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

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that epidural steroid injection (ESI) will be considered medically reasonable and necessary 
when the history, physical examination, and concordant radiological image-based diagnostic testing support 
  
  lumbar, cervical or thoracic radiculopathy and/or neurogenic claudication due to central disc herniation, 
osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or central spinal 
stenosis, or radiculopathy radicular pain and/or neurogenic claudication is severe enough to greatly impact 
quality of life or function. 
 
Duration of the pain must be at least four weeks with the inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to four (4) weeks of noninvasive conservative care. You can find 
this information in the Local Coverage Determination (LCD): Epidural Steroid Injections for Pain Management 
(L39054). 
 
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 only for the following services: oral exams, x-rays, cleanings, fillings, root canals, crowns, 
periodontics, extractions, dentures and bridges, oral surgery, and anesthesia. You can find this information on 
pages 66 and 67 of the Plans 2021 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 A group 2 support surface is covered if the beneficiary meets at least one of the following 
three Criteria (1, 2 or 3): 
1. The beneficiary has multiple stage 2 pressure ulcers located on the trunk or pelvis which have failed to 
improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment 
program including each of the following: 
   a. Use of an appropriate group 1 support surface, and 
   b. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and 
   c. Appropriate turning and positioning, and 
   d. Appropriate wound care, and 
   e. Appropriate management of moisture/incontinence, and 
f. Nutritional assessment and intervention consistent with the overall plan of care 
2. The beneficiary has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis, 
3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within 
the past 60 days and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital 
or nursing facility within the past 30 days. 
 
You can find this information in the Local Coverage Determination (LCD): Pressure Reducing Support 
Surfaces - Group 2 (L33642). 
 
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 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). 
 
The rules say that the appropriate use criteria for echocardiography is a meta-analysis that addresses 
appropriate use of echocardiography. Stress echocardiography is recommended for asymptomatic patients with 
a coronary calcium Agatston score >400, for patients with new or worsening symptoms with a previous 
abnormal stress test and the inability to exercise. A stress echocardiography is also recommended for 
evaluating inducible ischemia in patients with an intermediate risk for coronary artery blockages and have 
established CAD, experienced an ACS event (STEMI, NSTEMI, or unstable angina) within the past 90 days 
provided that they did not undergo coronary angiography at the time of the acute event and are currently 
clinically stable. You can find this information in Local Coverage Determination (LCD) Cardiology Non-
emergent Outpatient Stress Testing L35083. 
 
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 repeat epidural steroid injection is covered when the first injection directly and significantly 
provided improvement of the condition being treated. It may be considered medically reasonable and necessary 
when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement 
in function measured from baseline using SAME scale for at least three months. You can find this rule in the 
Local Coverage Determination (LCD) - Epidural Steroid Injections for Pain Management (L38994) - Effective 
December 5, 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 testing for 12 or more organisms will only be covered in critically ill or immunosuppressed 
patients. You can find this rule in the the Local Coverage Determination (LCD) - Foodborne Gastrointestinal 
Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs) (L37766) - Effective August 5, 
2021. 
 
The rules say that in immune competent individuals, most people with Cryptosporidium, a parasitic disease, 
will recover without treatment. The pathogens in some of the GIP panels are determined by the manufacturers 
that make them, and do not represent specific pathogens that cause a common age-based syndrome or represent 
organisms that commonly are found in a specific sample type, patient population or reflect community acquired 
foodborne infections. Because of the unique clinical circumstances of immune compromised patients, ICU 
patients, and HIV positive patients with diarrhea, GIP testing for bacteria, virus and parasite testing may be 
indicated, and thus a Medicare benefit. You can find this rule in the the Local Coverage Determination (LCD) 
- Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs) 
(L37766) - Effective August 5, 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 state that a second confirmatory diagnostic facet joint procedure is considered medically reasonable 
and necessary in patients who achieved at least 80% relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). You can find this information in the Local Coverage Determination 
(LCD): Facet Joint Interventions for Pain Management (L34892). 
 
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 services provided outside of the United States are excluded from coverage except for 
emergency inpatient hospital services, physician an ambulance services connected to a covered foreign 
hospitalization, or services rendered on board a ship in a US port or within 6 hours of the ship's arrival in or 
departure from a US port.  You can find this rule at Centers for Medicare and Medicaid Services, Internet-Only 
Publication 100-02, Medicare Benefit Policy Manual Chapter 16, Section 60. 
 
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 it covers worldwide emergency and urgent care services outside of the United States. 
You can find this information on page 44 of your 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 radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen 
simultaneous tests are in vitro techniques for determining whether a patient's serum contains IgE antibodies 
against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on 
the findings during a complete history and physical examination of the patient. The multiple antigen 
simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of 
allergic antibodies in the blood of the patient being tested. With the multiple antigen simultaneous test system, 
several antigens may be used to test for specific IgE simultaneously. You can find this rule in the Local 
Coverage Determination (LCD) - RAST Type Tests (L33591) - Effective November 7, 2019. 
 
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 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 per calendar year when each trip does not exceed 75 miles. You can find this 
information on pages 4-83 and 4-84 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 no payment may be made for the implantation of dorsal column or deep brain stimulators or 
services and supplies related to such implantation, unless all of the conditions listed below have been met: 
 
A. The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic 
intractable pain; 
B. 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; 
C. 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); 
D. 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 
E. Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find this rule in National Coverage Determination (NCD) for Electrical Nerve Stimulators (160.7) - 
Effective August 7, 1995. 
 
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 thyroid function tests are used to define hyper function, euthyroidism, or hypofunction of 
thyroid disease. Thyroid testing may be reasonable and necessary to: 
 
-Distinguish between primary and secondary hypothyroidism; 
-Confirm or rule out primary hypothyroidism; 
-Monitor thyroid hormone levels (for example, patients with goiter, thyroid nodules, or thyroid cancer); 
-Monitor drug therapy in patients with primary hypothyroidism; 
-Confirm or rule out primary hyperthyroidism; and 
-Monitor therapy in patients with hyperthyroidism. 
 
You can find this rule in the National Coverage Determination (NCD) - Thyroid Testing (190.22). 
 
The rules say that thyroid function testing may be medically necessary in patients with disease or neoplasm of 
the thyroid and other endocrine glands. Thyroid function testing may also be medically necessary in patients 
with metabolic disorders; malnutrition; hyperlipidemia; certain types of anemia; psychosis and non-psychotic 
personality disorders; unexplained depression; ophthalmologic disorders; various cardiac arrhythmias; 
disorders of menstruation; skin conditions; myalgias; and a wide array of signs and symptoms, including 
alterations in consciousness; malaise; hypothermia; symptoms of the nervous and musculoskeletal system; skin 
and integumentary system; nutrition and metabolism; cardiovascular; and gastrointestinal system. You can find 
this rule in the National Coverage Determination (NCD) - Thyroid Testing (190.22) 
 
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 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 Outpatient Prospective Payment System (OPPS) Status Indicator N means that payment 
for covered services is always packaged into payment for other services. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 4, 10.1.1. 
 
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 dental services only when received from a network dentist. You can find this information on 
pages 81-83 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. This benefit includes several 
oral surgery procedures; however, neither code D7286 nor D9630 are listed as covered. You can find this 
information pages 4-80 through 4-103 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 $35 copayment for each exam to diagnose and treat diseases and 
conditions of the eye. You can find this information on pages 129-130 of the Plan's 2022 Evidence of Coverage 
(EOC).