Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
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 Plan 
contract says that 1 crown - porcelain/ceramic is covered per calendar year and that the enrollee must pay a 
$75% coinsurance when provided out-of-network. The Plan contract says that 2 procedure codes for resin-
based composite (white)  anterior (front) or posterior (back) are covered per calendar year and that the 
enrollee must pay a 55% coinsurance when provided out-of-network. 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. 
 
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 $15 copayment that applies to UV treatment, tint, or standard plastic 
scratch coating. You can find this information on pages 89 to 91 of the Plans 2022 Evidence of Coverage. 
 
The Plan contract also states enrollees must pay a $65 copayment which applies to standard and premium 
progressive lenses and standard anti-reflective coating. You can find this information on pages 89 to 91 of the 
Plans 2022 Evidence of Coverage. 
 
The Plan contract also states enrollees must pay 80% coinsurance which applies to premium progressive lenses 
and other coatings, oversized lenses, prism and other lens options. You can find this information on pages 89 to 
91 of the Plans 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 20% coinsurance for Medicare-covered durable medical equipment. You 
can find this information on page 86 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 there is no Medicare payment for shipping or delivery of durable medical equipment.  You 
can find this rule at Centers for Medicare and Medicaid Services, Medicare Durable Medical Equipment 
Administrative Contractor, Region B, Supplier Manual, Chapter 5. 
 
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.
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 breast magnetic resonance imaging (MRI) studies are to be used very selectively. The 
modality should be restricted to: 
- cases where diagnosis is inconclusive, even after standard work-up; 
- evaluation of the post-operative patient when scar tissue cannot be differentiated from tumors; 
- patients with positive axillary nodes but no known primary; 
- patients with rupture of a breast implant; or 
- determination of the extent of disease in patients with known malignancy, prior to treatment (to assure 
confinement to one segment of the breast). 
- Breast MRI should be performed under the general supervision of a physician qualified in magnetic 
resonance imaging. 
 
A treating provider's (physician or qualified non-physician practitioner) order is required for breast MRI. You 
can find these rules in Local Coverage Determination (LCD) Breast Imaging Mammography/Breast 
Echography (Sonography)/Breast MRI/Ductography (L33950). 
 
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 claims submitted with the GA modifier will be denied as not reasonable and necessary. You 
can find this rule at Centers for Medicare and Medicaid Services, Region B Durable Medical Equipment 
Administrative Contractor CGS Article entitled Supplies- Use of Upgrade Modifiers. 
 
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 Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. 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 test strips and blood glucose monitors must be obtained from our preferred manufacturer 
- LifeScan. If you do not have a LifeScan blood glucose monitor, please contact your doctor to request a 
prescription for a replacement monitor from a participating pharmacy. You can find this information on page 
61 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 does not include 
dental implants. You can find this information in Chapter 4 on page 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 say that Medicare does not cover chiropractic maintenance care. When further clinical improvement 
cannot be reasonably expected from ongoing care, the care is considered maintenance. The AT modifier must 
not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will 
be considered as maintenance therapy and denied. 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 240.1.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.   
The Plan contract says that the only covered chiropractic service is manual manipulation of the spine to correct 
a subluxation. You can find this information on page 56 of the Plans 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. 
The Plan contract says that the only covered chiropractic service is manual manipulation of the spine to correct 
a subluxation. You can find this information on page 37 of the Plans 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 Intensity Modulated Radiation Therapy (IMRT) is a technology in radiation oncology that 
delivers radiation more precisely to the tumor while relatively sparing the surrounding normal tissues. It is an 
advanced form of three-dimensional conformal radiation therapy (3D CRT) that allows for varying intensities 
of radiation to produce dose distributions that are more conformal than those possible with standard 3D CRT. It 
introduces inverse planning and computer-controlled radiation deposition, and normal tissue avoidance in 
contrast to the conventional trial-and-error approach. 
 
The clinical objectives are defined mathematically and the IMRT optimization process determines the beam 
parameters that will lead to the desired solution while sparing normal tissues. 
 
Examples of situations where IMRT is covered include tumors of the prostate, head and neck, brain, and 
paraspinal regions when needed to reduce the incidence and severity of the side effects of radiation, including 
compromise of visual function, mucositis, and xerostomia. 
 
An IMRT candidate includes a patient who has already received a maximum amount of radiation delivered by 
conventional means. IMRT allows these patients to receive additional radiation safely, which can result in a 
prolonged survival and an improved quality of life. 
 
You can find these rules in the Local Coverage Article Billing and Coding Billing and Coding: Intensity 
Modulated Radiation Therapy (IMRT) A58245. 
 
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 Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
The rules say that for an oral anti-cancer drug to be covered under Part B, it must: 
- Be prescribed by a physician or other practitioner licensed under State law to prescribe such drugs as anti-
cancer chemotherapeutic agents; 
- Be a drug or biological that has been approved by the Food and Drug Administration (FDA); 
- Have the same active ingredients as a non-self-administrable anti-cancer chemotherapeutic drug or biological 
that is covered when furnished incident to a  
physicians service. The oral anti-cancer drug and the non-self-administrable drug must have the same 
chemical/generic name as indicated by the FDAs  
Approved Drug Products (Orange Book), Physicians Desk Reference (PDR), or an authoritative drug 
compendium; 
- Be used for the same indications, including unlabeled uses, as the non-self-administrable version of the drug; 
and 
- Be reasonable and necessary for the individual patient. 
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 50.5.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
requested pontic - porcelain fused to high noble metal and retainer crown  porcelain fused to high noble metal 
but is limited up to four units of fixed dentures per year, covered one per tooth per life. You can find this 
information on pages 128-129 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 drugs/biologicals are covered by Medicare Part B when they meet all the general 
requirements for coverage of items as incident to a physician's services. In order to meet all the general 
requirements for coverage under the incident-to provision, a drug must be furnished by a physician, or by all 
the general requirements for coverage of items as incident to a physician's services. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 15, Section 50 and 50.3. 
 
The rules say that Medicare pays for services and supplies that are furnished incident to a physician's or other 
practitioner's services, are commonly included in the physician's or practitioner's bills. Coverage of services 
and supplies incident to the professional services of a physician in private practice is limited to situations in 
which there is direct supervision of auxiliary personnel. Direct supervision in the office setting means the 
physician must be present in the office suite and immediately available and able to provide assistance and 
direction throughout the time the service is performed. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, 
Chapter 15, Section 60.1(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.
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 pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. 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. 
 
The rules say that a power seat elevation feature and power standing feature are non-covered because they are 
not primarily medical in nature. You can find this information in Local Coverage Article: Wheelchair 
Options/Accessories - Policy Article (A52504). 
 
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 a list of 
covered preventive and comprehensive dental benefits and benefit exclusions. You can find this information in 
Chapter 4 on pages 75 to 78 and pages 82 to 84 of the Plans 2023 Evidence of Coverage (EOC).