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 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 $350 copayment for hospital outpatient facility visit. You can find this 
information on page(s) 87 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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.  
 
The rules say a brace is covered when furnished incident to physicians' services or on a physician's order. A 
brace includes rigid and semi-rigid devices that are used for the purpose of supporting a weak or deformed 
body member or restricting or eliminating motion in a diseased or injured part of the body. You can find this in 
Center for Medicare Services (CMS) Publication 100-04, Medicare Claims Processing Manual, Chapter 20, 
Section 10.1.3. 
 
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 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 
coverage for the requested items or services, but only when they are received from an in-network provider. You 
can find this information on pages 71-73 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 certain individual genetic tests are unlikely to impact therapeutic decision making, directly 
impact treatment, outcome and/or clinical management in the care of the beneficiary and will be denied as not 
medically necessary. This list includes the MLH1 gene. You can find this information in the Centers for 
Medicare and Medicaid Services, 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.
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 is the secondary payer to certain primary plans. When Medicare is the secondary 
payer, the provider or enrollee must first submit the claim to the primary payer. If the primary payer does not 
pay in full for the services, Medicare secondary benefits may be paid. The enrollee must file a claim with the 
primary payer or cooperate fully with the provider so that the provider can file the necessary claim. You can 
find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-05, 
Medicare Secondary Payer Manual, Chapter 1, Sections 10 and 30.  
 
The rules say that plans must identify payers that are primary to Medicare, identify the amounts payable by the 
primary payer, and coordinate benefits to Medicare enrollees with the benefits of the primary payer. You can 
find this rule at 42 CFR Section 422.108. 
 
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 $40 copayment for physician/practitioner service. You can find this 
information on page(s) 86 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 state that payment may be made for the replacement of a prosthetic device that is an artificial limb, or 
replacement part of a device if the ordering physician determines that the replacement device or part is 
necessary because of any of the following: 
 
    1. A change in the physiological condition of the patient; 
    2. An irreparable change in the condition of the device, or in a part of the device; or 
    3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would 
    be more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being 
    replaced. 
 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 120. 
 
The rules say that Medicare will pay for durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers 
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment 
already available to an enrollee. You can find these rules in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(C). 
 
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 417.414. 
 
The rules say that except for emergency and urgently needed services, Cost plans are not required to make 
payments for any services received by enrollees that are not provided directly by the Plan or through 
arrangements made by the Plan. You can find this rule at 42 CFR Section 417.448(a). 
 
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 the enrollee generally must receive care from a network provider for the Plan to cover the 
services. If we do not cover services the enrollee receives from an out-of-network provider, the services will be 
covered by Original Medicare if they are Medicare-covered services. Except for emergency or urgently needed 
services, if you get services covered by Original Medicare from an out-of-network provider then you must 
pay Original Medicares cost-sharing amount. You can find this information on pages 30 and 31 of the Plans 
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 we cover diabetic supplies made by OneTouch/LifeScan. We do not cover other brands of  
monitors and test strips unless you or your provider requests a medical exception and it is approved. You can 
find this information on page 70-71 of the 2021 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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be 
ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or 
treats a beneficiary for a specific medical problem and who uses the results in the management of the 
beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are 
not reasonable and necessary. You can find this rule in 42 CFR, Section 410.32. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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 impotence is a failure of a body part for which the diagnosis, and frequently the treatment, 
require medical expertise. Depending on the cause of the condition, treatment may be surgical; e.g., 
  
  implantation of a penile prosthesis, or nonsurgical; e.g., medical or psychotherapeutic treatment. Program 
payment may be made for diagnosis and treatment of sexual impotence. Since causes and, therefore, 
appropriate treatment vary, if abuse is suspected it may be necessary to request documentation of 
appropriateness in individual cases. 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 230.4. 
 
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 whole gland HIFU is considered medically necessary as a local treatment for recurrent PCa 
following radiation therapy (RT) when ALL of the following criteria are met (1,2): 
1. Biochemical recurrence (BCR) according to the Phoenix definition (PSA nadir + 2 ng/mL) 
2. Positive post-RT transrectal ultrasound guided (TRUS) biopsy 
3. Candidate for local curative therapy as evidenced by favorable clinical and pathologic factors 
(BOTH of the following) 
a. Original (pre-RT)- clinical stage T1-T2, NX or N0 
b. Current (ALL are required) 
i. PSA < 10 ng/mL 
ii. absence of distant metastases per National Comprehensive Cancer Network (NCCN) 
imaging guidelines 
iii. no lymph node involvement 
iv. interval to biochemical failure greater than 18 months 
v. International Society of Urological Pathology (ISUP) grade less than 4 
vi. local recurrence amenable to entire destruction 
4. Multi-disciplinary consensus (surgeon, oncologist, radiologist) 
5. Hi comorbidity (i.e., not a candidate for radical prostatectomy (RP)) (3) 
You can find this information in Medicare's Local Coverage Determination (LCD): Salvage High-intensity 
Focused Ultrasound (HIFU) Treatment in Prostate Cancer (PCa) (L38262). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 all of the following criteria must be met for a power mobility device to be covered.  
A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, 
grooming, and bathing in customary locations in the home. 
B. The beneficiarys mobility limitation cannot be sufficiently and safely resolved by the use of an 
appropriately fitted cane or walker. 
C. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-
configured manual wheelchair in the home to perform MRADLs during a typical day. 
D. The beneficiary is able to: 
 Safely transfer to and from a power operated vehicle (POV), and 
 Operate the tiller steering system, and 
 Maintain postural stability and position while operating the POV in the home. 
E. The beneficiarys mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) 
are sufficient for safe mobility using a POV in the home. 
F. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for 
the operation of the POV that is provided. 
G. The beneficiarys weight is less than or equal to the weight capacity of the POV that is provided and 
greater than or equal to 95% of the weight capacity of the next lower weight class POV  
H. Use of a POV will significantly improve the beneficiarys ability to participate in MRADLs and the 
beneficiary will use it in the home. 
I. The beneficiary has not expressed an unwillingness to use a POV in the home. 
 
If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable 
and necessary. You can find this rule in the Local Coverage Determination for Power Mobility Devices, 
L33789 (eff 01/01/20). 
 
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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 25-30 of the Plan's 2022 
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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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 Plan contract says that the only covered chiropractic service is manual manipulation of the spine to correct 
a subluxation. You can find this information on page 54 of the Plans 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 state that a repeat thermal facet joint radiofrequency ablation (RFA) at the same anatomic site is 
considered medically reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform 
previously painful movements and activities of daily living (ADL) as compared to baseline measurement using 
the same scale. You can find this information in Local Coverage Determination (LCD): Facet Joint 
Interventions for Pain Management (L35936). 
 
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.