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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
   Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 63 of the Plans 2023 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 the following clinical indications apply to the Computerized Axial Tomography (CT or 
CAT) of the thorax: 
 
  
  Evaluation of pulmonary, mediastinal, pleural and chest wall infections and their complications 
Detection and characterization of mediastinal neoplasms and other processes 
Assessment of cardiopulmonary failure or insufficiency 
Diagnosis and/or staging of neoplastic and hematologic processes arising in the thorax or with potential  
 involvement of the thorax 
Detection and determination of nature and extent of cardiovascular abnormalities such as, but not limited to  
 aneurysm, dissection, embolism, thrombosis, congenital anomalies, postoperative complications and sequelae   
 of atherosclerotic disease 
For assessing and/or guiding drainage of pulmonary or pleural fluid collections such as abscess, empyema,  
 effusion or pneumothorax 
For characterizing and follow-up evaluation of interstitial and alveolar lung disease due to idiopathic, allergic,  
 collagen-vascular, environmental or other causes 
For evaluating thoracic sequelae of remote processes including, but not limited to, pancreatitis, gastrointestinal  
 perforation and other processes 
For assessing injury, potential injury or thoracic sequelae after trauma, burn, surgery, transplantation, radiation  
 therapy, chemotherapy or invasive procedure such as pacemaker placement, chest tube placement or  
 mechanical ventilation 
Evaluation of the patient with symptoms that may be arising from the chest, or be referred to the chest  
 including but not limited to cough, hemoptysis, chest pain, abdominal pain and others 
To further characterize a suspected abnormality detected by another imaging test 
 
You can find this information in the Local Coverage Determination (LCD): Computerized Axial Tomography 
(CT), Thorax (L33459). 
 
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 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 50 one-way trips per benefit period. You can find this information on pages 72-73 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 effective April 7, 2022, the Centers for Medicare & Medicaid Services (CMS) covers Food 
and Drug Administration (FDA) approved monoclonal antibodies directed against amyloid for the treatment of 
AD when furnished in accordance with Section B under coverage with evidence development (CED) for 
  
  patients who have a clinical diagnosis of mild cognitive impairment (MCI) due to AD or mild AD dementia, 
both with confirmed presence of amyloid beta pathology consistent with AD. 
 
Coverage Criteria: 
 
1) Monoclonal antibodies directed against amyloid that are approved by the FDA for the treatment of AD based 
upon evidence of efficacy from a change in a surrogate endpoint (e.g., amyloid reduction) considered as 
reasonably likely to predict clinical benefit may be covered in a randomized controlled trial conducted under an 
investigational new drug (IND) application. 
 
2) Monoclonal antibodies directed against amyloid that are approved by the FDA for the treatment of AD based 
upon evidence of efficacy from a direct measure of clinical benefit may be covered in CMS-approved 
prospective comparative studies. Study data for CMS-approved prospective comparative studies may be 
collected in a registry. 
 
You can find this rule in the Center for Medicare and Medicaid Services (CMS) Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determination (NCD) Manual, Section 200.3. 
 
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 Plan 
contract says that only certain codes/services are covered under the supplemental dental plan. The handbook 
lists specific services which are a covered benefit and any service not listed in this section is not a covered 
benefit. 
 
Dental x-rays - 1 set(s) every 12 to 36 months depending on type of service 
 
You can find this information in Chapter 4 on pages 62-64 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 effective for dates of service specified below, the Centers for Medicare & Medicaid 
Services (CMS) has determined that PILD will be covered by Medicare when provided in a clinical study under 
section 1862(a)(1)(E) of the Social Security Act through Coverage with Evidence Development (CED) for 
beneficiaries with LSS who are enrolled in an approved clinical study. You can find this information in the 
Centers for Medicare and Medicaid Service, Internet-Only Manual, Publication Number 100-03, Medicare 
National Coverage Determinations Manual, Section 150.13. 
 
