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 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 on page 52 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes only the 
items and services listed in the Dental Rider. Extractions (D7210), bone replacement grafts (D7953), and 
biological materials (D4265) are not covered by the Plan's dental benefits. You can find this information on 
pages 137-138 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 40% coinsurance for out-of-network Medicare-covered dental services. 
You can find this information in Chapter 4 on pages 70 to 71 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $35 copayment per visit with a specialist. You can find this 
information in Chapter 4 on pages 111 to 112 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 state that an epidural steroid injection (ESI) will be considered medically reasonable and necessary 
when the following three (3) requirements are met:  History, physical examination, and concordant radiological 
image-based diagnostic testing supporting one of the following: -Lumbar, cervical or thoracic radiculopathy, 
radicular pain and/or neurogenic claudication due to disc herniation, osteophyte or osteophyte complexes, 
severe degenerative disc disease, producing foraminal or central spinal stenosis; OR -Post-laminectomy 
syndrome; OR-Acute herpes zoster associated pain AND  
 
Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality of life 
or function.  An objective pain scale or functional assessment must be performed at baseline (prior to 
interventions). The same scale must be repeated at each follow-up for assessment of response, AND 
 
Pain duration of at least four (4) weeks, and the inability to tolerate non-invasive conservative care or medical 
documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes zoster 
refractory to conservative management where a four (4) week wait is not required. You can find this rule in the 
Local Coverage Determination (LCD) - L39036, Epidural Steroid Injections for Pain Management. 
 
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 48 one-way trips every year. You can find this information on page 116 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. 
 
In the case of a molecular pathology test performed by a laboratory other than a blood bank or center, or a 
test designated by CMS as an Advanced Diagnostic Laboratory Tests (ADLT) under paragraph (1) of the 
definition of advanced diagnostic laboratory test in 42 CFR 414.502, the DOS must be the date the test was 
performed only if: 
1. The test was performed following a hospital outpatients discharge from the hospital outpatient department; 
2. The specimen was collected from a hospital outpatient during an encounter (as both are defined in 42 CFR 
410.2); 
3. It was medically appropriate to have collected the sample from the hospital outpatient during the hospital 
outpatient encounter; 
4. The results of the test do not guide treatment provided during the hospital outpatient encounter; and 
5. The test was reasonable and medically necessary for the treatment of an illness. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 16, Section 40.8. 
 
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 general rule for the date of service (DOS) policy for either a clinical laboratory test or the 
technical component of physician pathology service is to bill the date the specimen was collected as the date of 
service. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, Section 40.8. 
 
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 use of infrared therapy devices and any related accessories is not reasonable and 
necessary under section 1862(a)(1)(A) of the Social Security Act (the Act). The use of infrared and/or near-
infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, 
including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral 
sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. You can find this rule in the 
National Coverage Determination (NCD) for Infrared Therapy Devices (270.6). 
 
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 Facet Joint Interventions are considered medically reasonable and necessary for the 
diagnosis and treatment of chronic pain in patients where there is no non-facet pathology per clinical 
assessment or radiology studies that could explain the source of the patients pain, including but not limited to 
fracture, tumor, infection, or significant deformity. This rule is found in Local Coverage Determination (LCD): 
Facet Joint Interventions for Pain Management (L38773). 
 
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 item or service but is limited to one D5110 every five years. You can find this information on pages 
4-61 to 4-74 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 lactulose breath hydrogen for diagnosing small bowel bacterial overgrowth and measuring 
small bowel transit time is not covered. You can find this information in National Coverage Determination 
(NCD): Diagnostic Breath Analysis (100.5). 
 
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 quantity of ostomy supplies needed by a beneficiary is determined primarily by the type 
of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will 
be variation according to individual beneficiary need and their needs may vary over time. The table below lists 
the maximum number of items/units of service that are usually reasonable and necessary. The actual quantity 
needed for a particular beneficiary may be more or less than the amount listed depending on the factors that 
affect the frequency of barrier and pouch change. 
 
The LCD states that the usual number per month of ostomy skin barrier with flange is 20. The usual number 
per month of ostomy pouches is 20. The usual number per six months of skin barrier wipes is 150. 
 
You can find these rules in the Local Coverage Determination (LCD) for Ostomy Supplies, L33828. 
 
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 each one-way trip not exceeded 50 miles of driving distance. You can find this information on page 4-
53 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 state that TENS therapy for Chronic Low Back Pain (CLBP) will be denied as not reasonable and 
necessary.  
You can find this rule in the Local Coverage Determination (LCD) for Transcutaneous Electrical Nerve 
Stimulators (TENS), L33802. 
 
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 does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 hearing aids are covered when they are received by any network hearing aid provider. The Plan 
contract also says any fees for any services rendered by a non-network hearing aid provider are excluded from 
coverage. You can find this information on pages 86 and 91 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that 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). 
 
Medicare will consider the removal of benign skin lesions as medically necessary, and not cosmetic, if one or 
more of the following conditions is present and clearly documented in the medical record: 
 
A. The lesion has one or more of the following characteristics: 
1. bleeding 
2. intense itching 
3. pain 
 
B. The lesion has physical evidence of inflammation, e.g., purulence, oozing, edema, erythema. 
 
C. The lesion obstructs an orifice or clinically restricts vision. 
 
D. The clinical diagnosis is uncertain, particularly where malignancy is a realistic consideration based on 
lesional appearance (e.g. non-response to conventional treatment, or change in appearance). However, if the 
diagnosis is uncertain, either biopsy or removal may be more prudent than destruction. 
 
E. A prior biopsy suggests or is indicative of lesion malignancy or premalignancy. 
 
F. The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that 
such trauma has in fact occurred. 
 
G. Wart removals will be covered under (a) through (f) above. In addition, wart destruction will be covered 
when the following clinical circumstance is present: 
  
o Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesional 
virus shedding 
o Evidence of spread from one body area to another, particularly in 
immunocompromised/immunosuppressed patients. 
 
If the beneficiary wishes one or more benign asymptomatic lesions removed for cosmetic purposes, the 
beneficiary becomes liable for the service(s) rendered. 
 
You can find this in the Local Coverage Determination (LCD): Benign Skin Lesion Removal (Excludes Actinic 
Keratosis, and Mohs) (L33979). 
 
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.