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 providers/suppliers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).
The rules say that for bone mass measurements to be covered, a beneficiary must meet at least one of the five conditions listed below: 1. A woman who has been determined by the physician or qualified nonphysician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings. NOTE: Since not every woman who has been prescribed estrogen replacement therapy (ERT) may be receiving an "adequate" dose of the therapy, the fact that a woman is receiving ERT should not preclude her treating physician or other qualified treating nonphysician practitioner from ordering a bone mass measurement for her. If a BMM is ordered for a woman following a careful evaluation of her medical need, however, it is expected that the ordering treating physician (or other qualified treating nonphysician practitioner) will document in her medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis. 2. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture. 3. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months. 4. An individual with primary hyperparathyroidism. 5. An individual being monitored to assess the response to or efficacy of an FDA [1] approved osteoporosis drug therapy. The Medicare Benefit Policy Manual, Chapter 15, Section 80.5.6
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 providers/suppliers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).
The rules say that the applicable payments made under the prospective payment systems are payment in full for all facility or hospital services, as defined in 42 CFR Section 409.10. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements (as defined in 42 CFR Section (409.3). You can see this in 42 CFR Section 412.50 "Furnishing of inpatient hospital services directly or under arrangements."
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 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 says that you are responsible for a $0 copay for a fitting and evaluation from an in-network provider. The Plan contract also says you must use the Plan's approved hearing aid vendor to receive hearing aid benefits. You can find this information on page 73 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 for services performed on or after January 21, 2020, Medicare will now provide limited coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may be provided by a physician in accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 30.3.3.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan offers additional coverage for acupuncture beyond what is covered by Medicare. This benefit is combined with the additional chiropractic services and limited to 18 combined visits every calendar year. You can see this on page 59 of the Plans 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that reduction mammaplasty will be considered medically reasonable and necessary when 
performed: 
To reduce the size of the breasts and help ameliorate symptoms caused by hypertrophy when: 
The surgeon's estimate of breast size/weight/volume to be removed is proportional to the body surface area 
(BSA) per the Schnur scale per breast to relieve symptoms. 
There are signs or symptoms resulting from the enlarged breasts (macromastia) that have not responded 
adequately to non-surgical interventions. 
Symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, 
persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast. 
Dermatologic signs or symptoms are refractory to or recurrent following a completed course of medical 
management. 
Intertriginous maceration, discoloration, chronic or recurrent infection of the inframammary skin refractory to 
dermatologic treatment measures. 
There is back pain from macromastia, unrelieved by: 
Conservative analgesia. 
Supportive measures (custom garment, etc.). 
Physical therapy. 
There is shoulder grooving to a depth greater than 1 cm with skin irritation or darkening by supporting garment 
(bra strap). 
There are optimally managed significant arthritic changes in the cervical or upper thoracic spine, with 
persistent symptoms or significant restriction of activity. 
The macromastia is not due to an active endocrine, pharmaceutical or metabolic process. 
      OR 
 
To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery. 
Note: either the involved breast or contralateral breast may be treated to achieve symmetry. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Cosmetic and 
Reconstructive Surgery (L35090).  
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 facet joint interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL the following criteria: 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale* 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. There is no non-facet 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. 
 
For the first diagnostic facet joint procedure: 
a. For the first diagnostic facet joint procedure to be considered medically reasonable and necessary, the 
patient must meet the criteria outlined under indications for facet joint interventions. 
b. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and 
necessary in patients who meet ALL the following criteria: 
i. The patient meets the criteria for the first diagnostic procedure; AND 
ii. After the first diagnostic facet joint procedure, there must be a consistent positive response of at 
least 80% relief of primary (index) pain (with the duration of relief being consistent with the 
agent used) 
 
One to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or 
four-level procedure bilaterally may be considered under unique circumstances and with sufficient 
documentation of medical necessity on appeal. You can find this rule in the Local Coverage Determination for 
Facet Joint Interventions for Pain Management, L35936.  
 
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 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:1,2,5,9,10,11,12,13 
 
    Chronic lumbar back pain of =6 months duration that causes functional deficit measured on a pain or 
disability scale*, AND 
    Documented failure to respond to =6 months of non-surgical management**, AND 
    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 
    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. 
 
You can find this information in the Local Coverage Determination (LCD) Thermal Destruction of the 
Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain L39420. 
 
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 state that a white cane for use by a blind person is more an identifying and self-help device than an 
item which makes a meaningful contribution in the treatment of an illness or injury and is not covered. You can 
find this rule in National Coverage Determination (NCD) White Cane for Use by a Blind Person (280.2). 
 
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 to qualify for home health services, the patient must be: 
 
1. Confined to the home;  
2. Under the care of a physician or allowed practitioner;  
3. Receiving services under a plan of care established and reviewed by a physician;  
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) 
continuing occupational therapy. You can find this rule at 42 CFR Section 409.42. 
 
The rules say that eligibility for the home health benefit will be determined based on the certifying physician or 
allowed practitioners records. If the enrollee was directly admitted to home health from an acute or post-acute 
care facility, the facility records may be used instead. The medical records for the enrollee must contain 
information that justifies the referral for home health services. 
  
The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the 
enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face 
encounter visit. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and 
30.5.1.2. 
 
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 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 63 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 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 ultrasound diagnostic procedures utilizing low energy sound waves are being widely 
employed to determine the composition and contours of nearly all body tissues except bone and air-filled 
spaces. This technique permits noninvasive visualization of even the deepest structures in the body. The use of 
the ultrasound technique is sufficiently developed that it can be considered essential to good patient care in 
diagnosing a wide variety of conditions. 
 
Ultrasound diagnostic procedures are listed below and are divided into two categories. Medicare coverage is 
extended to the procedures listed in Category I. Periodic claims review by the A/Medicare Administrative 
Contractor (A/MAC) medical consultants should be conducted to ensure that the techniques are medically 
appropriate, and the general indications specified in these categories are met. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National 
Coverage Determination for Ultrasound Diagnostic Procedures, 220.5.  
 
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 pontic - 
porcelain fused to noble metal (D6242) and retainer crown - porcelain fused to noble metal (D6752) but is 
limited to once per 60 months. To approve a bridge, you must be missing only one upper front tooth or only 
two lower front teeth. The two lower front teeth must be next to each other. You also cannot be missing any of 
your back teeth. You can find this information on pages 107-108 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 only those items and services specifically listed in your Plan contract. Core buildup, including any 
pins when required is not covered under the Plans dental benefits. You can find this information on pages 61-
62 of the Plans 2023 Evidence of Coverage (EOC) and in the Plan's 2023 Enhanced Benefit Dental Code List 
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 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). 
 
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 there is a $750 deductible which applies to certain items and services. The Plan deductible 
applies to out-of-network lab services and radiology services. You can find this information on pages 61 and 62 
of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay 50% of the total cost for out-of-network Medicare-covered 
outpatient x-ray services, lab services, and radiology services. You can find this information on page 88 of the 
Plan's 2022 Evidence of Coverage (EOC).