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 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 page 32 of the Plan's 2023 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that more than one spring powered device (code A4258) per 6 months is not reasonable and 
necessary. You can find this rule in the Local Coverage Determination for Glucose Monitors, L33822. 
 
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 an initial thermal radiofrequency ablation (RFA) of cervical, thoracic, or lumbar 
paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients 
who have had at least two (2) medically reasonable and necessary diagnostic medial branch blocks (MBBs), 
with each one providing a consistent minimum of 80% sustained 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 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 only 
those items and services specifically listed in your Plan contract. Custom fabricated abutment  includes 
placement (D6057) and abutment supported porcelain/ceramic crown (D6058) are not covered under the Plans 
dental benefits. You can find this information on pages 50-55 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 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 a percutaneous vertebral augmentation (PVA) which includes a percutaneous vertebroplasty 
(PVP) or kyphoplasty (PKP), is covered in patients with acute (< 6 weeks) or subacute (6-12 weeks) 
osteoporotic vertebral compression fracture of the T1  L5, based on symptom onset, and documented by 
advanced imaging. Patients must also have worsening pain with greater than 25% vertebral body height 
reduction. You can find this information in the Local Coverage Determination (LCD) L38201: Percutaneous 
Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF). 
 
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 does not include 
coverage for the dental service code D2783. You can find this information in Chapter 4 on page 123 of the 
Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a second confirmatory diagnostic facet joint procedure is considered medically reasonable 
and necessary in patients who meet ALL the following criteria: 
The patient meets the criteria for the first diagnostic procedure; AND 
After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% 
relief of primary (index) pain (with the duration of relief being consistent with the agent used). 
 
You can find this rule in the Local Coverage Determination (LCD) for Facet Joint Interventions for Pain 
Management, L38765. 
 
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 the 
requested service (D0220) but is limited to one procedure code per calendar year. You can find this information 
in Chapter 4 on pages 75-79 and 88-91 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare 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 surgical placement of implant body: endosteal implant (D6010) but is limited to 1 every 60 
months per arch per procedure. 
 
Surgical Implant Placement (D6010) 
 If missing more than 2 teeth (not including 3rd molars) in an arch: Above criteria applies, in addition to the 
following: 
1. Anterior Region Criteria requires that the utilization of the implant benefit must result in a full 
    complement of anterior teeth for that arch; No anterior teeth can remain missing in the same arch. 
2. Posterior Region: Criteria requires that there must be at least 8 points of existing posterior contact at 
    the time of request for services. 
    a. Contact defined as occlusion between fixed dentition 
    b. Contact of one upper and one lower posterior tooth equals 2 points of contact 
 
Post-operative periapical radiograph(s), showing placement of the implant, must be taken and included 
with claim submission for payment. 
 
You can find this information on page 29 of the Plans  2023 National Clinical Criteria Guidelines and Practice 
Parameters, which is available on Plans website. This benefit also includes coverage for preventive and comprehensive dental services. Sinus augmentation with 
bone or bone substitutes via a lateral open approach (D7951 x2) is not listed as covered. You can find this 
information on page 52 of the Plans 2023 Evidence of Coverage (EOC) and in the Plans 2023 Dental Benefits 
Coverage booklet.
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
 
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information page 108 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 cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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 the following reconstructive procedures are considered medically reasonable and necessary when 
specific criteria are met: 
1. Dermabrasion 
2. Abdominal Lipectomy/Panniculectomy 
3. Reconstructive Breast Surgery: Removal of Breast Implants 
4. Reduction Mammaplasty 
5. Mastectomy for Gynecomastia 
6. Gigantomastia of Pregnancy 
7. Rhinoplasty/Reconstructive Nasal Surgery 
 
You can find this information in the Local Coverage Determination (LCD): Cosmetic and Reconstructive 
Surgery (L38914). 
 
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 Coverage (CMS) conducted a National Coverage 
Analysis that focused on the topic of gender reassignment surgery. Effective August 30, 2016, after examining 
the medical evidence, CMS determined that no national coverage determination (NCD) is appropriate at this 
time for gender reassignment surgery for Medicare beneficiaries with gender dysphoria. In the absence of an 
NCD, coverage determinations for gender reassignment surgery, under section 1862(a)(1)(A) of the Social 
Security Act (the Act) and any other relevant statutory requirements, will continue to be made by the local 
Medicare Administrative Contractors (MACs) on a case-by-case basis. You can find this information at 
National Coverage Determination-Gender Dysphoria and Gender Reassignment Surgery (140.9). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3. 
 
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). 
 
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 payment may be made for a one-time ultrasound screening for an abdominal aortic aneurysm 
(AAA) for beneficiaries who meet the following criteria: 
i. receives a referral for such an ultrasound screening from the beneficiary's attending physician, 
physician assistant, nurse practitioner or clinical nurse specialist; 
ii. receives such ultrasound screening from a provider or supplier who is authorized to provide covered 
ultrasound diagnostic services; 
iii. has not been previously furnished such an ultrasound screening under the Medicare Program; and 
iv. is included in at least one of the following risk categories-- 
i.has a family history of abdominal aortic aneurysm; 
ii.is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or 
iii.is a beneficiary who manifests other risk factors in a beneficiary category recommended for screening 
by the United States Preventive Services Task Force regarding AAA, as specified by the Secretary 
of Health and Human Services, through the national coverage determination process. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 18, Section 110.2. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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 percutaneous vertebral augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients with BOTH the following: 
 
1. Inclusion criteria (ALL are required):  
   1. Acute (fewer than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture 
(VCF) (T1  L5) by recent (within 30 days) advanced imaging 
   2. Symptomatic (ONE): 
      1. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
greater than or equal to 8) 
      2. Non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) despite optimal 
non-surgical management (NSM) (ONE): 
         1. Worsening pain 
         2. Stable to improved pain (but NRS or VAS still greater than or equal to 5) (with greater than or 
equal to 2 of the following): 
            1. Progression of vertebral body height loss 
            2. Greater than 25% vertebral body height reduction 
            3. Kyphotic deformity 
            4. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
greater than 17) 
2. Exclusion criteria (Can have NONE of the following): 
   a. Absolute contraindication 
      1. Current back pain is not primarily due to the identified acute or subacute VCF(s) 
      2. Osteomyelitis, discitis or active systemic or surgical site infection 
      3. Pregnancy 
   b. Relative contraindication 
      1. Allergy to bone cement or opacification agents 
      2. Uncorrected coagulopathy 
      3. Spinal instability 
      4. Myelopathy from the fracture       5. Neurologic deficit 
      6. Neural impingement 
      7. Fracture retropulsion/canal compromise 
      8. Greater than three vertebral fractures 
 
You can find this information in the 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.