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 epidural steroid injection (ESI) will be considered medically reasonable and necessary
when the following three (3) requirements are met: 1. History, physical examination, and concordant
radiological image-based diagnostic testing and supporting one of the following: - Lumbar, cervical or thoracic
radiculopathy, radicular pain and/or neurogenic claudication due to central disc herniation, osteophyte or
osteophyte complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis; or
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
repeated 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. Patients should be part of an active rehabilitation program, home exercise
program or functional restoration program. You can find this information in Local Coverage Determination
(LCD): Epidural Steroid Injections for Pain Management (L38994).

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). 
 
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 has determined for which surgical services an assistant surgeon is medically 
necessary. This information can be found in the Medicare Fee Schedule Database. If the database contains an 
assistant at surgery indicator of 1 for the surgical procedure in question, Medicare has determined that an 
assistant is not medically necessary. Assistant surgeons will not be paid for these procedures. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing 
Manual, Chapter 12, Section 40.8. 
 
The rules say that procedures billed with the assistant-at-surgery physician modifiers -80, -81, -82, or the AS 
modifier for physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant-
at-surgery policy. Accordingly, pay claims for procedures with these modifiers only if the services of an 
assistant-at-surgery are authorized. Medicares policies on billing patients in excess of the Medicare allowed 
amount apply to assistant-at-surgery services. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 12, Section 
20.4.3. 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. The only exception is as 
follows:  
 
For the same date of service only one physician of the same specialty in the group practice may report code 
99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care 
services with CPT code 99292. 
 You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
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 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 9 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 a specific diagnosis code is required to be present for coverage for percutaneous image
guided breast biopsy coded as 19083. You can find this in the Medicare National Coverage Determination
(NCD) Percutaneous Image-Guided Breast Biopsy (220.13).

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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual
for Medicare Services, Chapter I(A).

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.

Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to
aid vision or magnify images. This rule applies no matter the size, form, or technological features of the device.
This rule does not apply to:

1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after
each cataract surgery with insertion of an IOL; and
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with
an IOL.
You can find this rule at 42 CFR Section 411.15(b).
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in
connection with otherwise covered diagnosis or treatment of illness or injury.

You can find these rules at 42 CFR Section 411.15(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 the maximum plan allowance for supplemental eye wear is $300 every calendar year. You
can find this information on page 96 of the 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 and benefit
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 members must meet and maintain all three eligibility criteria below to qualify for
special supplemental benefits for the chronically ill (SSBCI):
1. The member must require intensive care management.
- Based on physician assessment of patient having had 2 or more inpatient admissions in the
last 60 days OR having had 3 or more emergency room visits in the last 60 days.
2. The member must be at high risk for hospitalization.
- Based on physician assessment of patient being at high-risk for unplanned hospitalization in
the next 60 days.
3. The member must have a documented and active diagnosis for one or more of the qualifying
comorbid and medically complex conditions. The condition must be life threatening or
significantly limit the overall health or function of the member.
- After required office visit, physician to submit claim showing diagnosis code(s) for
qualifying eligible condition(s).
- Eligibility is determined at the discretion of your plan through processes that review claims history,
risk classification, and other information. Members who cannot be automatically qualified will be
required to schedule a visit with their physician to ensure sufficient documentation (e.g., claims,
qualifying assessment) are available to validate eligibility. Copays or other costs not covered by
your plan may apply.
- Confirmation that all criteria has been met is required prior to receiving access to these benefits.
- All benefits end on December 31, 2023 and members will be required to re-qualify each plan year. You can
find this starting on page 70 of the Plans 2023 Dual Align 001 (HMO D-SNP), Medicare Medi-Cal Plan
Member Handbook.
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 Members must meet and maintain all three eligibility criteria below to qualify for
special supplemental benefits for the chronically ill (SSBCI):
1. The member must require intensive care management.
- Based on physician assessment of patient having had 2 or more inpatient admissions in the
last 60 days OR having had 3 or more emergency room visits in the last 60 days.
2. The member must be at high risk for hospitalization.
- Based on physician assessment of patient being at high-risk for unplanned hospitalization in
the next 60 days.
3. The member must have a documented and active diagnosis for one or more of the qualifying
comorbid and medically complex conditions. The condition must be life threatening or
significantly limit the overall health or function of the member.
- After required office visit, physician to submit claim showing diagnosis code(s) for
qualifying eligible condition(s).
- Eligibility is determined at the discretion of your plan through processes that review claims history,
risk classification, and other information. Members who cannot be automatically qualified will be
required to schedule a visit with their physician to ensure sufficient documentation (e.g., claims,
qualifying assessment) are available to validate eligibility. Copays or other costs not covered by
your plan may apply.
- Confirmation that all criteria has been met is required prior to receiving access to these benefits.
- All benefits end on 12/31/2023 and members will be required to re-qualify each plan year. You can find this
starting on page 57 of the Plans 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 a Medicare plan may restrict enrollees 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 and cover any medically necessary covered benefit outside of the plan provider network, but at in-
network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollees 
medical needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community based 
services. You can find this rule at 42 CFR Section 422.112. 
 
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 30 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.

Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to
aid vision or magnify images. This rule applies no matter the size, form, or technological features of the device.
This rule does not apply to:
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after
each cataract surgery with insertion of an IOL; and
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with
an IOL.

You can find this rule at 42 CFR Section 411.15(b).

Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42
CFR Section 411.15(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 the maximum plan allowance for supplemental eye wear is $300 every calendar year. You
can find this information on page 96 of the 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 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) 34-35 of the Plan's 
2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
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 that enrollees must pay $200 copayment for Outpatient hospital observation. You can find this 
information on pages 63 and 68 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 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 does not include 
D5650. You can find this information on pages 50-52 of the Plans 2023 Evidence of Coverage (EOC).