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). 
 
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 20% coinsurance for Part B covered prescription drugs. You can find this 
information on page(s) 85 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 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 37-41 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 $100 copayment for Medicare-covered ultrasound. You can find this 
information on page(s) 97 of the Plan's 2021 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 $300 copayment for a computerized tomography (CT) scan. You can 
find this information in Chapter 4 on pages 77-78 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. 
 
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 
routine/preventive and comprehensive dental care services such as tooth extractions, 1 procedure per year. 
Services must be performed by a participating general dentist. You can find this information in Chapter 4 on 
pages 69 to 71 of the Plans 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 Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
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. The Plan 
contract says covered drugs include: Drugs that usually aren't self-administered by the patient and are injected 
or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. You can 
find this information in Chapter 4 on page 59 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 services that do not require the professional skills of a therapist to perform or supervise are 
not medically necessary, even if they are performed or supervised by a therapist, physician or non-physician 
practitioner (NPP). The skills of a therapist may also be furnished by an appropriately trained and experienced 
physician or NPP, or by an assistant (Physical therapy assistant-PTA, Occupational therapy assistant-OTA) 
appropriately supervised by a therapist. Therefore, if a patients therapy can proceed safely and effectively 
through a home exercise program, self-management program, restorative nursing program or caregiver assisted 
program, payment cannot be made for therapy services. 
 
You can find this information at Local Coverage Determination: Outpatient Physical and Occupational Therapy 
Services (L33631). 
 
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 one intermittent catheter with insertion supplies (A4353) will be covered per episode of 
reasonable and necessary sterile intermittent catheterization. Intermittent catheterization is covered when basic 
coverage criteria are met and the beneficiary or caregiver can perform the procedure. 
 
For each episode of covered catheterization, Medicare will cover one catheter (A4351, A4352) and an 
individual packet of lubricant (A4332); or one sterile intermittent catheter kit (A4353) if additional coverage 
criteria (see below) are met. Intermittent catheterization using a sterile intermittent catheter kit (A4353) is 
covered when the beneficiary requires catheterization and the beneficiary meets one of the following criteria 
(1-5): 
 
    1. The beneficiary resides in a nursing facility, 
    2. The beneficiary is immunosuppressed, for example (not all-inclusive): 
          a. on a regimen of immunosuppressive drugs post-transplant, 
          b. on cancer chemotherapy, 
          c. has AIDS, 
          d. has a drug-induced state such as chronic oral corticosteroid use. 
    3. The beneficiary has radiologically documented vesico-ureteral reflux while on a program of intermittent 
catheterization, 
    4. The beneficiary is a spinal cord injured female with neurogenic bladder who is pregnant (for duration of 
pregnancy only), 
    5. The beneficiary has had distinct, recurrent urinary tract infections, while on a program of sterile 
intermittent catheterization with A4351/A4352 and sterile lubricant A4332, twice within the 12-month prior to 
the initiation of sterile intermittent catheter kits. 
 
Usual Maximum Quantity of Supplies: 
Code      Number per Month 
 
A4332           200 
A4351           200 
A4352           200 
A4353           200 
 
 Refer to Coding Guidelines section of the related Policy Article for contents of the kit (A4353). A4353 should 
not be used for billing if the components are packaged separately rather than together as a kit. Separately 
provided components do not provide the equivalent degree of sterility achieved with an A4353. If separate 
components are provided instead of a kit (A4353) they will be denied as not reasonable and necessary. You can 
find this rule in the Local Coverage Determination (LCD) Urological Supplies L33803. 
 
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 epidural steroid injections (ESI) will be considered medically reasonable and necessary when 
the following requirements are met: 
 
1. History, physical examination, and concordant radiological image-based diagnostic testing that supports one 
of the following: 
 
-Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to disc 
herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis 
-Post-laminectomy syndrome, 
-Acute herpes zoster associated pain. 
 
2. Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality of 
life or function. An objective pain scale or functional assessment must be performed at baseline (prior to 
interventions). The same scale must be used at each follow-up for assessment of response. 
 
3. Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or medical 
documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes zoster 
refractory to conservative management where a four (4) week wait is not required. 
 
You can find this rule in the Local Coverage Determination (LCD) - Epidural Steroid Injections for Pain 
Management (L36920) - Effective December 12, 2021. 
 
