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 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 30-33 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 items and services furnished outside the United States are excluded from coverage except 
for the following services, and certain services rendered on board a ship: 
 - Emergency inpatient hospital services where the emergency occurred:  
       - While the beneficiary was physically present in the United States; or  
       - In Canada while the beneficiary was traveling without reasonable delay and by the most direct 
route between Alaska and another State. 
 - Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the 
United States, if the hospital was closer to, or substantially more accessible from, the beneficiary's United 
States residence than the nearest participating United States hospital which was adequately equipped to deal 
with and available to provide treatment of the illness or injury;  
 - Physician and ambulance services furnished in connection with a covered foreign hospitalization. 
Program payment may not be made for any other Part B medical and other health services, including outpatient 
services furnished outside the United States;  
 - Services rendered on board a ship in a United States port, or within 6 hours of when the ship arrived 
at, or departed from, a United States port, are considered to have been furnished in United States territorial 
waters. Services not furnished in a United States port, or within 6 hours of when the ship arrived at, or departed 
from, a United States port, are considered to have been furnished outside United States territorial waters, even 
if the ship is of United States registry; and  
 - The term "United States" means the 50 States, the District of Columbia, the Commonwealth of Puerto 
Rico, the Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of services 
rendered on a ship, includes the territorial waters adjoining the land areas of the United States. 
 
You can find these rules in Medicare Benefit Policy Manual Chapter 16, Section 60. 
 
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 worldwide emergency and urgently needed services outside the United States 
under the following circumstances: emergency services, including emergency or urgently needed care and 
emergency ambulance transportation from the scene of an emergency to the nearest medical treatment facility. 
Transportation back to the United States from another country is not covered. Pre-scheduled, pre-planned 
treatments (including dialysis for an ongoing condition) and/or elective procedures are not covered. You can 
find this information on page 3-7 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 a contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
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 160. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. 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 contract 
says that you pay $0 for the choice of 1 pair of select eyeglasses, frames and lenses, per plan year. The Plan 
contract also says to see a network vision provider for more information on your no cost eyeglass option. You 
can find this information on page 85 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 plans may specify brands and manufacturers as preferred and charge lower cost-sharing for 
the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the 
following conditions are met (42 CFR 422.100(l)): 
1. The MA plan provides all categories of DME covered under original Medicare Part B; 
2. The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) 
DME products or brands; 
3. The MA plans contracted suppliers provide access to all preferred DME brands; 
4. During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will 
provide a 90-day transition period (commencing with the initial time of enrollment) during which the plan 
provides (and repairs, as applicable) non-preferred DME brands furnished in the previous year; 
5. Although the MA plan may add brands to its preferred formulary during the year, it may not remove 
any brands mid-year; 
6. The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
7. The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-
preferred DME product or brand with the EOC and ANOC and on its website; and 
8. The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories 
or subcategories annually determined by CMS to require full coverage. 
 
You can find this rule in the Center for Medicare Services (CMS) Internet-Only Manual, Publication 100-16, 
Medicare Managed Care Manual, Chapter 4, Section 10.12.2. 
 
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 OneTouch products by Lifescan are our preferred diabetic testing supplies (glucose monitors 
& test strips). You can find this information on page 61 of the 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). 
  
   
Botulinum toxins (Botox, Dysport, Xeomin and Myobloc), will be considered medically reasonable and 
necessary when administered for treatment of Food and Drug Administration (FDA)-labeled indications and 
Off-label indications (as applicable) below: 
 
    1. FDA indications for onabotulinumtoxinA (Botox) as noted on the FDA website 
 
    2. Off-Label indications for onabotulinumtoxinA (Botox) may be considered medically reasonable and 
necessary in patients for the following conditions: 
 
    - Esophageal achalasia in adults who are considered poor surgical candidates 
    - Chronic anal fissure for patients with inadequate response to conservative or pharmacologic treatment 
    - Essential hand tremor for patients with a high amplitude tremor that disrupts activities of daily living and 
have had inadequate response to oral pharmacotherapy such as propranolol and primidone 
    - Focal limb dystonia 
    - Hemifacial spasm in adults (cranial nerve VII disorder) 
    - Isolated oromandibular dystonia in adults 
    - Laryngeal dystonia (spastic dysphonia) for adductor type (ADSD) 
    - Bothersome simple motor tics in adolescents and adults when the benefits of treatment outweigh the risks 
    - Severely disabling or aggressive vocal tics in older adolescents and adults when the benefits of treatment 
outweigh the risks 
 
You can find this information in the Local Coverage Determination (LCD) for Botulinum Toxins (L38809). 
 
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 each year (limited to ground transportation only). Th Plan contract also says that 
each one-way trip must not exceed 50 miles of driving distance. You can find this information on page 121 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 a $275 copayment for outpatient diagnostic test. You can find this 
information on page(s) 54 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 $240 copayment for ambulance services. You can find this information 
on page(s) 45 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 $345 copayment for outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers. You can find this information on page(s) 80 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 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 $275 copayment for outpatient diagnostic test. You can find this 
information on page(s) 102 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 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 outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information on page(s) 90 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 $15 copayment for physician/practitioner services, including doctors 
office visits. You can find this information on page(s) 82 of the Plan's 2021 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 $231 copayment for inpatient hospital care. You can find this 
information on page(s) 100 of the Plan's 2021 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). 
 
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 current medical literature indicates that this procedure is considered reasonable and necessary for the 
treatment of lower back pain, when you 
have: 
o Had chronic low back pain (CLBP) for at least six (6) months, and lower back pain is your main symptom; 
and 
o Pain characteristics that are compatible with pain related to damage to ends of the bones in your spine 
(anterior-column (vertebrogenic)); and 
o Failed to adequately improve despite attempts at non-surgical management; and 
o Changes in the bones (vertebral body) of your spine noted on magnetic resonance imaging study (MRI) 
-  Type 1 or Type 2 Modic changes on MRI 
 Endplate hyperintensity (Type 1); or   
 Hyperintensity (Type 2) in T1 plus hyperintensity in T2  in the endplates between L3 and S1 
 This procedure is NOT indicated if you have any of the following: 
o Metabolic bone disease (e.g., osteoporosis), treatment of spine fragility fracture, trauma/compression 
fracture or spinal cancer 
o Spine infection or active systemic infection 
o Evidence on an imaging study (MRI) suggesting another obvious cause for your low back pain (LBP), 
(including lumbar stenosis or facet arthropathy) 
o Evidence of instability identified on imaging studies (including spondylolisthesis of greater than two (2) 
mm at any level)   
o Leg pain or numbness that occurs with walking (neurogenic claudication), severe pain that radiates from the back into the hip and outer side of the leg (lumbar radiculopathy), or radicular pain due to pinched 
nerve(s) (neurocompression (e.g., herniated nucleus pulposus, stenosis)), or posterior-spinal column 
pain as primary symptoms 
o Severe heart (cardiac) or lung (pulmonary) compromise 
o BMI greater than 40 
o Implantable pulse generator (e.g., pacemakers, defibrillators) or other electronic implants unless specific 
precautions are taken to maintain patient safety 
 
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.