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 state that both percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA) 
will be considered reasonable and necessary for osteoporotic conditions when all of the following criteria are 
met: 
- Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) 
(T1 - L5) based on symptom onset, and documented by recent (within 30 days) advanced imaging and 
- The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or 
visual Analog Scale [VAS] pain score of 8 or more) or is non-hospitalized with moderate to severe pain 
(NRS or VAS of 5 or more) despite optimal non-surgical management (NSM) with one of the 
following: 
~ Worsening pain or 
~ Stable to improved pain (but NRS or VAS of 5 or more) when 2 or more of the following are 
present: 
- Progression of vertebral body height loss 
- More than 25% vertebral body height reduction 
- Kyphotic deformity 
- Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire 
(RDQ) greater than 17) 
- Steroid-induced fractures 
- Reinforcement or stabilization of vertebral body prior to surgery 
- Continuum of Care 
~ All patients presenting with vertebral compression fractures (VCF) should be referred for 
evaluation of bone mineral density and osteoporosis education for subsequent treatment as 
indicated and instructed to take part in an osteoporosis prevention/treatment program. 
 
You can find these rules in Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L38213). 
 
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 cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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 blepharoplasty and surgical procedures of the brow performed for the sole purpose of 
improving appearances are considered not medically reasonable and necessary. You can find this information 
in Local Coverage Determination (LCD): Blepharoplasty, Blepharoptosis Repair, and Surgical Procedures of 
the Brow (L35004). 
 
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 $30 copayment for outpatient diagnostic tests/x-ray. You can find this 
information on page 89 of the Plan's 2023 Evidence of Coverage (EOC). Also, a $5 copayment for outpatient 
rehabilitation service. You can find this information on page 95 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 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 generally, carriers must pay for only one interpretation of a procedure furnished to an 
emergency room patient. They pay for a second interpretation (which may be identified through the use of 
modifier -77) only under unusual circumstances (for which documentation is provided) such as a 
questionable finding for which the physician performing the initial interpretation believes another physician's 
expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the 
procedure. 
 
When carriers receive multiple claims for the same interpretation, they must generally pay for the first bill 
received. Carriers must pay for the interpretation and report that directly contributed to the diagnosis and 
treatment of the individual patient. If the first claim received is from a radiologist, carriers generally pay the 
claim because they would not know in advance that a second claim would be forthcoming. When carriers 
receive the claim from the emergency room (ER) physician and can identify that the two claims are for the 
same interpretation, they must determine whether the claim from the ER physician was the interpretation that 
contributed to the diagnosis and treatment of the patient and, if so, they pay that claim. In such cases, carriers 
must determine that the radiologist's claim was actually quality control and institute recovery action. The two 
parties should reach an accommodation about who should bill for these interpretations.  
 
You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 13, Section 100. 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 to be eligible for coverage of a continuous glucose monitor (CGM) and related supplies, the 
beneficiary must meet all of the following initial coverage criteria (1)-(5): 
 
1. The beneficiary has diabetes mellitus; and, 
2. The beneficiarys treating practitioner has concluded that the beneficiary (or beneficiarys caregiver) has 
sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
3. The CGM is prescribed in accordance with its Food and Drug Administration (FDA) indications for use; 
and, 
4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the 
criteria below: 
   A. The beneficiary is insulin-treated; or, 
   B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the 
following: 
      -     Recurrent level 2 hypoglycemic events that persist despite multiple attempts to adjust  
            medication(s) and/or modify the diabetes treatment plan; or, 
      -     A history of one level 3 hypoglycemic event characterized by altered mental and/or physical state 
requiring third-party assistance for treatment of hypoglycemia 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-
approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1)-
(4) above are met. You can find this information in the Local Coverage Determination (LCD): Glucose 
Monitors (L33822). 
 
The rules say that the date of delivery may be entered by the beneficiary, designee or the supplier. As a general 
Medicare rule, the date of service shall be the date of delivery. Exceptions are made for suppliers who use a 
delivery/shipping service. If the supplier uses a delivery/shipping service, the supplier may use the shipping 
date as the date of service on the claim.  The shipping date may be defined as the date the delivery/shipping service label is created or the date the item 
is retrieved for delivery; however, such dates should not demonstrate significant variation. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Program Integrity Manual, Chapter 4, Section 4.7.3.1.1. 
 
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 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 when you received care from a provider who is not part of our network, you are only 
responsible for paying your share of the cost. (Your share of the cost may be higher for an out-of-network 
provider than for a network provider. If you pay the entire amount yourself at the time you receive the care, ask 
us to pay you back for our share of the cost. You can find this information on page 176 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 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 20% coinsurance for each in-network Medicare-covered Part B drug. 
You can find this information on page 77 of the Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that enrollees must pay a $280 copayment for each in-network outpatient hospital and 
observation service. You can find this information on page 82 of the Plan's 2023 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 home health agencies (HHAs) must report where home health services were provided. The 
following codes are used for this reporting:  
 
Q5001: Hospice or home health care provided in patients home/residence  
Q5002: Hospice or home health care provided in assisted living facility  
Q5009: Hospice or home health care provided in place not otherwise specified.  
 
The location where services were provided must always be reported along with the first visit reported on the 
claim. In addition to reporting a visit line using the G codes, HHAs must report an additional line item with the 
same revenue code and date of service, reporting one of the three Q codes (Q5001, Q5002, and Q5009), one 
unit and a nominal covered charge (e.g., a penny). If the location where services were provided changes during 
the period of care, the new location should be reported with an additional line corresponding to the first visit 
provided in the new location. You can find this information in the Centers for Medicare & Medicaid Services, 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, 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.
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. This benefit includes 
coverage for specific dental items/services stated in the Plans contract. You can find this information on pages 
56-58 of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 & 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 44 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 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 Medicare Part B prescription drugs. You can find 
this information in Chapter 4 on pages 4-29 to 4-30 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay $35 copayment for services obtained from a specialist. You can 
find this information in Chapter 4 on pages 4-43 to 4-48 of the Plans 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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. This benefit includes a root 
canal, but the Plan only pays up to the calendar year maximum of $1,000 for all covered supplemental dental 
services. You can find this information on page 64 and 117 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 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 $220 copayment for outpatient surgery at an ambulatory surgical center 
You can find this information on page 79 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 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 $275 copayment for inpatient hospital care. The enrollee must pay a 
$275 copayment per day, for days one to five, for each inpatient hospital stay. There is a $0 copayment for 
additional days after day five. You can find this information on page(s) 83 and 84 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 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) 44 and 45 of the 
Plan's 2023 Evidence of Coverage.