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 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). 
 
Medicare rules also state that modifier 25 should only be used on claims for evaluation and management (E/M) 
services. This information is found in the Medicare Claims Processing Manual, Chapter 12 - Physicians/Non-
physician Practitioners, Section 30.6.6. 
 
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 Pneumatic Compression Device (PCD) that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a 
preventative service or function are excluded from coverage under the Medicare Durable Medical Equipment 
(DME) benefit. A PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
There is insufficient evidence to demonstrate that reimbursement is justified. Claims for E0675 will be denied 
as not reasonable and necessary. You can find this information in the Local Coverage Article: Pneumatic 
Compression Devices - Policy Article (A52488) and in the Local Coverage Determination (LCD): Pneumatic 
Compression Devices (L33829). 
 
The rules say that CMS does not pay any provider or supplier other than the facility or hospital for services 
furnished to the beneficiary while an inpatient. The facility or hospital must furnish all necessary covered 
services to the beneficiary either directly or under arrangements made between the facility and hospital and 
outside providers. You can find this information in 42 CFR 409.10. 
 
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 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 a new patient is a patient who has not received any professional services from the physician 
or physician group practice within the previous three years.  You can find this rule at Centers for Medicare and 
Medicaid Services, Internet-Only Publication 100-04, Medicare Claims Processing Manual Chapter 12, Section 
30.6.7. 
 
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 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 and 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 page 98 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. Retainer crowns and pontics are covered by the Plan's dental benefits. You can find this 
information on pages 93 to 100 of the Plans 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 say that a spinal orthosis (L0450 - L0651) is covered when it is ordered for one of the following 
indications: 
 
-To reduce pain by restricting mobility of the trunk; or 
 
-To facilitate healing following an injury to the spine or related soft tissues; or 
 
-To facilitate healing following a surgical procedure on the spine or related soft tissue; or 
 
-To otherwise support weak spinal muscles and/or a deformed spine. 
 
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically 
necessary. You can find this rule in Local Coverage Determination (LCD): Spinal Orthoses: TLSO and LSO 
(L33790). 
 
The rules say that a written order/prescription is a written communication from a treating practitioner that 
documents the need for a beneficiary to be provided an item of Durable Medical Equipment, Prosthetics, 
Orthotics, and Supplies (DMEPOS). All DMEPOS items require a written order/prescription from the treating 
practitioner for Medicare payment as a condition of payment. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Pub 100-08, Medicare Program Integrity Manual, 
Chapter 5, Section 5.2. 
 
The rules say that for any DMEPOS item to be covered by Medicare, the patients medical record must contain 
sufficient documentation of the patients medical condition to substantiate the necessity for the type and 
quantity of items ordered and for the frequency of use or replacement (if applicable). The information should 
include the patients diagnosis and other pertinent information including, but not limited to, duration of the 
patients condition, clinical course (worsening or improvement), prognosis, nature and extent of functional 
limitations, other therapeutic interventions and results, past experience with related items, etc. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Pub 100-08, Medicare Program 
Integrity Manual, Chapter 5, Section 5.9. 
 
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 for services performed on or after January 21, 2020, Medicare will now provide limited 
coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, 
CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, 
such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This 
benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated 
improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may 
be provided by a physician in accordance with state requirements, or by physician assistants, nurse 
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. 
Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, 
physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determinations Manual, Section 30.3.3. 
 
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 offers additional coverage for acupuncture beyond what is covered by Medicare. This benefit 
covers supplemental acupuncture, which is an alternative method to treat illness or pain. You can find this 
information on page 52 of the Plans 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 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 $300 copayment for inpatient hospital care. You can find this information 
on page 91 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. 
 
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
The rules say Fundus Photography is not covered for routine screening. In general, fundus photography is 
considered medically necessary only when it would assist in: 
 
1. Monitoring potential progression of a disease process; or  
2. Guidance in evaluating the need for or response to a specific treatment or intervention. 
 
In other words, medical necessity for fundus photography should guide a clinical decision. Therefore, baseline 
photos to document a condition that is reasonably expected to be static and/or not require future treatment 
would not be medically necessary. Such photos to provide a means of comparison to detect, for example, 
potential progression of diabetic retinopathy, advanced non-neovascular (dry) macular degeneration with 
suspicious areas, or a nevus or other tumor could be medically necessary. You can find this rule at Centers 
for Medicare and Medicaid Services, Local Coverage Determination (LCD) L33467: Ophthalmology: 
Extended Ophthalmoscopy and Fundus Photography. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
preventive and comprehensive services. The tooth mold (D0470), local anesthesia (D9215), and temporary 
crowns (D2799) are excluded from this benefit. This benefit also includes a false tooth for bridge (D6240) and 
a white glass cap (D6750); however, prior authorization is needed. You can find this information on pages 95 
to 101 of the Plans 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 say that contract suppliers are not required to furnish a specific brand name item or mode of delivery 
to a beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical outcome. 
A physician or treating practitioner (that is a physician assistant, clinical nurse specialist, or nurse practitioner) 
may prescribe, in writing, a particular brand of a competitively bid item or mode of delivery for an item if he or 
she determines that the particular brand or mode of delivery is necessary to avoid an adverse medical outcome 
for the beneficiary. The physician or treating practitioner must document in the beneficiarys medical record 
the reason why the specific brand or mode of delivery is necessary to avoid an adverse medical outcome. This 
documentation should include the following: 
 
1. The product's brand name or mode of delivery 
2. The features that this product or mode of delivery has versus other brand name products or modes of 
delivery; and 
3. An explanation of how these features are necessary to avoid an adverse medical outcome. 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 36, Section 30.4. 
 
The rules say that if a physician or treating practitioner prescribes a particular brand or mode of delivery to 
avoid an adverse medical outcome, the contract supplier must either:  
 
1. Furnish the particular brand or mode of delivery as prescribed by the physician or treating practitioner; 
2. Consult with the physician or treating practitioner to find another appropriate brand of item or mode of 
delivery for the beneficiary and obtain a revised written prescription from the physician or treating practitioner; 
or 
3. Assist the beneficiary in locating a contract supplier that can furnish the particular brand of item or mode of 
delivery prescribed by the physician or treating practitioner. 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 36, Section 30.4. 
 
 
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 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 dental services. Dentures are not covered by the Plan's dental benefits. You can find this information 
on page 65 of the Plans 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 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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that there is a $150 deductible which applies to certain items and services. The Plan contract 
also says that this is the amount enrollees must pay out-of-pocket before the Plan will pay its share for covered 
services. The Plan deductible applies to all in and out-of-network services besides preventative services, 
emergency room visits, emergency ambulance services, and urgent care services. You can find this information 
on page 1 of the Plan's 2022 Schedule of Cost Sharing. 
 
The Plan contract also says that enrollees must pay a $20 copayment after the deductible is met for each 
Medicare-covered primary care doctor visit (including telehealth services and urgently needed services). You 
can find this information on page 37 of the Plan's 2022 Schedule of Cost Sharing.
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 $160 copayment for Medicare-covered radiological diagnostic services, 
not including X-rays, performed in a physicians office or at a free-standing facility (such as a radiology center 
or medical clinic). You can find this information on pages 4-42 to 4-47 of the Plan's 2022 Evidence of 
Coverage (EOC).