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 patients admitted to a partial hospitalization program (PHP) must be under the care of a 
physician who certifies the need for partial hospitalization and require a minimum of 20 hours per week of 
therapeutic services, as evidenced by their plan of care. The patients also require a comprehensive, structured, 
multimodal treatment requiring medical supervision and coordination, provided under an individualized plan of 
care, because of a mental disorder which severely interferes with multiple areas of daily life, including social, 
vocational, and/or educational functioning. Such dysfunction generally is of an acute nature. In addition, PHP 
patients must be able to cognitively and emotionally participate in the active treatment process, and be capable 
of tolerating the intensity of a PHP program. Patients meeting benefit category requirements for Medicare 
coverage of a PHP comprise two groups: those patients who are discharged from an inpatient hospital treatment 
program, and the PHP is in lieu of continued inpatient treatment; or those patients who, in the absence of partial 
hospitalization, would be at reasonable risk of requiring inpatient hospitalization. Where partial hospitalization 
is used to shorten an inpatient stay and transition the patient to a less intense level of care, there must be 
evidence of the need for the acute, intense, structured combination of services provided by a PHP. 
Recertification must address the continuing serious nature of the patients psychiatric condition requiring active 
treatment in a PHP. You can find these rules in Medicare Benefit Policy Manual Chapter 6, Section 70.3. 
 
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.
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 all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be 
ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or 
treats a beneficiary for a specific medical problem and who uses the results in the management of the 
beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are 
not reasonable and necessary. You can find this information in the 42 Code of Federal Regulations (CFR), 
Section 410.32. 
 
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). 
 
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. The contract also says that 
enrollees may be billed by the out-of-network provider for any charged amount greater than the payment made 
by the Plan. Additionally, the Plans contract states that one intraoral x-ray is covered per calendar year. You 
can find this information on pages 78-82 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 Pap tests and pelvic exams are covered once every 24 months. If you are at high risk of 
cervical or vaginal cancer or you are of childbearing age and have had an abnormal Pap test within the past 3 
years: one Pap test every 12 months. You can find this information on page 52 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 Medicare encourages physicians, hospitals and other providers and suppliers to care for and 
administer drugs and biologicals to patients in such a way that they can use drugs or biologicals most 
efficiently, in a clinically appropriate manner. When a billing provider or supplier must discard the remainder 
of a single-dose container or single-use package after administering a dose to a Medicare patient, the program 
provides payment for the amount of drug or biological discarded as well as the dose administered, up to the 
amount of the drug or biological as indicated on the vial or package label. You can find this rule in the Centers 
for Medicare & Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 17, Section 40. 
 
The rules say that generally, the discarded amount is the labeled amount on the single-dose container (or 
containers if more than one is required) minus the dose (the dose being the prescribed amount of drug 
administered to the patient). You can find this rule in the Centers for Medicare & Medicaid Services, Internet-
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Section 40. 
 
The rules say that Medicare uses ampules, single dose and multiple dose vials and repacks to compare the 
strength and dosage. If multiple dose vials are used, contractors must determine how they are used, based on 
the strength indicator compared with the HCPCS code description (i.e., if the strength on the vial matches the 
HCPCS description, multi-dose vials should be used). You can find this rule in the Centers for Medicare & 
Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
17, Section 20.5.4. 
 
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.
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 
$2,500 annual dental allowance amount for covered dental benefits You can find this information on pages 75-
77 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 & 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. Covered dental services and 
limitations/exclusions are listed on pages 1-18 in the Plan's Description of Benefits and Copayments. Any 
service not listed is not covered.
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 
75-79 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 the clinical effectiveness of arthroscopic lavage and arthroscopic debridement for the severe 
osteoarthritic knee has not been verified by scientifically controlled studies. After thorough discussions with 
clinical investigators, the orthopedic community, and other interested parties, CMS determines that the 
following procedures are not considered reasonable or necessary in treatment of the osteoarthritic knee and are 
not covered by the Medicare program: 
 
1. Arthroscopic lavage used alone for the osteoarthritic knee; 
2. Arthroscopic debridement for osteoarthritic patients presenting with knee pain only; or, 
3. Arthroscopic debridement and lavage with or without debridement for patients presenting with severe 
osteoarthritis (Severe osteoarthritis is defined in the Outerbridge classification scale, grades III and IV. 
Outerbridge is the most commonly used clinical scale that classifies the severity of joint degeneration of 
the knee by compartments and grades. Grade I is defined as softening or blistering of joint cartilage. 
Grade II is defined as fragmentation or fissuring in an area <1 cm. Grade III presents clinically with 
cartilage fragmentation or fissuring in an area >1 cm. Grade IV refers to cartilage erosion down to the 
bone. Grades III and IV are characteristic of severe osteoarthritis.) 
 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication Number 100-03, Medicare National Coverage Determinations Manual, Section 150.9. 
 
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 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 does not include 
guided tissue regeneration or bone replacement grafts. You can find this information on pages 60 and 87-91 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 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 restorative and extraction services (Basic Class II) which includes only stainless steel crowns. 
You can find this information on page 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 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 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. The core buildup is not covered by the Plan's dental benefits. You can find this information on 
pages 74 to 77 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 state that sacroiliac joint injections (SIJI) will be considered medically reasonable and necessary 
when all the following requirements are met: 
 
Moderate to severe low back pain primarily experienced over the anatomical location of the SI joints between 
the upper level of the iliac crests and the gluteal fold, AND 
Low back pain duration of at least three (3) months, AND 
Low back pain below L5 without radiculopathy, AND 
Clinical findings and/or imaging studies do not suggest any other diagnosed or obvious cause of the 
lumbosacral pain (such as central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis 
or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, pseudoarthrosis, or 
pain related to spinal instrumentation), AND 
At least three positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior 
Shear, SI Compression, SI Distraction and Yeoman Tests,3,4 AND 
Low back pain persists despite a minimum of four weeks of conservative therapies. 
B. Diagnostic Sacroiliac Joint Injections 
 
Diagnostic SIJI is used to determine if the etiology of pain is from the sacroiliac joint complex.3 
 
Diagnostic SIJI are considered reasonable and necessary for patients who meet ALL the following criteria: 
 
The patient must meet the above criteria for Covered Indications for SIJI, AND 
The SI joint injections must be performed under CT or fluoroscopy image guidance with contrast, except 
ultrasound guidance may be considered reasonable and necessary when there is a documented contrast allergy 
or pregnancy, since the accuracy with ultrasound guidance is inferior to fluoroscopic guidance,6 AND 
SI joint injection are not performed with other musculoskeletal injections in the lumbosacral spine, AND 
The documentation should show direct causal benefit from the SI joint injection and not from other 
musculoskeletal injections or treatments, AND 
The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a 
positive diagnostic response is defined as =75% sustained and constant pain relief for the duration of the local anesthetic and =75% sustained and constant pain relief for the duration of the anti-inflammatory steroid) was 
measured by the SAME pain scale* at baseline. The measurements of pain must be taken pre-injection on the 
day of the SIJ injection, post-intervention on the day of the injection, and the days following the injection to 
substantiate and corroborate the pain scores consistent with the pain relief for the duration of the local 
anesthetic and/or steroid used. 
 
You can find this information Local Coverage Determination (LCD) Sacroiliac Joint Injections and Procedures 
L39464. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 the requested items or services, but only when they are received from an in-network provider. You 
can find this information on page 51 of the Plan's 2023 Evidence of Coverage (EOC).