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 
requested item or service but is limited to once per 6 floating months. You can find this information in the 2023 
Dental Benefits Chart.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that functional blepharoplasty procedures and surgical procedures of the brow  will be 
considered medically reasonable and necessary in the following situations: 
1. When the goal of the surgery is to restore function and normalcy to a structure that has been altered by 
trauma, infection, inflammation, degeneration, neoplasia, or developmental errors or; 
2. When there is interference with visual field, near or far visual impairment, or difficulty reading due to 
any of the following: 
- Dermatochalasis 
- Blepharochalasis 
- Blepharoptosis 
- Brow ptosis causing malposition of the upper eyelid1 and demonstrating a MRD1 (Margin 
reflex distance) of 2 mm or less 
- Looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis 
- Pseudoptosis 
- When there is visual impairment secondary to redundant skin weighing down on upper lashes 
resulting in eye strain, headache and loss of vision. 
- When there is chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid 
skin which has not been successfully treated by conservative measures such as education 
regarding hygiene, antibiotics, etc.; or 
3. Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual 
field impairment; or 
4. When there is the presence of prosthesis difficulties in an anophthalmic socket; or 
5. When there is laxity of the lower eyelid tissues causing lower eyelid ectropion resulting in eye irritation 
and inflammation and excessive tearing; or 
6. When there is inward rotation of the eyelid margin causing entropion where the eyelashes are 
contacting the cornea resulting in discomfort, redness, tearing, and foreign body sensation; or 
7. Lower eyelid edema, tumor or mass causing signs and symptoms of eyelid ectropion. 
 You can find these rules in Local Coverage Determination (LCD) Blepharoplasty, Blepharoptosis Repair, and 
Surgical Procedures of the Brow (L34028). 
 
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 dental services. Bridges are covered by the Plan's dental benefits. Splinting 
teeth, including multiple abutments, or any service to stabilize periodontally weakened teeth are not covered by 
the Plan's dental benefits. You can find this information on pages 76 to 77 and pages 81 to 82 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 UV light therapy systems are covered for selected patients with generalized intractable 
psoriasis. Using appropriate consultation, the MAC should determine whether medical and other factors justify 
treatment at home rather than at alternative sites, e.g., outpatient department of a hospital. You can find this 
information in the National Coverage Determination (NCD) for Durable Medical Equipment Reference List 
(280.1). 
 
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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, 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 35-43 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 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 $25 copayment for consultation, diagnosis, and treatment by a specialist 
or under certain circumstances, treatment by a nurse practitioner, physicians assistant, or other non-physician 
health care professional in a specialists office (as allowed by Medicare). You can find this information on page 
76 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 for purposes of coverage under Medicare, hyperbaric oxygen therapy (HBOT) is a modality 
in which the entire body is exposed to oxygen under increased atmospheric pressure. 
 
Program reimbursement for HBO therapy will be limited to that which is administered in a chamber (including 
the one man unit) and is limited to the following conditions: 
1. Acute carbon monoxide intoxication, 
2. Decompression illness, 
3. Gas embolism, 
4. Gas gangrene, 
5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in 
combination with accepted standard therapeutic measures when loss of function, limb, or life is 
threatened. 
6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an 
adjunctive treatment when loss of function, limb, or life is threatened. 
7. Progressive necrotizing infections (necrotizing fasciitis), 
8. Acute peripheral arterial insufficiency, 
9. Preparation and preservation of compromised skin grafts (not for primary management of wounds), 
10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, 
11. Osteoradionecrosis as an adjunct to conventional treatment, 
12. Soft tissue radionecrosis as an adjunct to conventional treatment, 
13. Cyanide poisoning, 
14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to 
antibiotics and surgical treatment, 
15. Diabetic wounds of the lower extremities in patients who meet the following three criteria: 
a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; 
b. Patient has a wound classified as Wagner grade III or higher; and 
c. Patient has failed an adequate course of standard wound therapy. 
 You can find these rules in National Coverage Determination (NCD) Hyperbaric Oxygen Therapy (20.29). 
 
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 and 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. You can find this information on pages 36-43 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 an event monitor, or event recorder, is a patient-activated or event-activated 
electrocardiographic (EKG) device that intermittently records cardiac arrhythmic events as they occur. The 
recording is captured either on a magnetic tape or another digital medium. Upon detecting symptoms, the 
wearer presses a button, which activates the recorder to save (i.e., memorize) an interval of pre-symptom EKG 
data along with data during and subsequent to the symptomatic event. Self-sensing recorders (also known as 
event-activated or automatic trigger) do not require patient input to capture these data. Single or multiple events 
may be recorded. The device is worn at all times, usually for up to 30 days. These are considered memory loop 
recorders (MLR). 
 
