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). 
 
The rules say that percutaneous transluminal angioplasty (PTA) is covered when used for treatment of 
atherosclerotic obstructive lesions: 
 
 In the lower extremities, i.e., the iliac, femoral, and popliteal arteries, or in the upper extremities, i.e., the 
innominate, subclavian, axillary, and brachial arteries. The upper extremities do not include head or neck 
vessels. 
 
 Of a single coronary artery for patients for whom the likely alternative treatment is coronary bypass surgery 
and who exhibit the following characteristics: 
- Angina refractory to optimal medical management; 
- Objective evidence of myocardial ischemia; and 
- Lesions amenable to angioplasty. 
 
 Of the renal arteries for patients in whom there is an inadequate response to a thorough medical management 
of symptoms and for whom surgery is the likely alternative. PTA for this group of patients is an alternative to 
surgery, not simply an addition to medical management. 
 
 Of arteriovenous dialysis fistulas and grafts when performed through either a venous or arterial approach. 
 
You can find this information in the National Coverage Determination (NCD): Percutaneous Transluminal 
Angioplasty (PTA) (20.7). 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).  
 
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 there is a $1,000 deductible, which applies to certain items and services. The Plan deductible 
applies to an MRI. You can find this information on page 4-2 of the Plans 2022 Evidence of Coverage (EOC). 
 
The Plan contract also says after the deductible is met, there is 20% coinsurance for medical supply, including 
chemical agents used in certain diagnostic procedures and a $65 copayment for radiological diagnostic 
services, not including x-rays. You can find this information on pages 4-43 to 4-46 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 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 a Group 3 PWC with no power options is described by codes K0848, K0849, K0850, K0851, 
K0852, K0853, K0854, and K0855. You can find this rule at Local Coverage Determination (LCD) L33789: 
Power Mobility Devices (eff. 5/16/23). 
 
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 the most you will have to pay out-of-pocket for in-network covered Part A and Part B services in 
2022, is $2,000. You can find this information on page 62 of the Plans 2022 Evidence of Coverage (EOC). 
 
The Plan contract also says that enrollees must pay a $30 copayment for each physical therapy visit. You can 
find this information on page 96 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. This benefit includes 
coverage for specific dental items/services stated in the Plans contract. You can find this information on pages 
51-52 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 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 up to $75 per day for diagnostic radiology services. You 
can find this information on page 90 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 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. The core buildup is not covered by the Plan's dental benefits. You can find this information on 
pages 83 to 86 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 effective for dates of service specified below, the Centers for Medicare & Medicaid 
Services (CMS) has determined that percutaneous image-guided lumbar depression (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 LSS who are enrolled in an 
approved clinical study that meets the criteria in section I below: 
I. Effective for services performed on or after January 9, 2014, PILD will be covered by Medicare 
through CED for beneficiaries with lumbar spinal stenosis (LSS) who are enrolled in an approved 
clinical study that meets the following criteria. CMS has a particular interest in improved beneficiary 
function and quality of life, specific characteristics that identify patients who may benefit from the 
procedure, and the duration of benefit. A clinical study seeking Medicare payment for PILD for LSS 
must address one or more aspects of the following questions in a prospective, randomized, controlled 
design using current validated and reliable measurement instruments and clinically appropriate 
comparator treatments, including appropriate medical or surgical interventions or a sham-controlled 
arm, for patients randomized to the non-PILD group.  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-03, National Coverage Determination (NCD) 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 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 60 one-way trips that do not exceed 50 miles. You can find this information on page 91 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 
blepharoplasty may be performed for functional, reconstructive or cosmetic purposes. Functional or 
reconstructive eyelid surgery is performed to improve abnormal function, reconstruct deformities, repair 
defects due to trauma or to restore normalcy to the eyelids. The rules say covered indications include visual 
field testing demonstrating a 12-to-15-degree superior field loss or 24% to 30% superior visual field 
impairment. You can find this information in Medicare's Local Coverage Determination - Blepharoplasty, 
Blepharoptosis Repair and Surgical Procedures of the Brown (L35004). 
 
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 thirty-four (34) one-way trips each year to a plan approved health-related location through contracted 
supplies. You can find this information on page 108 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 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 17-19 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 psychological tests are used to identify problems in a variety of mental abilities and 
attributes, such as neuro-cognitive, mental status, achievement and ability, personality, and neurological 
functioning. 
 
Psychological testing requires a clinically trained examiner. All psychological tests should be administered, 
scored, and interpreted by a trained professional such as a clinical psychologist, psychologist, advanced nurse 
practitioner with education in this area, or a physician assistant who works with a psychiatrist with expertise in 
the appropriate area. The purpose of psychological testing includes the following: 
 
To assist with diagnosis and management following clinical findings where a mental illness or psychological 
abnormality is suspected. 
To provide a differential diagnosis from a range of neurological/psychological disorders that present with 
similar constellations of symptoms, e.g., differentiation between pseudodementia and depression. 
To determine the clinical and functional significance of a brain abnormality. 
To delineate the specific cognitive basis of functional complaints. 
Neuropsychological Testing: 
These tests are requested for patients with a history of psychological, neurologic or medical disorders known to 
impact cognitive or neurobehavioral functioning. 
 
You can find these rules in the Local Coverage Determination (LCD) Psychological and Neuropsychological 
Testing L34646. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules state that the EnvisiaTM classifier is reasonable and necessary when all of the following conditions are 
met: 
- That are healthy enough to undergo a bronchoscopy with transbronchial lung biopsies (TBBs), and 
- High-resolution computed tomography (HRCT) scan of the chest (defined by high kernel ~1mm axial 
reconstructions, including both inspiratory and expiratory imaging) showing 1 of the following:  
- A Probable usual interstitial pneumonitis (UIP) pattern (see comment below) as defined by 
the 2018 Fleichner Society White paper (https://www.ncbi.nlm.nih.gov/pubmed/29154106 ), or 
- An "Indeterminate for UIP pattern as defined by the 2018 Fleichner Society White paper 
(https://www.ncbi.nlm.nih.gov/pubmed/29154106 ) 
- Exclusion of autoimmune disease by clinical evaluation and serologic testing, including, when 
indicated, an evaluation by a rheumatologist 
- Absence of a definitive occupational, environmental, medication-related, or other cause of the 
patients lung disease 
Situations in which EnvisiaTM should not be used: 
1. Typical UIP pattern on HRCT as defined by the 2018 Fleischner Society White paper 
(https://www.ncbi.nlm.nih.gov/pubmed/29154106  
2. Computed tomography (CT) features most consistent with non-interstitial pulmonary fibrosis (IPF) 
diagnosis on HRCT as defined by the 2018 Fleichner Society White paper 
(https://www.ncbi.nlm.nih.gov/pubmed/29154106  
3. When a positive EnvisiaTM result is considered unlikely to lead to a confident diagnosis of IPF (>90% 
confidence) 
 
You can find this information in the Local Coverage Determination (LCD): MolDX: EnvisiaTM, VeracyteTM, 
Idiopathic Pulmonary Fibrosis Diagnostic Test (L37887). 
 
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. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that the Plan covers meals delivered to your home immediately following discharge from a 
network hospital as an inpatient due to congestive heart failure, up to two meals per day in a consecutive four-
week period, once per calendar year. You can find this information on page 62 of the Plan's 2023 Evidence of 
Coverage.