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 no payment may be made for the implantation of dorsal column or depth brain stimulators or 
services and supplies related to such implantation, unless all of the conditions listed below have been met: 
 
    The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic 
intractable pain; 
    With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for 
the given patient; 
    Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
    All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be available; and 
    Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find this information in Medicare's National Coverage Determination (NCD): Electrical Nerve 
Stimulators (160.7). 
 
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 for transcutaneous electrical nerve stimulators (TENS) is covered for acute post-operative 
pain. Coverage is limited to 30 days (one month's rental) from the day of surgery. Payment will be made only 
as a rental. You can find this rule in the Local Coverage Determination (LCD) - Transcutaneous Electrical 
Nerve Stimulators (TENS) (L33802) - Effective November 20, 2021. 
 
The rule say that TENS is covered for chronic, intractable pain other than chronic low back pain when all of the 
following criteria must be met: 
 
1. The presumed etiology of the pain must be a type that is accepted as responding to TENS therapy. Examples 
of conditions for which TENS therapy is not considered to be reasonable and necessary are (not all-inclusive): 
 
a. headache 
b. visceral abdominal pain 
c. pelvic pain 
d. temporomandibular joint (TMJ) pain 
 
2. The pain must have been present for at least three months 
3. Other appropriate treatment modalities must have been tried and failed 
 
TENS therapy for chronic pain that does not meet these criteria will be denied as not reasonable and 
necessary. You can find this rule in the Local Coverage Determination (LCD) - Transcutaneous Electrical 
Nerve Stimulators (TENS) (L33802) - Effective November 20, 2021. 
 
The rules say TENS therapy for Chronic Low Back Pain (CLBP) will be denied as not reasonable and 
necessary. You can find this rule in the Local Coverage Determination (LCD) - Transcutaneous Electrical 
Nerve Stimulators (TENS) (L33802) - Effective November 20, 2021. 
 
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 pages 35 to 36 of the Plan's 
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: 
 
1. Inclusion criteria (ALL are required):  
 
    Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5) by recent (within 30 days) 
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 equals5) despite optimal non-surgical 
management (NSM)10* (ONE): 
            Worsening pain 
            Stable to improved pain (but NRS or VAS still =5) (with = 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) 
 
* consider including pedicle periosteal infiltration7 
 
c. Continuum of care10 (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. 
 
2. Exclusion criteria (Can have NONE of the following): 
 a. 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 
 
b. Relative contraindication 
 
        Allergy to bone cement or opacification agents 
        Uncorrected coagulopathy 
        Spinal instability 
        Myelopathy from the fracture 
        Neurologic deficit 
        Neural impingement 
        Fracture retropulsion/canal compromise 
        Greater than three vertebral fractures 
 
Vertebral augmentation and KYPHOPLASTY for vertebral compression fractures with intractable spinal pain 
not relieved with medical therapy will be covered for osteolytic vertebral metastatic disease or myeloma 
involving a vertebral body. You can find this information in Medicare's Local Coverage Determination (LCD): 
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38737). 
 
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 effective for dates of service on or after October 9, 2014, The CologuardTM test is covered 
once every three years for Medicare beneficiaries that meet all of the following criteria: 
1. Age 50 to 85 years, and, 
2. Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower 
gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test (gFOBT) or fecal 
immunochemical test (iFOBT)), and, 
3. At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal 
cancer, or inflammatory bowel disease, including Crohns Disease and ulcerative colitis; no family 
history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary 
nonpolyposis colorectal cancer). 
You can find more information in Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Colorectal Cancer Screening 
Tests, 210.3. 
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 the reasonable useful lifetime (RUL) for oxygen equipment is 5 years. The RUL is not 
based on the chronological age of the equipment. It starts on the initial date of service and runs for 5 years from 
that date. 
 
There is no further payment for oxygen equipment during the 5-year reasonable useful lifetime (RUL) of the 
equipment after 36 rental payments have been made. If use of portable equipment begins after the use of 
stationary equipment begins, payment for the portable equipment can continue after payment for the stationary 
equipment ends until 36 rental payments have been made for the portable equipment. 
 
You can find this information in the Local Coverage Article:Oxygen and Oxygen Equipment - Policy Article 
(A52514). 
 
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 $60 copayment for Medicare-covered x-rays. You can find this 
information on page(s) 104 of the Plan's 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 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 50% coinsurance for skilled nursing facility care. You can find this 
information in chapter 4 on page 134 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 state that Medicare covers cytogenetic tests when they are reasonable and necessary for the diagnosis 
or treatment of the following conditions: 
- Genetic disorders (e.g., mongolism) in a fetus; 
- Failure of sexual development; 
- Chronic myelogenous leukemia; 
- Acute leukemias lymphoid (FAB L1-L3), myeloid (FAB M0-M7), and unclassified; or 
- Myelodysplasia 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 190.3. 
 
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 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 durable medical equipment and related supplies. 
You can find this information in chapter 4 on pages 63-64 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. 
 
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). 
  
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 the Plan covers a mandatory supplemental vision benefit with a frames and lens package. 
You have a choice of a $200 benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact 
lenses (1 per calendar year). Contact lenses will include conventional or disposable. Ultraviolet protection and 
scratch resistant coating are included in the eyeglass allowance benefit. You can find this information on page 
86 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 Up to two TruHearing-branded hearing aids every year (one per ear, per year). Benefit is 
limited to the TruHearing Advanced and Premium hearing aids, which come in various styles and colors. 
Premium hearing aids are available in rechargeable style options (for an additional fee). You must see a 
TruHearing provider to use this benefit. You can find this information on pages 85-86 in the Plan's 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 state that all drugs and biologicals used for the treatment of End-Stage Renal Disease (ESRD) are 
included in the ESRD prospective payment system (PPS) and are not separately paid as of January 1, 2011. 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 11, Section 20.3. 
 
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 say that molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) L35025 and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) (A56853). 
 
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 $45 copayment for specialist office visit. You can find this information 
on page(s) 111 of the Plan's 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 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 $50 copayment for urgent care services. You can find this information 
in Chapter 4 on page 99 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 long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of 
stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).   
 
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need 
medical care. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2. 
 
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 you are covered for 90 days for Medicare-covered inpatient hospital stays. You can find 
this information on page 69 of the Plans 2022 Evidence of Coverage.