Another type of pre-symptom loop recorder is implanted subcutaneously in a patients upper left chest and may 
remain implanted for many months. An ILR is used when syncope is thought to be cardiac-related but is too 
infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom MLR. 
 
Covered uses are to: 
a. Detect, characterize, and document symptomatic transient arrhythmias; 
b. Initiate, revise, or discontinue arrhythmic drug therapy; or,  
c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); (only 
if 24-hour coverage is provided). You can find this information in the Centers for Medicare & Medicaid 
Services, Internet-Only Manual, Publication Number 100-03, Medicare National Coverage Determinations 
(NCD) Manual, Section 20.15. 
 
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 coverage indications for urinary drug testing include the following groups: 
- Group A - Symptomatic patients, multiple drug ingestion and/or patients with unreliable history 
- Group B - Treatment for substance abused or dependence 
- Group C - Chronic pain management drug testing for patients on chronic opioid therapy (COT) 
 
Criteria to establish medical necessity for drug testing must be based on patient-specific elements identified 
during the clinical assessment, and documented by the clinician in the patients medical record and minimally 
include the following elements: 
- Patient history, physical examination and previous laboratory findings 
- Current treatment plan 
- Prescribed medication(s) 
- Risk assessment plan 
 
You can find these rules in Local Coverage Determination (LCD) Controlled Substance Monitoring and Drugs 
of Abuse Testing (L36393). 
 
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 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 & Medicaid 
Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and 
Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. You can find this rule in 
the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 23, Section 20.9. 
 
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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, 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 37-38 in 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 there is a $250 deductible which applies to certain items and services. The Plan contract says 
that enrollees must pay a 20% coinsurance of the approved amount after they meet their annual deductible for 
in and out-of-network facility evaluation and management services. You can find this information on page 27 
of the Plans 2023 Medical Benefits Chart. 
 
The Plan contract also says that all outpatient diagnostic tests and therapeutic services and supplies are covered 
up to 100% of the approved amount. You can find this information on page 22 of the Plans 2023 Medical 
Benefits Chart.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that generally, the date of service shall be the date of delivery for durable medical equipment, 
prosthetics, orthotics, and supplies (DMEPOS) items. Exceptions are made for suppliers that use a 
delivery/shipping service. If the supplier uses a delivery/shipping service, the supplier may use the shipping 
date as the date of service. The shipping date may be defined as the date the delivery/shipping service label is 
created or the date the item is retrieved for delivery; however, such dates should not demonstrate significant 
variation. You can find this rule in Medicare Program Integrity Manual Chapter 4, Section 4.7.3.1.1. 
 
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 ESAs are covered for the following indications: 
1. Treatment of significant anemia in patients with non-myeloid malignancies where anemia is due to the 
effect of concomitantly administered chemotherapy; 
2. Treatment of anemia induced by AZT and/or other Nucleoside Reverse Transcriptase Inhibitors (NRTI) 
used in treatment of HIV/AIDS; 
3. Treatment of selected patients with anemia related to myelodysplastic syndrome; 
4. Perisurgical adjuvant therapy (epoetin alfa only); 
5. Treatment of anemia of selected chronic diseases: rheumatoid arthritis, systemic lupus erythematosus, 
inflammatory bowel diseases, and hepatitis C undergoing treatment. 
The following causes of anemia should be considered, documented, and corrected (when possible) before 
starting ESA therapy for any of the covered indications: 
1. Iron deficiency; 
2. Underlying infection or inflammatory process; 
3. Underlying hematological disease; 
4. Hemolysis; 
5. Vitamin deficiencies (e.g. folic acid or B12); 
6. Blood loss; 
7. Aluminum intoxication. 
The ESA treatment is not reasonable and necessary for beneficiaries with certain clinical conditions, either 
because of a deleterious effect of the ESA on their underlying disease or because the underlying disease 
increases their risk of adverse effects related to ESA use. These conditions include: 
1. any anemia in cancer or cancer treatment patients due to folate deficiency, B-12 deficiency, iron 
deficiency, hemolysis, bleeding, or bone marrow fibrosis; 2. the anemia associated with the treatment of acute and chronic myelogenous leukemias (CML, AML), or 
erythroid cancers; 
3. the anemia of cancer not related to cancer treatment; 
4. any anemia associated only with radiotherapy; 
5. prophylactic use to prevent chemotherapy-induced anemia; 
6. prophylactic use to reduce tumor hypoxia; 
7. patients with erythropoietin-type resistance due to neutralizing antibodies; and 
8. anemia due to cancer treatment if patients have uncontrolled hypertension. 
You can find this rule at Local Coverage Determination (LCD) L34356: Erythropoiesis Stimulating Agents 
(ESA) (eff. 3/2/23). 
 
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.