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. The contract also says the 
Plan lists all covered procedures. Any code not listed is not covered. You can find this information on pages 
67-69 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 a 20% coinsurance for Medicare Part B drugs administered by a physician or medical professional. You can see this on page 84 of the Plans 2021 Evidence of Coverage.
The Plan contract says that enrollees must pay a $100 copayment for a PET scan. You can find this on page 88 of the Plans 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 repeat epidural steroid injections are covered when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using the same scale for at least three months. You can find 
this rule in the Local Coverage Determination (LCD) L38994 - Epidural Steroid Injections for Pain 
Management. 
 
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 genetic testing is available for a number of types of inherited thrombophilia, including 
mutations in the FVL, F2 and MTHFR genes. However, the clinical utility of testing is uncertain. The clinical 
utility of genetic testing depends on the ability of testing results to change management that results in improved 
clinical outcomes. The clinical utility of genetic testing for thrombophilia is based on the overall risk of 
thromboembolism and the risk/benefit ratio of treatment, primarily with anticoagulants. 
 
Medicare benefit applies only to individuals with signs and symptoms of disease. There is no Medicare benefit 
for assessment of thrombosis risk in asymptomatic patients (aka screening for inherited thrombophilia) or in 
asymptomatic individuals whose relatives have documented inherited thrombophilia. 
 
The population for which genetic testing results have direct implications for treatment is pregnant women with 
a previous history of venous thromboembolism (VTE) associated with a transient risk factor (e.g., surgery, 
trauma). These women would typically not be treated with antepartum anticoagulant prophylaxis unless they 
were found to have a genotype associated with a high risk of VTE recurrence (FVL homozygosity, F2 
G20210A homozygosity, or compound heterozygosity for FVL and F2 G20210A). Genetic testing for these 
patients is indicated. 
 
There is insufficient evidence in the published peer-reviewed scientific literature to support coverage for 
genetic testing for inherited thrombophilias outside the pregnant women as described above. Genetic testing for 
FVL and F2 G20210A is considered investigational for all other indications. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD): MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, 
Factor II Prothrombin, and MTHFR) (L36159). 
 
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
 
2. The services require the skills or direct supervision of a therapist,  
 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. 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 220.2. 
 
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.
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 40-44 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 state that FANCC gene testing is performed in association with Fanconi anemia (FA), a condition 
characterized by physical abnormalities, bone marrow failure, and increased risk of malignancy. For infants 
and children, FANCC genetic testing is used to confirm the clinical findings, such as blood counts and bone 
marrow biopsy, to diagnose FA. Genetic testing for adults is used to screen potential carriers of the mutation. 
Therefore, the MolDX Team has determined that testing for the FANCC is not a Medicare benefit and is a 
statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests that 
include the FANCC gene. You can find this information in the Centers for Medicare and Medicaid Services, 
Local Coverage Article (LCA) - Billing and Coding: MolDX: FANCC Genetic Testing (A55160). 
 
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 Place of Service (POS) code 31 should be used with services for patients in a Part A-covered 
skilled nursing facility (SNF) stay and POS code 32 should be used with services for beneficiaries in a 
noncovered stay. You can find this information in the Centers for Medicare and Medicaid Service, Internet-
Only Manual, Medicare Claims Processing Manual, Chapter 6, Section 110.1. 
 
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 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. These Medicare-covered services are provided by a network chiropractor. You can find this 
information on page 60 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 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 42-47 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 state that policy limits coverage of multiplex PCR respiratory viral panels. Panels of 3-5 pathogens 
are covered under limited circumstances. Specifically, the test must be ordered either in a healthcare setting 
that is equipped to care for and routinely does care for critically ill patients, or it must be ordered by an 
infectious disease specialist, unless an infectious disease specialist is not available. Multiplex PCR respiratory 
viral panels of 6 or more pathogens are non-covered. You can find this information in the Centers for Medicare 
and Medicaid Services, Local Coverage Determination (LCD): MolDX: Multiplex Nucleic Acid Amplified 
Tests for Respiratory Viral Panels (L37764). 
 
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 covers medical nutrition therapy services (MNT) for certain enrollees who have 
diabetes or a renal disease. You can find this rule at 42 CFR Section 410.132(b)(4) and in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, National Coverage 
Determinations Manual, Chapter 1, Section 180.1. 
 
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 also says that the Plan covers medical nutrition therapy. This benefit is for people with diabetes, renal 
(kidney) disease (but not on dialysis), or after a kidney transplant when ordered by your doctor. You can find 
this information on page 90 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 state that FANCC gene testing is performed in association with Fanconi anemia (FA), a condition 
characterized by physical abnormalities, bone marrow failure, and increased risk of malignancy. For infants 
and children, FANCC genetic testing is used to confirm the clinical findings, such as blood counts and bone 
marrow biopsy, to diagnose FA. Genetic testing for adults is used to screen potential carriers of the mutation. 
Therefore, the MolDX Team has determined that testing for the FANCC is not a Medicare benefit and is a 
statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests that 
include the FANCC gene. You can find this information in the Centers for Medicare and Medicaid Services, 
Local Coverage Article (LCA) - Billing and Coding: MolDX: FANCC Genetic Testing (A55183). 
 
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 following indications are covered for implanted permanent single chamber or dual 
chamber cardiac pacemakers: 
1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and 
2. Documented non-reversible symptomatic bradycardia due to second degree and/or third-degree 
atrioventricular block. 
C.  Nationally Non-Covered Indications 
 
The following indications are non-covered for implanted permanent single chamber or dual chamber cardiac 
pacemakers: 
1. Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and 
hypothermia, 
2. Asymptomatic first-degree atrioventricular block, 
3. Asymptomatic sinus bradycardia, 
4. Asymptomatic sino-atrial block or asymptomatic sinus arrest, 
5. Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without 
symptomatic bradycardia, 
6. Asymptomatic second-degree atrioventricular block of Mobitz Type I unless the QRS complexes are 
prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of 
the His Bundle (a component of the electrical conduction system of the heart), 
7. Syncope of undetermined cause, 
8. Bradycardia during sleep, 
9. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch 
block) without syncope or other symptoms of intermittent atrioventricular block, 
10. Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-
blocker drug therapy, 
11. Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the 
control of tachycardia, and 
12. A clinical condition in which pacing takes place only intermittently and briefly, and which is not 
associated with a reasonable likelihood that pacing needs will become prolonged. D.  Other 
Medicare Administrative Contractors will determine coverage under section 1862(a)(1)(A) of the Social 
Security Act for any other indications for the implantation and use of single chamber or dual chamber cardiac 
pacemakers that are not specifically addressed in this national coverage determination. You can find this 
information in the Medicare National Coverage Determination (NCD)- 20.8.3, Cardiac Pacemakers: Single 
Chamber and Dual Chamber Permanent Cardiac Pacemakers. 
 
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). 
 
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 $203 deductible which applies to certain items and services. The Plan 
deductible applies to an eye examination and refraction. You can find this information on pages 4-2 to 4-4 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). 
 
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 there is a $0 copayment for one routine eye exam and one contact lens fitting every two (2) years. 
The contract says that there is a $150 allowance toward the cost of routine contact lenses or eyewear every 2 
years from plan and non-plan providers. The Plan contract also says that this benefit is administered on a 
rolling calendar year since your last date of service. You can find this information on page 98 of the Plan's 
2022 Evidence of Coverage.