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 Advantage (MA) plan may offer coverage of a supplemental benefit only if it is 
medically necessary and additional to the benefit covered by original Medicare. A supplemental benefit is an 
item or service not covered by original Medicare, that is primarily health related and for which the MA plan 
must incur a non-zero direct medical cost. You can find this information in the Medicare Managed Care 
Manual, Chapter 4 - Benefits and Beneficiary Protections, 30.2  Supplemental Benefits Extending Original 
Medicare Benefits. 
 
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 if you request the Service Dog Support benefit, you must: 
- Provide supporting documentation identifying you (the member) as the owner and recipient who requires the 
use of a service dog and the services being rendered as defined under the Americans with Disabilities Act 
(ADA). We can help you obtain this information. 
- Be in compliance with all local and state laws for dog ownership and be able to supply documentation, upon 
request. Note: We are unable to initiate your benefit without speaking to you. By requesting this benefit, you 
are expressly authorizing us to contact you by telephone. 
You can find this information on pages 82 and 83 of the Plan's 2023 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 does not include 
D6010 or D6104. You can find this information on pages 60-62 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. 
 
Medicare does not pay for the services of a naturopath. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-06, Medicare Financial Management Manual, 
Chapter 3, Section 90.1(L). 
 
The rules say that Medicare pays for outpatient rehabilitation therapy services only when they are provided by 
those trained specifically in physical therapy, occupational therapy or speech-language 
pathology. This means that the services of massage therapists may not be billed as covered therapy services. 
You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 230.5. 
 
The rules say that Medicare health plans may not offer a massage therapy benefit. You can find this rule in the 
Medicare Managed Care Manual Chapter 4,  30.3. 
 
The rules say that a Licensed Massage Therapist is not eligible to enroll in Medicare. You can find this rule at 
the Medicare Program Integrity Manual, Chapter 15, Section 15.4.8. 
 
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. The Plan 
contract also says that naturopath services are not covered under any condition. You can find this information 
on page 103 of the Plan's 2023 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 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 $95 copayment for emergency care. This copayment is not waived if 
you are admitted to an inpatient hospital. You can find this information on page 64 of the Plan's 2023 Evidence 
of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $210 copayment per day for days 1-6 of each inpatient 
hospital stay. Enrollees then pay a $0 copayment per day for any additional days of the same inpatient hospital 
stay. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The 
day before you are discharged is your last inpatient day. You can find this information on pages 76-78 of the 
Plans 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 Medicare does not pay for over-the-counter (OTC) items, including non-prescription drugs. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 40.2.  
 
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 rules say 
that Medicare has started a new initiative on April 4, 2022, that will cover up to eight over-the-counter 
COVID-19 tests each calendar month, at no cost to you. Medicare will cover these tests if you have Part B, 
including those enrolled in a Medicare Advantage plan. If you are in a Medicare Advantage (MA) plan, the 
tests covered under this initiative will be covered outside of your existing plans coverage, and in addition to 
any over-the-counter tests that may be covered under the plan as a supplemental benefit. You can get over-the-
counter COVID-19 tests at any pharmacy or health care provider that participates in this initiative. Enrollees 
cannot submit a claim for these tests to Medicare or their MA plan (unless covered by a supplemental benefit) 
for reimbursement under this initiative. The participating provider would bill Medicare directly for 
reimbursement of the tests provided to the enrollee. You can find this information on the Centers for Medicare 
and Medicaid Services website at  https://www.cms.gov/newsroom/fact-sheets/medicare-covers-over-counter-
covid-19-tests.
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 a water circulating heat pad with pump (E0217) is reasonable and necessary compared to a 
standard electric heating pad (E0210); therefore, if code E0217 is provided it will be denied as not reasonable 
and necessary. You can find this rule in the Local Coverage Determination for Heating Pads and Heat Lamps, 
L33784. 
 
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 panels with greater than 5 respiratory pathogens performed in the Part B outpatient setting 
are considered not medically reasonable and necessary. You can find this information in Local Coverage 
Determination (LCD): Respiratory Pathogen Panel Testing (L38916). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The rules say that a panniculectomy will be considered medically necessary when: 
 the pannus or panniculus hangs below the level of the pubis, and the medical records document that the 
panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin 
irritation, infection or chafing that consistently recurs or remains refractory to appropriate medical 
therapy (e.g. topical antifungals, corticosteroids, antibiotics) over a period of 3 months.12 
 
 When surgery is performed to alleviate such complicating factors as inability to walk normally due 
to pannus size, chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis,           
such surgery is considered reconstructive. Preoperative photographs may be required to support 
justification and should be supplied upon request.12 
 