The rules say that repeat epidural steroid injection (ESI) when the first injection directly and significantly 
provided improvement of the condition being treated may be considered medically reasonable and necessary 
when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement 
in function measured from baseline using SAME scale* for at least three months. If a patient fails to respond 
well to the initial ESI, a repeat ESI after 14 days can be performed using a different approach, level and/or 
medication, if appropriate, with the rationale and medical necessity for the second ESI documented in the 
medical records. You can find this rule in the Local Coverage Determination (LCD) - Epidural Steroid 
Injections for Pain Management (L36920) - Effective December 12, 2021. 
 
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 Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
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. The Plan 
contract says covered drugs include: Drugs that usually arent self-administered by the patient and are injected 
or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. You can 
find this information in Chapter 4 on page 4-38 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 state that Facet Joint Interventions generally consist of four types of procedures: Intraarticular (IA) 
Facet Joint Injections, Medial Branch Blocks (MBB), Radiofrequency Ablations (RFA) and Facet cyst 
rupture/aspiration: 
  
   
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: 
 
    Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale* 
    Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
    Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst) 
    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. 
 
*Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the 
same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for 
functional assessment (if patient qualifies for treatment). 
 
You can find this information in the Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management L35936. 
 
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 an inpatient admission is generally appropriate when the admitting physician expects the 
patient to need hospital care that crosses at least two midnights. The expectation should be based on such 
  
  complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and 
medical risk. The factors must be documented in the medical record.  
 
If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be 
considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as 
inpatient only is generally appropriate, regardless of the length of stay. An inpatient admission may be 
appropriate if the admitting physician expects a patient to require hospital care for only a limited period of 
time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be 
supported by the medical record. You can find this rule at 42 CFR Section 412.3. 
 
The rules say effective for services performed on and after February 21, 2006, Open and laparoscopic Roux-en-
Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS) 
or Gastric Reduction Duodenal Switch (BPD/GRDS), and laparoscopic adjustable gastric banding (LAGB) are 
covered for Medicare beneficiaries who have a body-mass index = 35, have at least one co-morbidity related to 
obesity, and have been previously unsuccessful with medical treatment for obesity. You can find this 
information in Medicare's National Coverage Determination (NCD): Bariatric Surgery for Treatment of Co-
Morbid Conditions Related to Morbid Obesity (100.1). 
 
The rules say that the sleeve gastrectomy (SG) is a surgical procedure performed in either an open or 
laparoscopic manner. The surgery involves excision of the lateral aspect of the stomach, leaving a much 
reduced, tubular stomach. When performed laparoscopically, the term laparoscopic sleeve gastrectomy (LSG) 
is used. Presently, LSG is being used as a stand-alone approach to bariatric surgery. By reducing gastric 
capacity, there is both short- and long-term weight loss. A stand-alone SG is sometimes referred to as an 
isolated SG. There are variations in the detail and technique for the SG procedure itself. LSG has been gaining 
popularity over the last few years with increased experience among surgeons and the procedure has taken its 
place among other bariatric surgical procedures for extreme obesity. Unlike some bariatric surgical procedures, 
this technique is irreversible. You can find this information in Medicare's Local Coverage Determination 
(LCD): Laparoscopic Sleeve Gastrectomy for Severe Obesity (L34576). 
 
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 Medicare does not pay for over-the-counter (OTC) items, including non-prescription drugs. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 40.2. 
 
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 rules say 
that Medicare has started a new initiative on April 4, 2022, that will cover up to eight over-the-counter 
COVID-19 tests each calendar month, at no cost to you. Medicare will cover these tests if you have Part B, 
including those enrolled in a Medicare Advantage plan. If you are in a Medicare Advantage (MA) plan, the 
tests covered under this initiative will be covered outside of your existing plans coverage, and in addition to 
any over-the-counter tests that may be covered under the plan as a supplemental benefit. You can get over-the-
counter COVID-19 tests at any pharmacy or health care provider that participates in this initiative. Enrollees 
cannot submit a claim for these tests to Medicare or their MA plan (unless covered by a supplemental benefit) 
for reimbursement under this initiative. The participating provider would bill Medicare directly for 
reimbursement of the tests provided to the enrollee. You can find this information on the Centers for Medicare 
and Medicaid Services website at  https://www.cms.gov/newsroom/fact-sheets/medicare-covers-over-counter-
covid-19-tests.