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 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 68-69 in 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 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 pay a $0 copayment for each Medicare-covered eye exam. You can find this
information on page 4-54 of the Plan's 2022 Evidence of Coverage (EOC).

The Plan contract says that enrollees must pay a $25 copayment for Medicare-covered non-radiological
diagnostic services. You can find this information on page 4-33 of the Plan's 2022 Evidence of Coverage
(EOC).

The Plan contract says that enrollees must pay a 20% coinsurance for all other Medicare-covered Part B drugs.
You can find this information on page 4-28 of the Plan's 2022 Evidence of Coverage (EOC).
The Plan contract also says that enrollees must pay a $50 copayment for Medicare-covered surgery or other
services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility
charges and physician or surgical charges. You can find this information on page 4-39 of the Plan's 2022
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that the use of nerve blocks with or without the use of electrostimulation, and the use of
electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by
underlying systemic diseases is not considered medically reasonable and necessary. Medical management using
systemic medications is clinically indicated for the treatment of these conditions.

At present, the literature and scientific evidence supporting the use of peripheral nerve blocks with or without
the use of electrostimulation, and the use of electrostimulation alone for neuropathies or peripheral
neuropathies caused by underlying systemic diseases, is insufficient to warrant coverage. These procedures are
considered investigational and are not eligible for coverage for the treatment of neuropathies or peripheral
neuropathies caused by underlying systemic diseases. You can find this in the Local Coverage Determination
(LCD): Nerve Blocks and Electrostimulation for Peripheral Neuropathy (L37642).

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 certain dental services as a supplemental (extra) benefit. This
benefit includes coverage for specific dental items/services stated in the Plan's contract. You can find this
information on pages 60 and 96-102 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 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 certain dental services as a supplemental (extra) benefit. The Plan
contract says that a complete mandibular (lower) denture and complete maxillary (upper) denture are each
covered once per 60 months. You can find this information on page 107 of the 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 state that to report a circulating tumor cell (CTC) service, submit the following claim information: 
- Code 81479 
- 1 unit of service 
- The appropriate DEX Z-Code identifier adjacent to the procedure code in the comment/narrative field 
- The appropriate diagnosis code 
 
You can find this rule in Local Coverage Article (LCA) Billing and Coding: MolDX: Phenotypic Biomarker 
Detection from Circulating Tumor Cells (A58183). 
 
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. The Plan has a Point-of-Service (POS) option for certain 
services. Most services obtained from out-of-network providers require prior authorization and are subject to a 
$500 deductible and 50% coinsurance. You can find this information on page 32 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.

Medicare does not pay for acupuncture as an anesthetic, as an analgesic, or for other therapeutic purposes. You
can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
03, Medicare National Coverage Determinations Manual, Chapter 1, Sections 30.3, 30.3.1, and 30.3.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract provides supplemental coverage for a wellness allowance benefit. The Plan reimburses you
up to $150 per calendar year towards your cost for membership in a qualified health club or fitness facility,
covered instructional fitness classes, participation in wellness programs such as Matter of Balance, Chronic
Disease self-management, diabetes workshop, Healthy Eating for Successful Living, Healthy IDEAS, Powerful
Tools for Caregivers, Arthritis Foundation Exercise, Enhance Wellness, Fit For Your Life, AAA Senior
Driving, memory fitness activities, acupuncture, and/or covered nutritional counseling sessions with a licensed
nutritional counselor or registered dietician. You pay all charges over $150 per calendar year. Sales tax is not
eligible for reimbursement. You can find this information on pages 73-74 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 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 effective for claims with dates of service on and after December 23, 2009, the Centers for 
Medicare and Medicaid Services (CMS) determines that the evidence is adequate to conclude that OIVIT does 
not improve health outcomes in Medicare beneficiaries. Therefore, CMS determines that OIVIT is not 
reasonable and necessary for any indication under section 1862(a)(1)(A) of the Social Security Act. Services 
comprising of an OIVIT regimen are nationally non-covered under Medicare when furnished pursuant to an 
OIVIT regimen. You can find this rule in the Centers for Medicare and Medicaid Service, Internet-Only 
Manual, Publication 100-03, National Coverage Determination (NCD) - Outpatient Intravenous Insulin 
Treatment (40.7). 
 
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 a pneumatic compression device (PCD) coded as E0650 or E0651 is covered for both
primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when all of the
following three requirements are met:

1. The beneficiary has a diagnosis of lymphedema as defined above, and
2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented
presence of at least one of the following clinical findings:
-Marked hyperkeratosis with hyperplasia and hyperpigmentation,
-Papillomatosis cutis lymphostatica,
-Deformity of elephantiasis,
-Skin breakdown with persisting lymphorrhea,
-Detailed measurements over time confirming the persistence of the lymphedema with a history
evidencing a likely etiology, and
3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to
other clinical treatment over the course of a required four-week trial.

A segmented, calibrated gradient pneumatic compression device (E0652) is only covered when the individual
has unique characteristics which prevent them from receiving adequate satisfactory pneumatic compression
treatment using a nonsegmented device along with a segmented appliance or compression device without
manual control of the pressure in each chamber.

A PCD coded as E0652, is covered for the treatment of lymphedema extending onto the chest, trunk and/or
abdomen when all of the following are met:
-The beneficiary has lymphedema of an extremity as defined above
-The coverage criteria for an E0650 or E0651 are met
-The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the
limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed
to improve with a four-week trial. (See below for trial guidelines.)

A PCD coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen that does not
meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable
and necessary.

PCD related accessories (E0667) are eligible for reimbursement only when the appropriate, related base PCDs
meets the applicable coverage criteria for that type of PCD. If the base PCD is not covered, related accessories
are not eligible for reimbursement. Claims for related items will be denied as not reasonable and necessary.
You can find this information in the Local Coverage Determination (LCD): Pneumatic Compression Devices
(L33829).

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). 
 
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 28 of the Plan's 2023 
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 you are allowed up to $200 combined every year towards the cost of supplemental contact lenses, 
eyeglasses (lenses and frames), and upgrades when rendered by an in-network provider. You can find this 
information on page 107 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 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 $35 copayment for specialist physician/practitioner services.  You can 
find this information on page(s) 73-74 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 say that if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
The rules say that screening services such as pre-symptomatic genetic tests and services used to detect an 
undiagnosed disease or disease predisposition are not a Medicare benefit and are not covered. You can find this 
rule in Local Coverage Article Billing and Coding: Molecular Pathology and Genetic Testing A58917. 
 
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 out-of-network annual wellness visit at a primary
care physician (PCP)'s office. You can find this information on page 60 of the Plan's 2022 Evidence of
Coverage (EOC).