints require an evaluation that includes, at a minimum, an 
assessment of the source of the pain and treatment of any underlying pathology. Evaluation must be 
documented in the patients records. In addition, those patients who do not respond to injections or otherwise 
continue with persistent or poorly responsive pain should be referred for a multi-disciplinary or other 
collaborative comprehensive evaluation. You can find these rules in Local Coverage Determination (LCD) 
Nerve Blockade for Treatment of Chronic Pain and Neuropathy (L35457). 
 
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 a Medicare plan may restrict members 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 of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
The rules say that Psychological and Neuropsychological testing is considered not reasonable and necessary 
when: 
1. The patient is not neurologically and cognitively able to participate in a meaningful way in the testing 
process, or  
2. Used as screening tests given to the individual or to general populations [Section 1862(a)(7) of the 
Social Security Act does not extend coverage to screening procedures], or  
3. Administered for educational or vocational purposes that do not establish medical management, or  
4. Performed when abnormalities of brain function are not suspected, or  
5. Used for self-administered or self-scored inventories, or screening tests of cognitive function (whether 
paper-and-pencil or computerized), e.g., AIMS, Folstein Mini-Mental Status Examination, or  
6. Repeated when not required for medical decision-making (i.e., making a diagnosis or deciding whether 
to start or continue a particular rehabilitative or pharmacologic therapy), or  
7. Administered when the patient has a substance abuse background and any of the following apply:  
a. the patient has ongoing substance abuse such that test results would be inaccurate, or 
b. the patient is currently intoxicated, or 
8. The patient has been diagnosed previously with brain dysfunction, such as Alzheimers diseases and 
there is no expectation that the testing would impact the patient's medical management, or  
9. The test is administered solely as a screening test for Alzheimer's disease - Medicare does not cover 
screening for this diagnosis. You can find this rule in Local Coverage Determination (LCD) Psychological and Neuropsychological Testing 
L34646. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 36 of the Plan's 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 
preventive and comprehensive dental services. Crowns and core buildup are covered by the Plan's dental 
benefits. You can find this information on pages 76 to 77 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 Medicare rules say that repeat epidural steroid injections (ESI) when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using the same scale for at least three months. If a patient 
fails to respond well to the initial ESI, a repeat ESI after 14 days can be performed, using a different approach, 
level and/or medication if appropriate, with the rationale and medical necessity for the second ESI documented 
in the medical record. You can find this information in the Local Coverage Determination (LCD) L39036: 
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 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 these 
services. However, prior authorization is needed. You can find this information on pages 54-55 and 90-102 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 the treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are > than 4 mm in diameter and if the patient 
remains symptomatic after a six-week trial of conservative therapy. 
 
The rules say that 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. 
  
You can find this information at Local Coverage Determination (LCD):Varicose Veins of the Lower Extremity, 
Treatment of (L33525). 
 
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 costs of certain end-stage renal disease (ESRD) services and supplies performed by either the ESRD 
facility or an independent laboratory are included in the composite rate and are not separately payable. These 
tests are either performed by the facility, in which case payment is included in the composite rate, or by an 
outside laboratory for the facility, in which case the laboratory bills the facility directly. The ESRD prospective 
payment system (PPS) will provide a single payment to ESRD facilities, i.e., hospital-based providers of 
services and renal dialysis facilities, that will cover all the resources used in providing an outpatient dialysis 
treatment, including supplies and equipment used to administer dialysis in the ESRD facility or at a patient's 
home, drugs, biologicals, laboratory tests, training, and support services. You can find this rule in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
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 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 procedures included in a dental benefits chart. D0330, D0350 and D1330 are not among the services 
covered by the Plans dental benefit. You can find this information on pages 57-58 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 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 lateral positioning items are used to provide lateral thigh or knee support (E0953) or lateral 
trunk or hip support (E0956). These are provided in a variety of shapes and sizes to suit the needs of the user. 
You can find this information in the Local Coverage Article for Wheelchair Seating  Policy Article (A52505). 
 
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 
in Chapter 4 on pages 55-56 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 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. 
 
The rules say that thermal destruction of the intraosseous BVN will be considered medically reasonable and 
necessary for the treatment of cLBP in patients who meet ALL the following criteria: 
1. Chronic lumbar back pain of 6 months duration that causes functional deficit measured on a pain or 
disability scale, AND 
2. Documented failure to respond to 6 months of non-surgical management, AND 
3. Absence of non-vertebrogenic 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, AND 
4. Evidence of Type 1 or Type 2 Modic changes on MRI, such as inflammation, edema, vertebral endplate 
changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent 
marrow, hypotensive signals (Type 1 Modic change), and changes to the vertebral body marrow 
including replacement of normal bone marrow by fat, and hypertensive signals (Type 2 Modic change), 
in 1 or more vertebrae from L3-S1. 
Local Coverage Determination (LCD): Thermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain (L39420). 
 
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 procuring an organ is not a covered service when performed independent of a Medicare 
covered transplant, however, the reasonable costs to procure an organ are reimbursable when billed in 
connection with a Medicare covered transplant. You can find this rule in 42 CFR 413.404. 
 
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.