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 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 10% of the cost for Part B covered drugs administered at non-hospital-
affiliated facilities. You can find this information on page 75 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 state that ESIs must be performed under CT or fluoroscopy image guidance with contrast, 10 unless 
the patient has a documented contrast allergy or pregnancy where ultrasound guidance without contrast may be 
  
  considered. You can find this ruel in Local Coverage Determination (LCD) for Epidural Steroid Injections for 
Pain Management (L38994). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $250 copayment for each one-way Medicare-covered ground ambulance 
trip. You can find this information in Chapter 4 on page 44 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 state that only the following codes should be billed for Cardiovascular Disease Screening: CPT code 
80061 (Lipid panel) which includes CPT codes: 82465 (Cholesterol, serum or whole blood, total), 83718 
(Lipoprotein, direct measurement; high density cholesterol) and/or 84478 (Triglycerides). This rule is found in 
Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services, Section 100.1. 
 
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 state that the Medicare approved amount for procedures includes payment for the following services 
related to the surgery when furnished by the physician who performs the surgery. The services included in the 
global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, physicians' offices. Visits to a 
patient in an intensive care or critical care unit are also included if made by the surgeon. However, critical care 
services (99291 and 99292) are payable separately in some situations.  
 Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day 
before the day of surgery for major procedures and the day of surgery for minor procedures;  
 Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a 
surgical procedure;  
 Complications Following Surgery - All additional medical or surgical services required of the surgeon 
during the postoperative period of the surgery because of complications which do not require additional trips to 
the operating room;  
 Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to 
recovery from the surgery;  
 Postsurgical Pain Management - By the surgeon;  
 Supplies - Except for those identified as exclusions; and  
 Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative 
pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, 
irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; 
and changes and removal of tracheostomy tubes.  
You can find this information in the Medicare Claims Processing Manual, Chapter 12, 40.1. 
 
  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 state that an ultrasonic osteogenesis stimulator (E0760) is covered only if all of the following criteria 
are met: 
 
1. Nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to starting 
treatment with the osteogenesis stimulator, separated by a minimum of 90 days. Each radiograph set must 
include multiple views of the fracture site accompanied by a written interpretation by a treating practitioner 
stating that there has been no clinically significant evidence of fracture healing between the two sets of 
radiographs; and 
2. The fracture is not of the skull or vertebrae; and 
3. The fracture is not tumor related. 
 
An ultrasonic osteogenesis stimulator will be denied as not medically necessary if any of the criteria above are 
not met. Use of an ultrasonic osteogenesis stimulator for the treatment of a fresh fracture or delayed union will 
be denied as not medically necessary. You can find this in the Local Coverage Determination 
(LCD): Osteogenesis Stimulators (L33796). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $40 copayment for each therapy visit. You can find this information on 
page 101 of the Plan's 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 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 $200 copayment for Outpatient Surgery. You can find this information 
in Chapter 4, on page 104, 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 
prosthodontics such as fixed bridges. You can find this information on page 61 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 according to the American Society of Plastic Surgeons (ASPS), the specialty of plastic 
surgery contains two main categories which are cosmetic surgery and reconstructive surgery. Cosmetic surgery 
is performed to reshape and adjust normal structures of the body to enhance the visual 
appearance. Reconstructive surgery is performed to restore and improve function and correct any deformities or 
abnormal structures of the body that have been caused by congenital defects, developmental abnormalities, 
trauma, infection, tumors or disease. You can find this rule in the Local Coverage Determination (LCD) - 
Cosmetic and Reconstructive Surgery (L35090) - Effective July 11, 2021. 
 
The rules say that no payment can be made under either the hospital insurance or supplementary medical 
insurance program for cosmetic surgery. Cosmetic surgery or expenses incurred in connection with such 
surgery is not covered. Cosmetic surgery includes any surgical procedure directed at improving appearance, 
except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the 
improvement of the functioning of a malformed body member. For example, this exclusion does not apply to 
surgery in connection with treatment of severe burns or repair of the face following a serious automobile 
accident, or to surgery for therapeutic purposes which coincidentally also serves some cosmetic purpose. You 
can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 16, Section 120. 
 
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 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. 
 
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 45-54 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 state that the rules state that the Medicare approved amount for procedures includes payment for the 
following services related to the surgery when furnished by the physician who performs the surgery. The 
services included in the global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, 
physicians' offices. Visits to a patient in an intensive care or critical care unit are also included if made by the 
surgeon. However, critical care services (99291 and 99292) are payable separately in some situations.  
 Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day 
before the day of surgery for major procedures and the day of surgery for minor procedures;  
 Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a 
surgical procedure;  
 Complications Following Surgery - All additional medical or surgical services required of the surgeon 
during the postoperative period of the surgery because of complications which do not require additional trips to 
the operating room;  
 Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to 
recovery from the surgery;  
 Postsurgical Pain Management - By the surgeon;  
 Supplies - Except for those identified as exclusions; and  
 Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative 
pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, 
irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; 
and changes and removal of tracheostomy tubes.  
You can find this information in the Medicare Claims Processing Manual, Chapter 12, 40.1. 
 
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 state that the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet
joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet ALL the
following criteria: Initial thermal RFA: After the patient has had at least two (2) medically reasonable and
necessary diagnostic 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) AND Repeat thermal facet joint
RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a
minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent
improvement in the ability to perform previously painful movements and ADLs as compared to baseline
measurement using the same scale. Frequency Limitation: For each covered spinal region no more than two (2)
radiofrequency sessions will be reimbursed per rolling 12 months. You can find this information in the Local
Coverage Determination (LCD) Facet Joint Interventions for Pain Management (L35936).
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 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. 
 
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 for periodontal scaling and root planing to be covered your tooth must have noticeable 
bone loss or show on an x-ray that there is a hard substance built up on the root of the tooth. You can find this 
information in the Clinical Criteria for Periodontal Services in the Plan's dental vendor's 2022 Office 
Reference Manual.
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 
D9999. You can find this information on pages 64-65 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 commode chair is covered only for enrollees who are confined to a bed or room. The term 
room confined means that the patients condition is such that leaving the room is medically contraindicated. 
The accessibility of bathroom facilities generally would not be a factor in this determination. However, 
confinement of a patient to a home in a case where there are no toilet facilities in the home may be equated to 
room confinement. You can find this information in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medical National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
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.