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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that there is an $800 deductible which applies to certain items and services. The Plan 
deductible applies to in-network durable medical equipment and related supplies. You can find this information 
on page 41 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollee must pay 10% coinsurance after meeting the deductible for in-network 
durable medical equipment and related supplies. You can find this information on pages 61-62 of the Plans 
2022 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 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. You can find this information on page(s) 34 to 47 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 Proton Beam therapy is considered medically reasonable and necessary for the following 
conditions: 
a. Unresectable benign or malignant central nervous system tumors to include but not limited to primary and 
variant forms of astrocytoma, glioblastoma, medulloblastoma, acoustic neuroma, craniopharyngioma, benign 
and atypical meningiomas, pineal gland tumors, and arteriovenous malformations 
b. Intraocular melanomas 
c. Pituitary neoplasms 
d. Chordomas and chondrosarcomas 
e. Advanced staged and unresectable malignant lesions of the head and neck 
f. Malignant lesions of the Para nasal sinus, and other accessory sinuses 
g. Unresectable retroperitoneal sarcoma 
h. Solid tumors in children 
 
In addition, the proton beam therapy indication must demonstrate that: 
 
a. The Dose Volume Histogram (DVH) one or more critical structures or organs protected by the use of proton 
beam therapy; 
b. The dose to control or treat the tumor cannot be delivered without exceeding the tolerance of the normal 
tissue; 
c. There is documented clinical rationale that doses generally thought to be above the level otherwise attainable 
with other radiation methods might improve control rates; or 
d. There is documented clinical rationale that higher levels of precision associated with proton beam 
therapy compared to other radiation treatments are clinically necessary. 
 
Proton beam therapy is considered investigational for the following conditions:  
 
1. Unresectable lung cancers and upper abdominal/peri-diaphragmatic cancers 
2. advanced stage, unresectable pelvic tumors including those with peri-aortic nodes or malignant lesions of the 
cervix 3. Left breast tumors 
4. Unresectable pancreatic and adrenal tumors 
5. Skin cancer with macroscopic perineural/cranial nerve invasion of skull base 
6. Unresectable Malignant lesions of the liver, biliary tract, anal canal and rectum 
7. Prostate Cancer, Non-Metastatic. 
 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination L36658 
entitled Proton Beam Therapy. 
 
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 CT scans are covered if there is literature to support its use for the patients condition and the 
scan is reasonable and necessary for the patient. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations 
Manual, Section 220.1(A). 
 
The rules say that there must be information on whether the PET scan was performed after an inconclusive 
non-invasive cardiac test.  The information submitted with respect to the previous noninvasive cardiac test 
must specify the type of test performed prior to the PET scan and whether it was inconclusive or unsatisfactory. 
You can find this rule in the National Coverage Determination (NCD) - PET for Perfusion of the Heart 
(220.6.1). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that sleep studies are coverable when medically necessary for the following conditions: 
 
1. Narcolepsy 
2.  Sleep Apnea  
3.  Impotence 
4.  Parasomnia  
 
Polysomnography or sleep studies are not covered in the following situations: 
 
1. To preoperatively evaluate a patient for laser-assisted uvulopalatopharyngoplasty without clinical evidence 
that obstructive sleep apnea is suspected; 
2. To diagnose chronic lung disease (nocturnal hypoxemia in patients with chronic, obstructive, restrictive or 
reactive lung disease is usually adequately evaluated by oximetry; however, if the patient's sign/symptoms 
suggest a diagnosis of obstructive sleep apnea, polysomnography may be considered medically necessary); 
3. In cases where seizure disorders have not been ruled out; 
4. In cases of typical, uncomplicated and non-injurious parasomnias when the diagnosis is clearly delineated; 
5. For patients with epilepsy who have no specific complaints consistent with a sleep disorder; 
6. For patients with symptoms suggestive of periodic limb movement disorder or restless leg syndrome unless 
symptoms are suspected of being related to a covered indication; 
7. For the diagnosis of insomnia related to depression; 
8. For the diagnosis of circadian rhythm sleep disorders (i.e., rapid time-zone change, shift-work sleep disorder, 
delayed sleep phase syndrome, advanced sleep phase syndrome, and non-24-hour sleep/wake disorder). 
 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD): Outpatient Sleep Studies: (L35050). 
 
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 pay for durable medical equipment (DME) that is mainly used to serve a 
medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment 
that are clearly used for medical purposes. You can find these rules in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 
110.1.  
 
The rules also say that prosthetic devices (other than dental) which replace all or part of an internal body organ 
(including contiguous tissue), or replace all or part of the function of a permanently inoperative or 
malfunctioning internal body organ are covered when furnished on a physician's order. You can find this in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 15, Section 120. 
 
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 states that it provides supplemental coverage for wigs. This coverage is limited to enrollees who 
experience hair loss due to treatment for cancer. You can find this on page 121 of the 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 surgical treatment of varicose veins may be indicated when a 3-month trial of conservative 
therapy such as exercise, periodic leg elevation, weight loss, compressive therapy, and avoidance of prolonged 
immobility where appropriate, has failed. There must also be documented symptoms such as pain, aching, 
cramping, burning, itching and/or swelling during activity or after prolonged standing severe enough to impair 
mobility, or other symptoms. You can find this information in the Local Coverage Determination (LCD): 
Treatment of Varicose Veins of the Lower Extremities (L34536). 
 
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 effective for services performed on or after September 26, 2022, cochlear implantation may 
be covered for treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in 
individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined 
by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of 
open-set sentence recognition. Patients must meet all of the following criteria: 
 
a. Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from 
appropriate hearing (or vibrotactile) aids; 
b. Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation; 
c. Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, 
and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system; 
d. No contraindications to surgery; and 
e. The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling. 
 
