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 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. 
 
The rules say that Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and 
manufacturers, as long as they ensure that enrollees have access to all medically necessary (including non-
preferred) DME products or brands. You can find this information in the Centers for Medicare and Medicaid 
Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual Chapter 4, 10.12.2. 
 
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 they only cover OneTouch and ACCU-CHECK blood glucose test strips. You can find this 
information on pages 57 and 58 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 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). 
 
The rules say that the following diagnoses are covered for CPT codes 93312, 93313, 93314 and C8925. (When 
reporting add-on CPT codes 93319, 93320, 93321 and 93325, the same ICD-10-CM code should be used as 
that used for the base code to which it is attached): 
 
Use ICD-10 codes R93.1 or R93.89 when a TEE is performed because of inadequate visualization of cardiac 
anatomy on TTE, for structures normally visualized by TTE and for which TEE is not usually indicated. The 
ICD-10 codes R93.1 or R93.89 should be coded as the primary diagnosis and the cardiac abnormality should be 
coded as a secondary diagnosis. 
 
Use ICD-10 codes Z01.30, Z01.31, or Z01.89 when a TEE is performed during an open chest procedure. ICD-
10 codes Z01.30, Z01.31, or Z01.89 should be coded as the primary diagnosis and the reason for the surgical 
procedure should be coded as the secondary diagnosis. You can find this rule in Local Coverage Article Billing 
and Coding Billing and Coding: Transesophageal Echocardiography (TEE) A52868. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the Centers for Medicare & Medicaid Services (CMS) has determined that percutaneous 
image-guided lumbar decompression (PILD) will be covered by Medicare when provided in a clinical study 
under section 1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development 
(CED) for beneficiaries with lumbar spinal stenosis (LSS) who are enrolled in an approved clinical study that 
meets the criteria. CMS will cover through a prospective, longitudinal study PILD procedures using an FDA-
approved/cleared device that completed a CMS-approved randomized control trial (RCT) that meet the criteria. 
All CMS-approved clinical research studies must adhere to the following standards of scientific integrity and 
relevance to the Medicare population. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determination for 
Percutaneous Image-Guided Lumbar Decompression for Lumbar Spinal Stenosis, 150.13. 
 
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 pages 59 to 113 of the Plans 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 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 includes a list of covered supplemental dental services. Periodontal scaling and root planing (D4341) 
is not included on this list and is not a covered supplemental benefit. This benefit includes restorations and is 
limited to two procedure codes per calendar year. You can find this information on pages 85 to 87 of the Plans 
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 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). 
 
The rules say that the Physician Fee Schedule Status Indicator N means that the service is non-covered. You 
can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, 30.2.2. 
 
The rules also say that multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. You can 
find this rule in the Local Coverage Determination (LCD) for MolDX: Multiplex Nucleic Acid Amplified Tests 
for Respiratory Viral Panels (L37713). 
 
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 pages 58 to 60 of the Plans 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 Negative Pressure Wound Therapy pump (NPWT) and supplies are covered when the 
criterion is met: 
A. Ulcers and Wounds in the Home Setting: 
The beneficiary has a chronic Stage 3 or 4 pressure ulcer (see Appendices Section), neuropathic (for 
example, diabetic) ulcer, venous or arterial insufficiency ulcer, or a chronic (being present for at least 
30 days) ulcer of mixed etiology. A complete wound therapy program described by criterion 1 and 
criteria 2, 3, or 4, as applicable depending on the type of wound, must have been tried or considered and 
ruled out prior to application of NPWT. 
 
1. For all ulcers or wounds, the following components of a wound therapy program must 
include a minimum of all of the following general measures, which should either be 
addressed, applied, or considered and ruled out prior to application of NPWT: 
a. Documentation in the beneficiary's medical record of evaluation, care, and 
wound measurements by a licensed medical professional, and 
b. Application of dressings to maintain a moist wound environment, and 
c. Debridement of necrotic tissue if present, and 
d. Evaluation of and provision for adequate nutritional status 
 
 
B. Ulcers and Wounds Encountered in an Inpatient Setting:  
 
1. An ulcer or wound (described under A above) is encountered in the inpatient setting and, 
after wound treatments described under A-1 through A-4 have been tried or considered 
and ruled out, NPWT is initiated because it is considered in the judgment of the treating 
practitioner, the best available treatment option. 
2. The beneficiary has complications of a surgically created wound (for example, 
dehiscence) or a traumatic wound (for example, pre-operative flap or graft) where there 
is documentation of the medical necessity for accelerated formation of granulation tissue 
which cannot be achieved by other available topical wound treatments (for example, 
other conditions of the beneficiary that will not allow for healing times achievable with 
other topical wound treatments). 
 
 In either situation B-1 or B-2, NPWT will be covered when treatment is ordered to continue beyond discharge 
to the home setting. If criterion A or B above is not met, the NPWT pump and supplies will be denied as not 
reasonable and necessary. You can find this rule in the Local Coverage Determination for Negative Pressure 
Wound Therapy Pumps, L33821.  
 
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 
restorations and are limited to 2 procedure codes per calendar year. You can find this information on page 87 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 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 an 
annual maximum benefit of $1,000. The contract says that after the annual maximum is exhausted, any 
remaining charges are your responsibility. You can find this information on page 4-78 of the Plans 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 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 pages 114 to 125 of the Plans 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 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 $10 copayment for outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information on page(s) 102 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 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 specific 
dental procedure codes included in the dental benefits chart. Incisional biopsy of oral tissue-soft (D7286). is not 
covered by the Plan's dental benefits. You can find this information in Chapter 4 on pages 61 to 73 of the 
Plans 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 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 includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. 2D oral/facial photographic image (D0350) is not included on this list and 
is not a covered supplemental benefit. You can find this information on pages 4-89 to 4-103 of the Plans 2022 
Evidence of Coverage (EOC). 
 
The contract also says for services obtained Out-of-Network the plan only pays up to a certain amount. If you 
choose to see an Out-of-Network dentist you might be billed by that provider for any amount greater than what 
the plan pays, even for services listed as $0 copayment. You can find this information on page 4-89 of the 
Plan's 2022 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. The Plan contract says 
fillings covered once every 24 months per surface, per tooth. White fillings on posterior teeth will be processed 
as a silver filling and the patient is responsible for up to the contracted fee. The contract also says you must pay 
a 50% coinsurance for Class 2 Basic Services, including fillings. You can find this information on page 77 of 
the Plans 2022 Evidence of Coverage (EOC).