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, generally, items and services provided outside of the United States (US) are not covered. 
The only exceptions are emergency hospital services when the emergency occurred within the US, 
emergency/non-emergency hospital services when the foreign hospital is substantially closer or more 
accessible than the US hospital, or services provided on a ship docked at a US port or within US Territorial 
waters. You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only 
Manual, Publication 100-02, 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 plan rules 
state that the plan covers worldwide emergency and urgent care services outside of the United States. If you 
have an emergency or an urgent need for care outside of the U.S. and its territories, you will be responsible to 
pay for those services upfront and request appropriate reimbursement from the plan. The plan will reimburse 
you, for covered out-of-network emergency and urgent care services outside of the U.S. and its territories, at 
rates no greater than the rates at which Original Medicare would pay for such services had the services been 
performed in the United States in the locality where you reside. This information is found on page 37 of the 
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 $30 copayment for in-network physician/practitioner services, including 
an in-person specialist visit.  You can find this information on page(s) 72-74 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 $10 copayment per day, for days 1 to 20, and a $196 copayment per 
day, for days 21 to 61, for in-network skilled nursing facility care. There is a $0 copayment for days 62 to 100. 
You can find this information on pages 52-53 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 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 & 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 pages 62 to 63 of the Plan's 2024 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 knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1843) is covered if the beneficiary has had recent injury to or a surgical procedure 
on the knee(s). You can find this rule in the Local Coverage Determination (LCD) - Knee Orthoses (L33318). 
 
The rules say that knee orthoses are also covered for a beneficiary who is ambulatory and has knee instability 
due to a condition. Knee instability must be documented by examination of the beneficiary and objective 
description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). Claims will be denied 
as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For 
example, they will be denied if only pain or a subjective description of joint instability is documented. You can 
find this rule in the Local Coverage Determination (LCD) - Knee Orthoses (L33318). 
 
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 knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1843) is covered if the beneficiary has had recent injury to or a surgical procedure 
on the knee(s). You can find this rule in the Local Coverage Determination (LCD) - Knee Orthoses (L33318). 
 
The rules say that knee orthoses are also covered for a beneficiary who is ambulatory and has knee instability 
due to a condition. Knee instability must be documented by examination of the beneficiary and objective 
description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). Claims will be denied 
as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For 
example, they will be denied if only pain or a subjective description of joint instability is documented. You can 
find this rule in the Local Coverage Determination (LCD) - Knee Orthoses (L33318). 
 
 
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 under certain circumstances, an anesthesia practitioner may separately report an epidural or 
peripheral nerve block injection (bolus, intermittent bolus, or continuous infusion) for postoperative pain 
management when the surgeon requests assistance with postoperative pain management. An epidural injection 
(CPT code 623XX) for postoperative pain management may be reported separately with an anesthesia 0XXXX 
code only if the mode of intraoperative anesthesia is general anesthesia and the adequacy of the intraoperative 
anesthesia is not dependent on the epidural injection. A peripheral nerve block injection (CPT code 64XXX) 
for postoperative pain management may be reported separately with an anesthesia 0XXXX code only if the 
mode of intraoperative anesthesia is general anesthesia, subarachnoid injection, or epidural injection, and the 
adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block injection. An epidural 
or peripheral nerve block injection (code numbers as identified above) administered preoperatively or 
intraoperatively is not separately reportable for postoperative pain management if the mode of anesthesia for 
the procedure is monitored anesthesia care, moderate conscious sedation, regional anesthesia by peripheral 
nerve block, or other type of anesthesia not identified above. If an epidural or peripheral nerve block injection 
(code numbers as identified above) for postoperative pain management is reported separately on the same date 
of service as an anesthesia 0XXXX code, modifier -59 or -XU may be appended to the epidural or peripheral 
nerve block injection code (code numbers as identified above) to indicate that it was administered for 
postoperative pain management. An epidural or peripheral nerve block injection (code numbers as identified 
above) for postoperative pain management in patients receiving general anesthesia, spinal (subarachnoid 
injection) anesthesia, or regional anesthesia by epidural injection as described above may be administered 
preoperatively, intraoperatively, or postoperatively. You can find this rule in the Centers for Medicare & 
Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 
2(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.
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 $390 copayment each day for days 1 through 5 for Medicare-covered in-
network inpatient hospital care each time they are admitted. There is a $0 copayment for additional Medicare-
covered days. You can find this information on page 65 of the Plans 2023 Evidence of Coverage (EOC).  
 
The Plan contract also says there is a $6,800 in-network maximum out-of-pocket. You can find this 
information on page 43 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 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 & 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 
coverage for specific dental items/services stated in the Plans contract. You can find this information on pages 
51-52 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 & 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 
coverage for one panoramic radiographic image (D0330) or related service every three plan years. You can find 
this information on page 179 of the 2023 Medicare quick reference guide.
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 physical therapy, occupational therapy, and/or speech-language pathology services 
furnished to a skilled nursing facility (SNF) resident must be billed by the SNF itself. This is known as 
consolidated billing, and no separate payment is made for these services. You can find this rule at Centers for 
Medicare & Medicaid Services, Internet-Only Publication 100-04, Medicare Claims Processing Manual, 
Chapter 6, Section 10.3. 
 
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.
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 an ultrasonic osteogenesis stimulator (E0760) is covered only if all of the following criteria 
are met: 
 
     1. Nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to starting 
treatment with the osteogenesis stimulator, separated by a minimum of 90 days. Each radiograph set must 
include multiple views of the fracture site accompanied by a written interpretation by a treating practitioner 
stating that there has been no clinically significant evidence of fracture healing between the two sets of 
radiographs; and 
     2. The fracture is not of the skull or vertebrae; and 
     3. The fracture is not tumor related. 
 
An ultrasonic osteogenesis stimulator will be denied as not medically necessary if any of the criteria above are 
not met. 
 
Use of an ultrasonic osteogenesis stimulator for the treatment of a fresh fracture or delayed union will be 
denied as not medically necessary. 
 
Ultrasound conductive coupling gel is covered and separately payable if an ultrasonic osteogenesis stimulator 
is covered. 
 
An ultrasonic osteogenesis stimulator will be denied as not medically necessary if it is used with other 
noninvasive osteogenesis stimulators. 
 
You can find these rules in the Local Coverage Determination (LCD) Osteogenesis Stimulators L33796. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a repeat epidural steroid injection (ESI) may be medically reasonable and necessary 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 information in Local 
Coverage Determination (LCD): Epidural Steroid Injections for Pain Management (L39036). 
 
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 & 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 
coverage for specific dental items/services stated in the Plans contract. You can find this information on pages 
283-296 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 a column II code is included in the allowance for the corresponding column I code when 
provided at the same time. When multiple codes are listed in column I, all the codes in column II relate to each 
code in column I. You can find this rule in the Local Coverage Article (LCA) for A52504. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare & 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. As a member of the Plan, the enrollee can choose either 
network or outofnetwork providers for nonMedicare covered dental services. You can find this information 
on pages 35-36 of the Plan's 2023 Evidence of Coverage (EOC).