Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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 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: 
 Arthroscopic lavage used alone for the osteoarthritic knee; 
 Arthroscopic debridement for osteoarthritic patients presenting with knee pain only; or, 
 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.) 
 National Coverage Determination (NCD): Arthroscopic Lavage and Arthroscopic Debridement for the 
Osteoarthritic Knee (150.9).
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 also says that the Plan pays up to $300 per year for the following contact lenses. You can find this 
information on pages 114-115 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 that application of a skin substitute graft for lower extremity chronic wound will be covered 
when the following conditions are met for the individual patient: 
- Presence of neuropathic diabetic foot ulcer(s) having failed to respond to documented conservative 
wound-care measures of greater than four weeks, during which the patient is compliant with 
recommendations, and without evidence of underlying osteomyelitis or nidus of infection. 
- Presence of a venous stasis ulcer for at least 3 months but unresponsive to appropriate wound care for at 
least 30 days with documented compliance. 
- Presence of a full thickness skin loss ulcer that is the result of abscess, injury or trauma that has failed to 
respond to appropriate control of infection, foreign body, tumor resection, or other disease process for a 
period of 4 weeks or longer. 
In all wound management the ulcer must be free of infection and underlying osteomyelitis with documentation 
of the conditions that have been treated and resolved prior to the institution of skin substitute therapy. For 
purposes of this LCD, appropriate therapy includes, but is not limited to: 
- Control of edema, venous hypertension or lymphedema 
- Control of any nidus of infection or colonization with bacterial or fungal elements 
- Elimination of underlying cellulitis, osteomyelitis, foreign body, or malignant process 
- Appropriate debridement of necrotic tissue or foreign body (exposed bone or tendon) 
- For diabetic foot ulcers, appropriate non-weight bearing or off-loading pressure 
- For venous stasis ulcers, compression therapy provided with documented diligent use of multilayer 
dressings, compression stockings of greater than 20 mmHg pressure, or pneumatic compression 
- Provision of wound environment to promote healing (protection from trauma and contaminants, 
elimination of inciting or aggravating processes) 
You can find this information in Local Coverage Determination (LCD): Application of Bioengineered Skin 
Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041). 
 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 services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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 
coverage for exams - 2 visits per year. You can find this information on page 58 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 this is a non-coverage policy for genetic testing for thrombophilia testing for the Factor V 
Leiden (FVL) variant in the F5 gene, the G20210G>A (G20210A) variant in the F2 gene, and the 
Methylenetetrahydrofolate reductase (MTHFR) gene which encodes the 5,10-methylenetetrahydrofolate 
reductase enzyme. Genetic testing for these genes for all risk factors, signs, symptoms, diseases, or conditions, 
including cardiovascular risk assessment, are non-covered except for pregnant patients. 
 
Testing for FVL and F2 G20210A mutations is indicated for pregnant patients who have a history of personal 
venous thromboembolism (VTE) associated with a non-recurrent (transient) risk factor who are not otherwise 
receiving anticoagulant prophylaxis. The results of genetic testing can inform risk stratification for VTE 
recurrence and subsequent need for antenatal prophylaxis. However, Medicare will not add coverage of 
thrombophilia testing for pregnant women because they likely represent a very small group of potential 
Medicare (disabled) patients. Claims submitted on this limited Medicare population will deny per the policy 
but should be appealed for coverage with submission of medical records supporting the necessity for testing 
and specify how testing changed anticoagulant prophylaxis management for the patient. 
 
You can find these rules in the Local Coverage Determination (LCD) MolDX: Genetic Testing for 
Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) L36155. 
 
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. You can find this information 
on page 61 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 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 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 Plan 
contract says that enrollees must pay a $25 copayment for extractions per tooth. You can find this information 
on page 72 of the Plans 2023 Evidence of Coverage (EOC).  
 
The Plan contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The 
contract says that enrollees may be billed by the out-of-network provider for any charged amount greater than 
the payment made by the Plan. You can find this information on page 73 of the Plan's 2023 EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for the complete denture - maxillary and complete denture mandibular but both are limited to 1 per 60 
floating months. You can find this information on page 202 of the Plan's 2023 Medicare quick reference guide.
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 chemotherapy administration codes apply to parenteral administration of non- radionuclide 
anti-neoplastic drugs; and also, to anti-neoplastic agents provided for treatment of noncancer diagnoses or to 
substances such as monoclonal antibody agents, and other biologic response modifiers. The following drugs are 
commonly considered to fall under the category of monoclonal antibodies: infliximab, rituximab, alemtuzumb, 
gemtuzumab, and trastuzumab. Drugs commonly considered to fall under the category of hormonal 
antineoplastics include leuprolide acetate and goserelin acetate. The drugs cited are not intended to be a 
complete list of drugs that may be administered using the chemotherapy administration codes. Local carriers 
may provide additional guidance as to which drugs may be considered to be chemotherapy drugs under 
Medicare. The administration of anti-anemia drugs and anti-emetic drugs by injection or infusion for cancer 
patients is not considered chemotherapy administration. You can find this information in the Centers for 
Medicare and Medicaid Service, Internet-Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 12, Section 30.5 D. 
 
The rules say that the administration of specifically listed drugs should not be billed using a chemotherapy 
administration code. Instead, the administration of these drugs in their subcutaneous or intramuscular forms 
should be billed using code 96372 - therapeutic, prophylactic, or diagnostic injection (specify substance or 
drug); subcutaneous or intramuscular. To avoid unnecessary rejections, claims for these types of drugs and 
their non-chemotherapy administration should be billed as a pair on a separate claim from any chemotherapy. 
One of the drugs listed that should not be billed using a chemotherapy administration code is denosumab 
(Prolia) represented by code J0897. You can find this information in the Local Coverage Article (LCA) Billing 
and Coding: Complex Drug Administration Coding (A59073). 
 
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
2. The services require the skills or direct supervision of a therapist,  
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. 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 220.2. 
 
The local Medicare Administrative Contractor has published its interpretation of the various outpatient therapy 
rules which provide more specific criteria for certain services. You can find this information in the Local 
Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L33631). 
 
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 regardless of the number of trips provided by an air 
ambulance. You can find this information on page 59 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 60 one-way trips, combined in and out-of-network, each year. You can find this information on 
page 110 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 that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 20-26 of the Plan's 2023 
Evidence of Coverage (EOC).