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 Medicare will cover and reimburse tests that demonstrate analytical and clinical validity. 
The molecular diagnostics (MolDX) contractor will review all new test/assay clinical information to determine 
if a test meets Medicares reasonable and necessary requirements. Medicare will cover approved tests covered 
for dates of service consistent with the effective date of the coverage determination. You can find these rules in 
Local Coverage Determination (LCD) MolDX: Molecular Diagnostic Tests (MDT) (L36021). 
 
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 CT colonography is indicated when a board certified or board eligible gastroenterologist, a 
surgeon trained in endoscopy or a physician with equivalent endoscopic training determines from an evaluation 
  
  of the patient that optical colonoscopy cannot be safely attempted. You can find this rule at Local Coverage 
Determination L33562 entitled Computed Tomography Colonography for Diagnostic Uses. 
 
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 plans can restrict members to using contract providers except for emergency care (including 
ambulance services), out-of-area urgently needed care, post-stabilization care, and pre-approved care. You can 
find this rule at 42 CFR Section 422.112(a)(9). 
 
The rules say that a Medicare plan must pay for emergency care regardless of whether the care is provided by a 
contract provider or a non-contract provider. Emergency care ends when the patient is stabilized.  
 
Post-stabilization care is care that is administered to maintain, improve, or resolve the enrollee's stabilized 
condition. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is 
obtained from a non-contract provider, approval is required from the plan. However, the requirement for pre-
approval does not apply if: 
 
1. The Plan does not respond to a request for pre-approval within one hour, 
 
2. The Plan cannot be contacted, or 
 
3. The Plan representative and the treating physician cannot reach an agreement concerning the enrollee's care 
and a plan physician is not available for consultation. 
You can find this rule at 42 CFR Section 422.113(c). 
 
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 39 to 44 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 that an ultrasonic osteogenesis stimulator (E0760) is covered only if all of the following criteria 
are met: 
1. Nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to 
starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days. Each 
radiograph set must include multiple views of the fracture site accompanied by a written 
interpretation by a treating practitioner stating that there has been no clinically significant 
evidence of fracture healing between the two sets of radiographs; and 
2. The fracture is not of the skull or vertebrae; and 
3. The fracture is not tumor related. 
An ultrasonic osteogenesis stimulator will be denied as not medically necessary if any of the criteria above are 
not met. You can find this rule at Local Coverage Determination (LCD) L33796: Osteogenesis Stimulators (eff. 
1/1/20). 
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 the following are examples of wound care items which are non-covered under the surgical 
dressing benefit because they do not meet the statutory definition of a dressing (not all-inclusive): Wound 
cleansers (A6260) or irrigating solutions. You can find this information in Medicare's Local Coverage Article: 
Surgical Dressings (A54563). 
 
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 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. The Plan 
contract also says that while you can get your care from an out-of-network provider, the provider must be 
eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to 
participate in Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be 
responsible for the full cost of the services you receive. You can find this information on page 41 to 42 of the 
Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
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 there is a $1,000 deductible which applies to certain items and services. The Plan 
deductible applies to vision care. The Plan also says that the deductible does not apply to supplemental 
benefits. You can find this information on pages 43-44 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 cosmetic surgery or expenses incurred in connection with such surgery is not covered. 
Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for 
the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the 
functioning of a malformed body member. For example, this exclusion does not apply to surgery in connection 
with treatment of severe burns or repair of the face following a serious automobile accident, or to surgery for 
therapeutic purposes which coincidentally also serves some cosmetic purpose. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 16, Section 120.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $225 copayment for all other diagnostic and nuclear medicine 
radiological services. You can find this information in Chapter 4 on page 52 of the Plan's 2021 Evidence of 
Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay 20% coinsurance for Medicare Part B chemotherapy drugs and 
other Part B drugs. The Plan contract also says that enrollees must pay a $20 copayment per visit (in office or 
via telehealth) for specialist doctor visits. You can find this information on pages 85 and 92 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 state that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question 
is not valid for Medicare purposes. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
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 pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
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. The Plan 
contract also says that you have a supplemental wellness allowance that reimburses you up to $150 per a 
calendar year to cover the cost towards a fitness membership in a qualified health club or fitness facility. You 
can find this information on page 80 to 81 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 that Epidural steroid injection (ESI) will be considered medically reasonable and necessary when 
the following three (3) requirements are met: 
 
 History, physical examination, and concordant radiological image-based diagnostic testing 
supporting 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; OR 
 Post-laminectomy syndrome; OR 
 Acute herpes zoster associated pain 
AND 
 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 repeated at each follow-up for 
assessment of response.  
AND 
 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 for Epidural Steroid Injections for Pain 
Management, L39015 (eff 12/05/21).  
 
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 Section 1833(t) of the Social Security Act (the Act) as amended by 4533 of the Balanced 
Budget Act (BBA) of 1997, authorizes CMS to implement a Medicare prospective payment system (PPS) for 
hospital outpatient services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Medicare Claims Processing Manual, Chapter 4, Section 10. 
 
The rules also say that the outpatient PPS recognizes that Current Procedural Terminology (CPT) code 99153 
is a practice expense (PE) only code and are finalizing the proposed PE inputs for CPT code 99153, as well as 
finalizing the proposed PE inputs for all other codes in this family without modification. You can find this 
information in the Physicians Fee Schedule Final Rule. 
 
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 dual-energy x-ray absorptiometry (axial) tests are covered when used to monitor FDA- 
approved osteoporosis drug therapy subject to the 2-year frequency standards described in chapter 15, section 
80.5.5 of the Medicare Benefit Policy Manual. Contractors will pay claims for monitoring tests when coded as 
follows: 
Contains CPT procedure code 77080 or 77085, and 
Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the  International Classification of 
Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis code or M81.0, M81.8, M81.6 or M94.9 
as the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)  diagnosis 
code.  
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 13, Section 140.1. 
 
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 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 one 
comprehensive or periodontal oral exam every three calendar years. This benefit does not list unspecified 
preventative procedures as a covered service. You can find this information on pages 101-107 of the Plans 
2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 Plan 
contract says that you have a Pick your perks reimbursement program to cover eligible expenses. You can find 
this information on pages 94 and 95 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 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. 
 
  
  The rules say that the plan must pay for emergency and urgently needed services. This rule applies whether the 
services are obtained in or out of the plans network. This rule applies whether or not there is prior 
authorization for the services. The rules say that an emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules 
say that urgently needed services are those needed because of an unforeseen illness or condition, and it is not 
reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside 
of the service area. You can find this rule at 42 CFR Section 422.113. 
 
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 does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 they will cover up to two Plan branded hearing aids every year (one per ear per year). 
Benefit is limited to specific hearing aids through the Plan, which come in various styles and colors. You must 
see a Plan provider to use this benefit. You can find this information on page 69 to 70 of the Plan's 2021 
Evidence of Coverage.