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 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 the full 
set of upper and lower dentures (D5110, D5120) but is limited to only one of any (D5110-D5286, D5863-
D5866) per arch every 60 months. You can find this information on pages 4 to 16 of the Plan's 2023 Dental 
Benefit Details.
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. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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. The Plan 
contract says that enrollees must pay 20% coinsurance for in-network durable medical equipment. You can find 
this information on pages 80-81 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 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 the 
requested item but replacement of removable and fixed prostheses is covered only if the existing prostheses 
were inserted at least 60 months prior to the replacement and satisfactory evidence is presented that the existing 
prostheses are not and cannot be made serviceable. You can find this information on page 60 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 the implantation of central nervous system stimulators may be covered as therapies for the 
relief of chronic intractable pain, subject to the following conditions: 
1. Types of Implantations 
There are two types of implantations covered by this instruction: 
 Dorsal Column (Spinal Cord) Neurostimulation - The surgical implantation of neurostimulator 
electrodes within the dura mater (endodural) or the percutaneous insertion of electrodes in the epidural 
space is covered. 
 Depth Brain Neurostimulation - The stereotactic implantation of electrodes in the deep brain (e.g., 
thalamus and periaqueductal gray matter) is covered. 
2. Conditions for Coverage 
No payment may be made for the implantation of dorsal column or depth brain stimulators or services and 
supplies related to such implantation, unless all of the conditions listed below have been met: 
 The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with 
chronic intractable pain; 
 With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or 
contraindicated for the given patient; 
 Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
 All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be 
available; and 
 Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
Medicare Administrative Contractors may find it helpful to work with Quality Improvement Organizations to 
obtain the information needed to apply these conditions to claims. You can find these rules in the Centers for Medicare & Medicaid Services, Medicare National Coverage 
Determination (NCD) for Electrical Nerve Stimulators, Section 160.7 
 
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 state that MolDX will reimburse approved tests covered for dates of service consistent with the 
effective date of the coverage determination. 
 
Please refer to the MolDX website www.palmettogba.com/MolDX for covered and excluded tests' specific 
coding and billing information. 
 
You can find this rule in the Local Coverage Determination (LCD) for MolDX: Molecular Diagnostic Tests 
(MDT), L35025. 
 
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 the four botulinum therapies are not interchangeable and are only covered as listed below. 
 
Botulinum toxins (Botox, Dysport, Xeomin and Myobloc), will be considered medically reasonable and 
necessary when administered for treatment of FDA-labeled indications and Off-label indications (as applicable) 
below: 
 
    FDA3 indications for onabotulinumtoxinA (Botox) as noted on the FDA website: 
https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=103000  
 
Off-Label indications for onabotulinumtoxinA (Botox) may be considered medically reasonable and 
necessary in patients for the following conditions: 
 
    Esophageal achalasia in adults who are considered poor surgical candidates4 
    Chronic anal fissure for patients with inadequate response to conservative or pharmacologic treatment5 
    Essential hand tremor for patients with a high amplitude tremor that disrupts activities of daily living and 
have had inadequate response to oral pharmacotherapy such as propranolol and primidone6 
    Focal limb dystonia6 
    Hemifacial spasm in adults (cranial nerve VII disorder)6 
    Isolated oromandibular dystonia in adults7 
    Laryngeal dystonia (spastic dysphonia) for adductor type (ADSD)6 
    Bothersome simple motor tics in adolescents and adults when the benefits of treatment outweigh the risks8 
    Severely disabling or aggressive vocal tics in older adolescents and adults when the benefits of treatment 
outweigh the risks8 
 
FDA9 indications for abobotulinumtoxinA (Dysport) as noted on the FDA website: 
https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=125274  
Off-label indications for abobotulinumtoxinA (Dysport) may be considered medically reasonable and 
necessary in patients for the following conditions: 
 
    Blepharospasm in adults6,7 
    Hemifacial spasm in adults (cranial nerve VII disorder)6 
    Isolated oromandibular dystonia in adults7 
 FDA10 indications for incobotulinumtoxinA (Xeomin) as noted on the FDA website: 
https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=125360  
 
    FDA11 indications for rimabotulinumtoxinB (Myobloc) as noted on the FDA website: 
https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=103846.  
 
You can find this information in the Local Coverage Determination (LCD) Botulinum Toxins L38809. 
 
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 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 page 32-39 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 the 
requested item or service but is limited to once every five years. You can find this information on page 63 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 state that covered supplies for reasonable and necessary non-routine irrigation of a catheter include 
either an irrigation tray (A4320) or an irrigation syringe (A4322), and sterile water/saline (A4217). When 
syringes, trays, sterile saline, or water are used for routine irrigation, they will be denied as not reasonable and 
necessary. You can find this information in the Local Coverage Determination (LCD) for Urological Supplies 
(L33803). 
 
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 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 32 one-way trips with each one-way trip not exceeding 75 miles of driving distance. You can find 
this information on page 85 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 bariatric surgery is generally not reasonable and necessary. Medicare does not 
provide prior authorization for these services. Claims for more than one bariatric surgical procedure most likely 
will create a denial. However, in the appeals process, medical documentation may be submitted for review and 
the service may potentially be covered when clinical circumstances demonstrate reasonability and necessity. 
Appropriate ABN and modifiers should be appended to any services potentially to be denied. Refer to IOM 
Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 15 for more information. 
 
You can find this information in the Local Coverage Determination (LCD) Bariatric Surgical Management of 
Morbid Obesity L35022. 
 
The RYGBP achieves weight loss by gastric restriction and malabsorption. Reduction of the stomach to a small 
gastric pouch (30 cc) results in feelings of satiety following even small meals. This small pouch is connected to 
a segment of the jejunum, bypassing the duodenum and very proximal small intestine, thereby reducing 
absorption. RYGBP procedures can be open or laparoscopic. 
 
Effective for services performed on and after June 27, 2012, Medicare Administrative Contractors (MACs) 
acting within their respective jurisdictions may determine coverage of stand-alone laparoscopic sleeve 
gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only 
when all of the following conditions a.-c. are satisfied. 
 
    The beneficiary has a body-mass index (BMI) = 35 kg/m2, 
    The beneficiary has at least one co-morbidity related to obesity, and, 
 
You can find this information in the National Coverage Determination (NCD) Bariatric Surgery for Treatment 
of Co-Morbid Conditions Related to Morbid Obesity 100.1. 
 
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 elevators (such as stair lifts) are not covered because they are considered convenience items 
that are not primarily medical in nature. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, 
Section 280.1. 
 
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 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 does not include 
coverage for the service code 41899. You can find this information in Chapter 4 on page 65 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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). 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(D). 
 
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 40 to 41 of the Plan's 
2022 Evidence of Coverage (EOC).