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 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 pages 42 to 47 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 primary indication of a diagnostic facet joint procedure is to diagnose whether the 
patient has facet syndrome. Intraarticular (IA) facet block(s) are considered reasonable and necessary as a 
diagnostic test only if medial branch blocks (MMB) cannot be performed due to specific documented anatomic 
restrictions or there is an indication to proceed with therapeutic intraarticular injections. These restrictions must 
be clearly documented in the medical record and made available upon request. 
Diagnostic procedures should be performed with the intent that if successful, radiofrequency ablation (RFA) 
procedure would be considered the primary treatment goal at the diagnosed level(s). 
A second diagnostic facet procedure is considered medically necessary to confirm validity of the initial 
diagnostic facet procedure when administered at the same level. The second diagnostic procedure may only be 
performed a minimum of 2 weeks after the initial diagnostic procedure. Clinical circumstances that necessitate 
an exception to the two-week duration may be considered on an individual basis and must be clearly 
documented in the medical record. 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. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and 
necessary in patients who meet ALL the following criteria: The patient meets the criteria for the first diagnostic 
procedure; AND 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). 
Frequency limitation: For each covered spinal region no more than four (4) diagnostic joint sessions will be 
reimbursed per rolling 12 months, in recognition that the pain generator cannot always be identified with the 
initial and confirmatory diagnostic procedure. You can find this rule at Centers for Medicare and Medicaid 
Services, Local Coverage Determination (LCD) L38765, Facet Joint Interventions 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 specific dental procedure codes included in a dental benefits chart. Sinus augmentation with bone or bone substitutes for upper right quadrant (code D7952) is not among the services covered by the Plan's dental benefits. You can find this information on pages 28 to 57 of the Dental Benefit Limitations and Exclusions Guide.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that injection of a tendon sheath, ligament or trigger point consists of an anesthetic agent and/or 
steroid agent injected into an area for the management of pain. This Local Coverage Determination only 
addresses the injection of trigger points. Trigger points are areas of taut muscle bands or palpable knots of the 
muscle, that are painful on compression and can produce referred pain, referred tenderness, and/or motor 
dysfunction. A trigger point may occur in any skeletal muscle/fascia in response to strain produced by acute or 
chronic overload. Pain from trigger points can be mild to severe. When trigger point pain is severe and 
unresponsive to non-invasive treatments (e.g., anti-inflammatory medications, physical therapy, etc.), trigger 
point injections with local anesthetic and/or a steroid agent may be helpful. Besides injection into trigger 
points, local injections are useful in the treatment of pain or dysfunction due to inflammation or other 
pathological changes of tendon sheaths, and ligaments. Findings may include pain on motion or palpation, 
swelling, friction rubs and/or catches. Injections; single or multiple trigger point(s), one or two muscle(s) 
(20552) or single or multiple trigger point(s), three or more muscle(s) (20553). The injection of trigger point(s) 
will be considered to be medically reasonable and necessary for the treatment of trigger points that are 
unresponsive to non-invasive treatments or when non-invasive methods of treatment are contraindicated. The 
medical record should clearly reflect all methods attempted and the results. If treatments are contraindicated, 
the medical record should indicate why the trigger point(s) is not amenable to other therapeutic modalities. 
Non-invasive treatments may include but are not limited to: Repeat trigger point injections may be necessary 
when there is evidence of persistent pain or inflammation. Evidence of partial improvements to the range of 
motion in any muscle area after an injection would justify a repeat injection. Again, the medical record should 
clearly reflect the medical necessity for repeated injections. You can find this rule at Centers for Medicare and 
Medicaid Services, Local Coverage Determination (LCD) L33912, Injection of Trigger Points. 
 
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, while electric nerve stimulation has been employed to control chronic intractable pain for 
some time, its use in the treatment of motor function disorders, such as multiple sclerosis, is a recent 
innovation, and the medical effectiveness of such therapy has not been verified by scientifically controlled 
studies. Where electric nerve stimulation is employed to treat motor function disorders, no reimbursement may 
be made for the stimulator or for the services related to its implantation since this treatment cannot be 
considered reasonable and necessary. 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 160.2. 
 
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 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 the Centers for Medicare & Medicaid Services has determined that there is sufficient 
evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and 
necessary under section 1862(a)(1)(A) of the Social Security Act (the Act). The use of infrared and/or near-
infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, 
including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral 
sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National 
Coverage Determination for Infrared Therapy Devices, 270.6. 
 
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 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 $25 copayment for each individual or group therapy visit for covered 
outpatient mental health care services. For services provided in 2021 you can find this information in Chapter 4 
on page 99 of the Plan's 2021 Evidence of Coverage (EOC). For services provided in 2022 you can find this 
information in Chapter 4 on page 104 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 state that a high activity knee control frame (L5930) is covered for beneficiaries whose functional 
level is 4. 
You can find these rules in the Local Coverage Determination (LCD) for Lower Limb Prostheses, L33787. 
 
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) 
 
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 $225 copayment each day for days 1-7 per admission. You can find this 
information in Chapter 4 on pages 67 to 69 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $50 copayment for diagnostic procedures and tests, including 
ultrasounds, at all locations. You can find this information in Chapter 4 on pages 95 to 96 of the Plan's 2022 
Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $20 copayment for office visits to specialists. You can find 
this information in Chapter 4 on pages 101 to 103 of the Plans 2022 Evidence of Coverage (ECO).
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 the services provided, but only when they are received from an in-network provider. You can find 
this information on pages 76 and 80 of the Plan's 2021 and 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $75 copayment for diagnostic procedures and tests, including 
ultrasounds, at all locations of service. You can find this information In Chapter 4, on pages 83 to 84, of the 
Plan's 2021 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 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 in-network specialist Physician/Practitioner services. 
You can find this information in Chapter 4 on page 95 of the Plan's 2021 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 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 $50 copayment for Diagnostic Mammography Outpatient Hospital. You 
can find this information in Chapter 4 on pages 70 to 73 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
The rules say that oral appliances generally are classified as dental devices and are not classified as durable 
medical equipment. The following items (not all-inclusive) are considered to be dental devices and will be 
denied as non-covered, not DME: 
 
    - Oral occlusal appliances used to treat temporomandibular joint (TMJ) disorders 
    - Tongue retaining devices used to treat OSA and/or snoring 
    - All oral appliances used only to treat snoring without a diagnosis of OSA 
    - Oral appliances used to treat other dental conditions 
    - Oral appliances that require repeated fitting and/or adjustments, beyond the first 90-days, in order to  
       maintain fit and/or effectiveness 
 
You can find this information in the Local Coverage Article: Oral Appliances for Obstructive Sleep Apnea - 
Policy Article (A52512). 
 
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.