You can find this information at Centers for Medicare and Medicaid Services, Internet-Only Publication 100-
03, National Coverage Determinations Manual: Cochlear Implantation (50.3). 
 
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 state that a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints 
(L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1843,L1845, L1851, L1852), are covered if the beneficiary has had recent injury 
to or a surgical procedure on the knee(s). Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are 
also covered for a beneficiary who is ambulatory and has knee instability due to certain conditions. Addition 
codes will be denied as not reasonable and necessary if the base orthosis is not reasonable and necessary or the 
addition is not reasonable and necessary. You can find this information in the Local Coverage Determination 
(LCD): Knee Orthoses (L33318). 
 
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 the evidence is sufficient to conclude that the use of implantable cardiac defibrillators 
(ICDs) is reasonable and necessary for the following: 
 
1. Patients with a personal history of sustained Ventricular Tachyarrhythmia (VT) or cardiac arrest due to 
Ventricular Fibrillation (VF). Patients must have demonstrated: 
a. An episode of sustained VT, either spontaneous or induced by an Electrophysiology (EP) study, not 
associated with an acute Myocardial Infarction (MI) and not due to a transient or reversible cause; or 
 
b. An episode of cardiac arrest due to VF, not due to a transient or reversible cause. 
  
2. Patients with a prior MI and a measured Left Ventricular Ejection Fraction (LVEF) = 0.30.  
 
3. Patients who have severe, non-ischemic, dilated cardiomyopathy but no personal history of cardiac arrest  
 
4. Clinical symptoms and findings that would make them a candidate for coronary revascularization. 
 
5. Patients with documented, familial or genetic disorders with a high risk of life-threatening tachyarrhythmias 
(sustained VT or VF, to include, but not limited to, long QT syndrome or hypertrophic cardiomyopathy. 
 
6. Patients with an existing ICD may receive an ICD replacement if it is required due to the end of battery life, 
Elective Replacement Indicator (ERI), or device/lead malfunction. 
 
For each of the six (6) covered indications above, the following additional criteria must also be met: 
 
1. Patients must be clinically stable  
2. Patients must not have significant, irreversible brain damage; or, any disease, other than cardiac disease (e.g., 
cancer, renal failure, liver failure) associated with a likelihood of survival less than one (1) year; or, 
supraventricular tachycardia such as atrial fibrillation with a poorly controlled ventricular rate. 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 20.4. 
 
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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for painful, debilitating, 
osteoporotic vertebral collapse/compression fractures, defined as those that have not responded to non-surgical 
medical management with and without methods of immobility (rest and bracing). You can find this information 
in the Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation (PVA) for Vertebral 
Compression Fracture (VCF) (L34976). 
 
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 another type of pre-symptom memory loop recorder (MLR), it is implanted subcutaneously 
in a patients upper left chest and may remain implanted for many months. An implanted loop recorder (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 rule in the National Coverage Determination 
(NCD) - Electrocardiographic Services (20.15) - Effective August 26, 2004. 
 
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 kyphoplasty is covered for acute or subacute osteoporotic vertebral compression fracture, 
based on symptom onset, and documented by advanced imaging. You can find this rule in the Local Coverage 
Determination (LCD) - Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression 
Fracture (VCF) (L348228). 
 
The rules say that kyphoplasty can be covered for symptomatic patients, non-hospitalized with moderate to 
severe pain, despite optimal non-surgical management. It can be covered for stable to improved pain with 
evidence of progression of vertebral body height loss and more than 25% vertebral body height reduction. You 
can find this rule in the Local Coverage Determination (LCD) - Percutaneous Vertebral Augmentation (PVA) 
for Osteoporotic Vertebral Compression Fracture (VCF) (L348228). 
 
The rules say that an absolute contraindication for kyphoplasty is if the current back pain is not primarily due to 
the identified acute or subacute fractures. A relative contraindication is fracture retropulsion/canal compromise. 
You can find this rule in the Local Coverage Determination (LCD) - Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L348228). 
 
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 effective for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement 
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following 
requirements are met: 
 
   a. Patient has: 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and not been previously 
tested with the same test using NGS for the same cancer genetic content, and decided to seek further cancer 
treatment (e.g., therapeutic chemotherapy). 
 
   b. The diagnostic laboratory test using NGS must have: 
Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, an FDA-
approved or -cleared indication for use in that patients cancer; and, results provided to the treating physician 
for management of the patient using a report template to specify treatment options. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, National Coverage Determinations (NCD) Manual: Next Generation Sequencing (NGS) 
(90.2). 
 
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 the plan must pay for emergency and urgently needed services. This rule applies whether the 
services are obtained in or out of the plans network. This rule applies whether or not there is prior 
authorization for the services. The rules say that an emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules 
say that urgently needed services are those needed because of an unforeseen illness or condition, and it is not 
reasonable to get the services from the Plan. Generally, these services are needed while the enrollee is outside 
of the service area. You can find this rule at 42 CFR Section 422.113. 
 
The rules say that, generally, items and services provided outside of the United States (US) are not covered. 
The only exceptions are emergency hospital services when the emergency occurred within the US, 
emergency/non-emergency hospital services when the foreign hospital is substantially closer or more 
accessible than the US hospital, or services provided on a ship docked at a US port or within US Territorial 
waters. You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 60. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that they provide a $100,000 benefit for emergency, urgent care, and emergency 
transportation received outside the United States. Services are covered worldwide under the same conditions of 
medical necessity and appropriateness that would have applied if the same services were provided within the 
United States. You must first pay for medical care received, obtain discharge summary or equivalent medical 
documentation and proof of payment. You can find this information on page 63 of the Plan's 2022 Evidence of 
Coverage.