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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers Up to 36 one-way trips, combined in and out-of-network, are covered each year (limited to ground 
transportation only). Each one-way trip must not exceed 50 miles of driving distance. A trip is one-way 
transportation; a round trip is 2 trips. You can find this information on page 4-75 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 will consider invasive procedures (only with the techniques outlined in this local 
coverage determination (LCD) and under the conditions described) as reasonable and necessary when 
documentation in the medical record includes a history, physical examination, CEAP clinical classification, and 
a venous duplex scan documenting reflux (>500 msec). 
1. Liquid sclerotherapy will be considered reasonable and necessary to treat telangiectasias, reticular 
veins, small varicose veins (3-6 mm), residual or recurrent veins following endovenous ablation or 
surgery, and perforator veins. Treatment of telangiectasias and reticular veins (C1) (<3 mm) is 
considered reasonable and necessary with documentation of spontaneous and/or traumatic venous 
hemorrhage, OR for dilated intradermal veins in the elderly judged to be a substantial risk for 
hemorrhage with minimal trauma, OR near an active or healed ulcer if judged to contribute to local 
venous hypertension. 
2. Saphenous veins (GSV, SSV, AAGSV) management, with UGFS, endovenous thermal ablation 
(radiofrequency or laser), chemical adhesive (cyanoacrylate embolization), MOCA, and surgery 
(surgical ligation and stripping) is considered reasonable and necessary with documentation in the 
medical record of CEAP class C2-C6 disease, reflux (>500 msec), and ANY of the following signs or 
symptoms: 
a. ulceration secondary to venous stasis; 
b. significant pain or significant edema associated with saphenous reflux that interferes with 
activities of daily living (ADLs); 
c. bleeding associated with ruptured superficial varicosity; 
d. recurrent episodes of superficial phlebitis; 
e. stasis dermatitis; 
f. refractory dependent edema 
3. Incompetent perforator veins (IPVs) are the most common cause of recurrent varicose veins after 
treatment. Minimally invasive treatments have replaced traditional surgical treatments for 
IPVs. UGFS and endovenous thermal ablation with either radiofrequency or laser energy sources will 
be considered reasonable and necessary
9
 with the following conditions: 
a. Demonstrated perforator reflux >500 msec; AND 
b. No saphenous reflux (greater, small, or accessory) and/or symptomatic varicose 
tributaries; AND 
c. An active venous ulcer; AND 
d. The IPV is at least 3.5 mm in diameter; AND e. The perforator is in the vicinity of the ulcer. 
You can find this rule at Local Coverage Determination (LCD) L39121: Treatment of Varicose Veins of the 
Lower Extremities (eff. 4/3/22). 
 
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 Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as the following conditions are met (42 CFR 422.100(l)): 
 
 The MA plan provides all categories of DME covered under original Medicare Part B; 
 The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
 The MA plans contracted suppliers provide access to all preferred DME brands; 
 During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 
90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year; 
 Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
 The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
 The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the Evidence of Coverage (EOC) and Annual Notice of Changes (ANOC) and on 
its website; and 
 The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by Medicare to require full coverage. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that diabetic testing supplies (meters and strips) obtained through the pharmacy are limited to 
specified branded products. Prior approval will be required for any other brands of meters and test strips. You 
can find this information on pages 66 to 67 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 
coverage for the requested items or services, but only when they are received from an in-network provider. You 
can find this information on pages 74-77 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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 9 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 a standard walker (E0130, E0135, E0141, E0143) and related accessories are covered if all of 
the following criteria (1-3) are met: 
1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADL) in the home. 
2. The beneficiary is able to safely use the walker; and 
3. The functional mobility deficit can be sufficiently resolved with use of a walker. 
You can find this information in the Local Coverage Determination (LCD): Walkers (L33791). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a 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 also says that as a member of our Plan, you can choose to receive care from out-of-network providers. 
However, please note providers that do not contract with us are under no obligation to treat you, except in 
emergency situations. Our Plan will cover services from either network or out-of-network providers, as long as 
the services are covered benefits and are medically necessary. If you are not a Full Dual or QMB member and 
you use an out of network provider, your share of the costs for your covered services may be higher. You can 
find this information on page 3-8 of the Plan's 2022 Evidence of Coverage.  
 
The Plan contract also says that the Plan covers chiropractic services. Out-of-network pay a 40% coinsurance 
for each Medicare-covered visit. You pay these amounts until you reach the out-of-pocket maximum. You can 
find this information on page 4-19 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 PVA (Percutaneous Vertebroplasty (PVP) or Kyphoplasty (PKP)) is covered in patients 
with BOTH the following: 
 
    Inclusion criteria (ALL are required): 
        Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5), based on symptom onset, 
and documented by advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT 
uptake)         Symptomatic (ONE): 
            Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
equals 8)  
            Non-hospitalized with moderate to severe pain (NRS or VAS equals 5) despite optimal non-surgical 
management (NSM) (ONE): 
                Worsening pain 
                Stable to improved pain (but NRS or VAS still equals 5) (with equals 2 of the following): 
                    Progression of vertebral body height loss 
                    Greater than 25% vertebral body height reduction 
                    Kyphotic deformity 
                    Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
greater than 17 
        Continuum of care (Both) 
            All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis education 
for subsequent treatment as indicated. 
            All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment 
program. 
 
    Exclusion criteria (Can have NONE of the following): 
        Absolute contraindication 
            Current back pain is not primarily due to the identified acute or subacute VCF(s). 
            Osteomyelitis, discitis or active systemic or surgical site infection 
            Pregnancy         Relative contraindication 
            Greater than three vertebral fractures per procedure 
            Allergy to bone cement or opacification agents 
            Uncorrected Coagulopathy 
            Spinal instability 
            Myelopathy from the fracture 
            Neurologic deficit 
            Neural impingement 
            Fracture retropulsion/canal compromise 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L34228). 
 
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 B.  Nationally Covered Indications 
 
The following indications are covered for implanted permanent single chamber or dual chamber cardiac 
pacemakers: 
 
    Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and 
    Documented non-reversible symptomatic bradycardia due to second degree and/or third degree 
atrioventricular block. 
 
C.  Nationally Non-Covered Indications 
 
The following indications are non-covered for implanted permanent single chamber or dual chamber cardiac 
pacemakers: 
 
    Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia, 
    Asymptomatic first degree atrioventricular block, 
    Asymptomatic sinus bradycardia, 
    Asymptomatic sino-atrial block or asymptomatic sinus arrest, 
    Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without 
symptomatic bradycardia, 
    Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are 
prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His 
Bundle (a component of the electrical conduction system of the heart), 
    Syncope of undetermined cause, 
    Bradycardia during sleep, 
    Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) 
without syncope or other symptoms of intermittent atrioventricular block, 
    Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker 
drug therapy, 
    Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the 
control of tachycardia, and 
    A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated 
with a reasonable likelihood that pacing needs will become prolonged.  
You can find this information in Medicare's National Coverage Determination (NCD): Cardiac Pacemakers: 
Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (20.8.3). 
 
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 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 all other Medicare-covered Part B drugs. You can 
find this information on page 4-38 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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers 50 one-way trips. You can find this information on page 82 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 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 the 
requested item or service but is limited to one per arch every five calendar years. You can find this information 
on pages 146 to 178 of the Plan's 2022 Evidence of Coverage (EOC).