 This procedure may also be medically necessary for the patient that has had a significant weight- 
loss following the treatment of morbid obesity, in addition to meeting the criteria noted above, 
there should be evidence that the individual has maintained a stable weight for at least 6 months. 
If the weight loss is the result of bariatric surgery, abdominoplasty/panniculectomy should not be 
performed until at least 18 months after bariatric surgery and only when weight has been stable 
for at least the most recent 6 months and infection and inflammation has continued for the most 
recent 3 months. 
 You can find this information in the Local Coverage Determination (LCD): Cosmetic and Reconstructive 
Surgery (L39051) 
 
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 polyethylene-glycol (PEG) hydrogel is covered ONCE in patients with clinically localized 
prostate cancer with a Low or Favorable Intermediate Prostate Cancer Risk Group. You can find this rule in the 
Local Coverage Determination (LCD) - Prostate Rectal Spacers (L37485). 
 
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 a fixed height hospital bed is covered if one or more of the following criteria (1-4) are met: 
1. The beneficiary has a medical condition which requires positioning of the body in ways not feasible 
with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the 
use of a hospital bed, or 
2. The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to 
alleviate pain, or 
3. The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due 
to congestive heart failure, chronic pulmonary disease, or problems with aspiration, or 
4. The beneficiary requires traction equipment, which can only be attached to a hospital bed. 
 
A heavy duty extra wide hospital bed (E0303) is covered if the beneficiary meets one of the criteria for a fixed 
height hospital bed and the beneficiary's weight is more than 350 pounds but does not exceed 600 pounds. You 
can find this rule in the Local Coverage Determination for Hospital Beds and Accessories, L33820.  
 
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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP) is covered in patients with 
osteoporotic vertebral compression fracture (VCF) when both the following: 
1. Inclusion criteria (all are required): 
a. Acute (less than 6 weeks) or subacute (6 to 12 weeks) osteoporotic VCF (T1 to L5), based on 
symptom onset, and documented by advanced imaging (bone marrow edema on MRI or bone-
scan/SPECT/CT uptake) 
b. Symptomatic (one): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score greater than or equal to 8) 
ii. 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): 
A. Progression of vertebral body height loss 
B. Greater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) greater than 17 
c. Continuum of care (Both are required) 
i. All patients presenting with VCF should be referred for evaluation of BMD and 
osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program. 
You can find this information in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L38201). 
 
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 if there is an extended time, two years or more, since the last radio-frequency ablation 
(RFA) and/or there is a question as to the source of the recurrent pain then diagnostic procedures must be 
repeated. You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions 
for Pain Management (L38803). 
 
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 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. The surgical placement of implant body is covered by the Plan's dental benefits. The second stage 
of implant surgery and custom abutments are not covered by the Plan's dental benefits. You can find this 
information on pages 52 to 54 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 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 set of complete or partial (upper and/or lower) dentures every 
five calendar years. You can find this information in Chapter 4 on page 79 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 state that studies do not demonstrate any advantage of  Intrapulmonary Percussive Ventilator (IPV) 
over that achieved with good pulmonary care in the hospital environment and there are no studies in the home 
setting. There are no data to support the effectiveness of the device. Therefore, IPV in the home setting is not 
covered. You can find this information in the National Coverage Determination Intrapulmonary Percussive 
Ventilator (IPV) 240.5. 
 
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 say that many applications of the molecular pathology procedures are not covered services given lack 
of benefit category (e.g., preventive service or screening for a genetic abnormality in the absence of a suspicion 
of disease) and/or failure to the reasonable and necessary threshold for coverage (e.g., based on quality of 
clinical evidence and strength of recommendation or when the results would not reasonably be used in the 
management of a beneficiary). Furthermore, payment of claims in the past (based on stacking codes) or in the 
future (based on the new code series) is not a statement of coverage since the service may not have been 
audited for compliance with program requirements and documentation supporting the reasonable and necessary 
testing for the beneficiary. Certain molecular pathology procedures may be subject to prepayment medical 
review (records requested) and paid claims must be supportable, if selected, for post payment audit by the 
MAC or other contractors. Molecular pathology tests for diseases or conditions that manifest severe signs or 
symptoms in newborns and in early childhood or that result in early death (e.g., Canavan disease) could be 
subject to automatic denials since these tests are not usually relevant to a Medicare beneficiary.  
 
F2 gene (prothrombin coagulation factor II) and F5 gene (coagulation factor V) The F2 and F5 genetic tests are 
not considered to be clinically efficacious; therefore, testing is not medically necessary. 
 
You can find these rules in the Local Coverage Determination (LCD) Molecular Pathology Procedures 
L35000. 
 
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.