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 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 & 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. The contract lists the dental 
services that are covered. Limited oral evaluation is not listed and therefore is not a covered service. You can 
find this information on pages 76 to 77 of the Plans 2023 Evidence of Coverage (EOC). 
 
The Plan contract also says that any service not listed in the Coverage Information is excluded from dental 
coverage. You can find this information on pages 82 to 83 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 $320 copayment for Medicare-covered services provided in an 
ambulatory surgery center. You can find this information on page 77 of the Plan's 2023 Evidence of Coverage 
(EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health
or overall function of the enrollee. The rules define a chronically ill enrollee as one who has one or more
comorbid and medically complex chronic conditions that meet all of the following:
1. Is life threatening or significantly limits the overall health or function of the enrollee;
2. Has a high risk of hospitalization or other adverse health outcomes; and
3. Requires intensive care coordination.
The rules also say that the Plan must have written policies for determining enrollee eligibility and must
document its determination that an enrollee is a chronically ill enrollee. You can find this information in 42
CFR 422.102.

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 if you have been diagnosed by a qualified provider with certain chronic conditions and you
meet certain criteria, you may be eligible for additional benefits. You can find this information on page 103 of
the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that protection of cranial nerves is a covered indication for intraoperative neuro monitoring in 
surgery for: 
a. tumors that are optic, trigeminal, facial, auditory nerves 
b. cavernous sinus tumors 
c. oval or round window graft 
d. endolymphatic shunt for Meniere's disease 
e. vestibular section for vertigo 
f. microvascular decompression of cranial nerves. 
 
You can find this information in the Local Coverage Determination (LCD) L34623: Intraoperative 
Neurophysiological Testing 
 
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that the 340B Drug Pricing Program is a federal program that requires drug manufacturers to 
provide outpatient drugs to eligible healthcare centers, clinics, and hospitals at a reduced price. Each separately 
payable, non-pass through (SI=K) 340B-acquired drug should be billed with the appropriate 340B modifier. 
When a drug or biological is acquired with 340B drug pricing program discount, modifier JG is applied to the 
applicable line(s). These modifiers should be appended to separately payable non-passthrough OPPS drugs that 
are acquired through the 340B program and do not need to be reported with pass through drugs that have SI=G. 
You can find this rule in the Integrated Outpatient Code Editor (IOCE), Centers for Medicare and Medicaid 
Services Specification V25.0, Section 6.15. 
 
The rules say that when applicable, providers are required to report either modifier JG or TB on OPPS 
claims (bill type 13X) beginning January 1, 2023. The presence of modifier JG or TB on a claim indicates 
that a drug has been acquired through the 340B program. The modifiers JG or TB will not trigger a 
payment reduction and will be used only for informational purposes, including to comply with certain 
requirements of the Inflation Reduction Act (IRA) of 2022. Though modifiers JG and TB are informational 
modifiers, reporting is mandatory for providers paid under the OPPS in calendar year 2023. You can find this 
rule in the Centers for Medicare & Medicaid Services, Medicare Fee-For-Service Program Billing 340B 
Modifiers under the Hospital Outpatient Prospective Payment System (OPPS) Frequently Asked Questions.  
 
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 $90 copayment for emergency care.  You can find this information on 
page(s) 65-66 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 state that percutaneous transluminal angioplasty (PTA) is covered when used for treatment of 
atherosclerotic obstructive lesions, concurrent with carotid stent placement in a Food and Drug Administration 
(FDA)-approved category B Investigational Device Exemption (IDE) clinical trials, concurrent with carotid 
stent placement in FDA-approved post approval studies, and concurrent with carotid stent placement in patients 
at high risk for Carotid Endarterectomy (CEA), and concurrent with intracranial stent placement in FDA-
approved category B IDE clinical trials. The rules also say that all other indications for PTA with or without 
stenting to treat obstructive lesions of the vertebral and cerebral arteries remain noncovered. All other 
indications for PTA without stenting for which Medicare has not specifically indicated coverage remain 
noncovered. You can find this information in the Centers for Medicare & Medicaid Service, Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual: Percutaneous 
Transluminal Angioplasty (PTA) (20.7). 
 
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 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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. You can find this rule in 
the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 23, Section 20.9. 
 
 The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V, and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. You 
can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 4, Section 10.4.C(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 thyroid testing may be reasonable and necessary to: 
1. Distinguish between primary and secondary hypothyroidism; 
2. Confirm or rule out primary hypothyroidism; 
3. Monitor thyroid hormone levels (for example, patients with goiter, thyroid nodules, or thyroid cancer); 
4. Monitor drug therapy in patients with primary hypothyroidism; 
5. Confirm or rule out primary hyperthyroidism; and 
6. Monitor therapy in patients with hyperthyroidism. 
 
Thyroid function testing may be medically necessary in patients with disease or neoplasm of the thyroid and 
other endocrine glands. Thyroid function testing may also be medically necessary in patients with metabolic 
disorders; malnutrition; hyperlipidemia; certain types of anemia; psychosis and non-psychotic personality 
disorders; unexplained depression; ophthalmologic disorders; various cardiac arrhythmias; disorders of 
menstruation; skin conditions; myalgias; and a wide array of signs and symptoms, including alterations in 
consciousness; malaise; hypothermia; symptoms of the nervous and musculoskeletal system; skin and 
integumentary system; nutrition and metabolism; cardiovascular; and gastrointestinal system. You can find this 
information in the Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 100-03, 
Medicare National Coverage Determinations (NCD) Manual, Section 190.22. 
 
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
2. The services require the skills or direct supervision of a therapist,  
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. You can find these rules in the Centers for Medicare & Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2. 
 
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable
and necessary when:

1. The services are specific and effective treatment for the patient's condition,
2. The services require the skills or direct supervision of a therapist,
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver,
or carry out a maintenance program.

Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for
skilled care. You can find these rules in the Centers for Medicare & Medicaid Services, Internet Only Manual,
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2.

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 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 in 2023 there was a $150 deductible for in network providers and a $490 combined in and out
of network deductible. The maximum out of pocket for in network services was $500. You can see this on page
47 of the Plans 2023 Evidence of Coverage.

The Plan contract says that inpatient care has a 10% coinsurance after the deductible is met. You can see this
on page 71 of the Plans 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare 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 & Medicaid Services,
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers certain dental services as a supplemental (extra) benefit. You can find this on page 55-
56 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 no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 10.1.2.

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 state that percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for the following indications: 
 
1) Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have not 
responded to non-surgical medical management (e.g., narcotic and/or non- narcotic medication, physical 
therapy modalities) with and without methods of immobility (e.g., rest, bracing). 
 
Both PVP and PVA will be considered reasonable and necessary when ALL of the following criteria are met: 
 
1) Acute (less than 6 weeks) or subacute (6-12 weeks)18,28,42 osteoporotic VCF (T1 L5), based on symptom 
onset, and documented by advanced imaging demonstrating bone marrow edema on MRI or bone-
scan/SPECT/CT uptake 1-3,8,26,43 and 
2) The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or Visual 
Analog Scale [VAS] pain score = 8)4-7 or is non-hospitalized with moderate to severe pain (NRS or VAS =5) 
despite optimal non-surgical management (NSM)8 with one of the following: 
a) Worsening Pain or 
b) Stable to improved pain (but NRS or VAS =5) when 2 or more of the following are present: 
c) Progression of vertebral body height loss 
d) more than 25% vertebral body height reduction 
e) Kyphotic deformity 
f) Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] >17) 
 
You can find this information in the Local Coverage Determination (LCD) L34976: Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF). 
 
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.