Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that a percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for painful, debilitating, 
osteoporotic vertebral collapse/compression fractures, defined as those that have not responded to non-surgical 
medical management (e.g., narcotic and/or non- narcotic medication, physical therapy modalities) with and 
without methods of immobility (e.g., rest, bracing). You can find this rule in the Local Coverage Determination 
(LCD) L34976: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF). 
 
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 in order to support additional research on the use of transcutaneous electrical nerve 
stimulation (TENS) for chronic low-back pain (CLBP), we will cover this item under section 1862(a)(1)(E) of 
the Social Security Act (the Act) subject to all of the following conditions: 
 
1. Coverage under this section expires three years after the publication of this decision on the Centers for 
Medicare & Medicaid Services (CMS) website. 
2. The beneficiary is enrolled in an approved clinical study meeting all of the requirements below. The study 
must address one or more aspects of the following questions in a randomized, controlled design using validated 
and reliable instruments. This can include randomized crossover designs when the impact of prior TENS use is 
appropriately accounted for in the study protocol. 
   i. Does the use of TENS provide clinically meaningful reduction in pain in Medicare beneficiaries with 
CLBP? 
   ii. Does the use of TENS provide a clinically meaningful improvement of function in Medicare beneficiaries 
with CLBP? 
   iii. Does the use of TENS impact the utilization of other medical treatments or services used in the medical 
management of CLBP? 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section  
160.27. 
 
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 {ADJUDICATOR: enter coverage provisions}. You can find this information in Chapter 4 on pages 119 
to 120 of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that when services are furnished in a mobile unit, they are often provided to serve an entity for 
which another Place of Service (POS) code exists. For example, a mobile unit may be sent to a physicians 
office or a skilled nursing facility. If the mobile unit is serving an entity for which another POS code already 
exists, providers should use the POS code for that entity. However, if the mobile unit is not serving an entity 
which could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15. 
Apply the nonfacility rate to payments for services designated as being furnished in POS code 15; apply the 
appropriate facility or nonfacility rate for the POS code designated when a code other than the mobile unit code 
is indicated. You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.5. 
 
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 Section 1833(t)(1)(B)(i) of the Act allows CMS to define the services for which payment 
under the outpatient prospective payment system (OPPS) is appropriate and the Secretary has determined that 
the services designated to be "inpatient only" services are not appropriate to be furnished in a hospital 
outpatient department. "Inpatient only" services are generally, but not always, surgical services that require 
inpatient care because of the nature of the procedure, the typical underlying physical condition of patients who 
require the service, or the need for at least 24 hours of postoperative recovery time or monitoring before the 
patient can be safely discharged. An example of an "inpatient only" service is CPT code 33513, "Coronary 
artery bypass, vein only; four coronary venous grafts. " The designation of services to be "inpatient-only" is 
open to public comment each year as part of the annual rulemaking process. Procedures removed from the 
"inpatient only" list may be appropriately furnished in either the inpatient or outpatient settings and such 
procedures continue to be payable when furnished in the inpatient setting. There is no payment under the OPPS 
for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator 
of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 
100-104, Chapter 4, Section 180.7. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
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 20% coinsurance for Medicare-covered benefits for outpatient dialysis 
treatment. You can find this information on pages 85 to 86 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say a semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if the 
beneficiary meets one of the criteria for a fixed height bed and requires frequent changes in body position 
and/or has an immediate need for a change in body position. 
 
A fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) 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. 
 
You can find this information in the Local Coverage Determination (LCD): 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 say that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, when you become a member of our plan, you must choose a plan provider to be your 
primary care physician (PCP). Your PCP is a provider who meets state requirements and is trained to give you 
basic medical care. Your Provider Directory will indicate which providers may act as your PCP. As we explain 
below, you can get your routine or basic care from your PCP. Your PCP can also coordinate the rest of the 
covered services you get as a plan member. For example, in order to see a network specialist, you usually need 
to get your PCP's approval first (this is called getting a "referral" to a specialist). 
 
This includes: 
 X-rays 
 Laboratory tests 
 Therapies 
 Care from doctors who are specialists 
 Hospital admissions 
 Follow-up care 
 
"Coordinating" your services includes checking or consulting with other plan providers about your care and 
how it is going. If you need certain types of covered services or supplies from network providers, you must get 
approval in advance from your PCP (such as giving you a referral). In some cases, your PCP will need to get 
prior authorization (prior approval). You can find this information on pages 31-36 of the Plan's 2023 Evidence 
of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
preventive and comprehensive dental services along with specific dental codes that are listed on the dental 
benefit chart. Crowns and amalgam-two surfaces are covered by the Plan's dental benefits. You can find this 
information in the Plans 2023 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 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 40% coinsurance for out-of-network annual wellness visit. You can find 
this information on page(s) 50 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 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 24 one-way trips each year. You can find this information on pages 107-108 of the Plans 2023 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that repeat epidural steroid injection (ESI) when the first injection directly and significantly 
provided improvement of the condition being treated may be considered medically reasonable and necessary 
when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement 
in function measured from baseline using the same scale* for at least three months. If a patient fails to respond 
well to the initial ESI, a repeat ESI after 14 days can be performed, using a different approach, level and/or 
medication if appropriate, with the rationale and medical necessity for the second ESI documented in the 
medical record. You can find this rule at the Medicare 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 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% coinsurance for Medicare-covered items for durable medical 
equipment (DME). You can find this information on pages A1 - 26 to A1 - 27 of the Plan's 2023 Medical 
Benefits Chart.
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 incision and drainage of abscess is not covered by the Plan's dental benefits. You can find 
this information on pages 63 to 64 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 $20 copayment for a Medicare-covered standard X-ray service, a $30 
copayment for services from a specialist, and a 10% coinsurance for Medicare Part B drugs. You can find this 
information on pages 102 to 105 and 116 of the Plan's 2023 Evidence of Coverage (EOC).