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 
unlimited coverage for overdentures up to the annual maximum of $4,000 per year. You can find this 
information on pages 75 to 76 and 79 to 80 of the Plans 2023 Evidence of Coverage (EOC) and on pages 14 
and 16 of the Plan's 2023 American Dental Association (ADA) Current Dental Terminology (CDT).
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 Percutaneous Left Atrial Appendage Closure (LAAC) for non-valvular 
atrial fibrillation (NVAF) through Coverage with Evidence Development (CED) with the following conditions: 
a. LAAC devices are covered when the device has received Food and Drug Administration (FDA) 
Premarket Approval (PMA) for that devices FDA-approved indication and meet all of the conditions 
specified below: 
The patient must have: 
 A CHADS2 score greater than or equal to 2 (Congestive heart failure, Hypertension, Age greater than 
75, Diabetes, Stroke/transient ischemia attack/thromboembolism) or CHA2DS2-VASc score greater 
than or equal to 3 (Congestive heart failure, Hypertension, Age greater than or equal to 65, Diabetes, 
Stroke/transient ischemia attack/thromboembolism, Vascular disease, Sex category) 
 A formal shared decision making interaction with an independent non-interventional physician using an 
evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. 
Additionally, the shared decision making interaction must be documented in the medical record. 
 A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following 
the conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral 
anticoagulants. The patient (preoperatively and postoperatively) is under the care of a cohesive, 
multidisciplinary team (MDT) of medical professionals. The procedure must be furnished in a hospital 
with an established structural heart disease (SHD) and/or electrophysiology (EP) program. 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 20.34. 
 
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 Centers for Medicare & Medicaid Services (CMS) covers Food and Drug Administration 
(FDA) approved monoclonal antibodies directed against amyloid for the treatment of Alzheimers disease (AD) 
when furnished in accordance with coverage with evidence development (CED) for patients who have a 
clinical diagnosis of mild cognitive impairment (MCI) due to AD or mild AD dementia, both with confirmed 
presence of amyloid beta pathology consistent with AD. You can find this information in the Centers for 
Medicare and Medicaid Service, Internet-Only Manual, Publication 100-03, Medicare National Coverage 
Determinations (NCD) Manual: Monoclonal Antibodies Directed Against Amyloid for the Treatment of 
Alzheimers Disease (AD). 
 
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 percutaneous Vertebral Augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
percutaneous kyphoplasty (PKP)) is covered in patients with BOTH the following: 
 
1. Inclusion criteria (ALL are required): 
    a. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) 
(T1  L5) by recent (within 30 days) advanced imaging (bone marrow edema on magnetic resonance imaging 
(MRI) or bone-scan/single photon emission computed tomography (SPECT)/computed tomography (CT) 
uptake) 
    b. Symptomatic (ONE): 
        i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
greater than or equal to 8) 
        ii. Non-hospitalized with moderate-to-severe pain (NRS or VAS greater than or equal to 5) despite 
optimal non-surgical management (NSM) (ONE): 
            1. Worsening pain 
            2. Stable-to-improved pain (but NRS or VAS still greater than or equal to 5) (with greater than or equal 
to 2 of the following): 
                A. Progression of vertebral body height loss 
                B. Greater than 25 percent vertebral body height reduction 
                C. Kyphotic deformity 
                D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
greater than 17) 
 
*Consider including pedicle periosteal infiltration 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38737). 
 
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 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 only the 
items and services listed in the Dental Rider. A custom fabricated abutment (D6057), an abutment supported 
crown (D6059), and an endosteal implant (D6010) are not covered by the Plan's dental benefits. You can find 
this information on pages 7-18 of the Plans 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 state that retreatment may be considered for patients who met the guidelines for initial treatment and 
subsequently developed relapse of depressive symptoms if the patient responded to prior treatments as 
evidenced by a greater than 50% improvement in standard rating scale measurements for depressive 
symptoms.  
 
All other uses of TMS therapy are considered investigational or experimental and remain non-covered services. 
 
You can find this information in the Local Coverage Determination (LCD) Transcranial Magnetic Stimulation 
(TMS) L37088. 
 
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 knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1845) are covered if the beneficiary has had recent injury to or a surgical 
procedure on the knee(s). You can find this rule in the Local Coverage Determination (LCD) - Knee Orthoses 
(L33318). 
 
The rules say that knee orthoses are also covered for a beneficiary who is ambulatory and has knee instability. 
Knee instability must be documented by examination of the beneficiary and objective description of joint laxity 
(e.g., varus/valgus instability, anterior/posterior Drawer test). Claims will be denied as not reasonable and 
necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied 
if only pain or a subjective description of joint instability is documented. You can find this rule in the Local 
Coverage Determination (LCD) - Knee Orthoses (L33318). 
 
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 to establish CCTA medical necessity, your case must meet at least 1 indication in the 
following 2 categories: 
 
Symptomatic (CAD) 
1. Evaluation of acute chest pain, unexplained dyspnea or symptoms suggesting angina pectoris (such as jaw 
pain) when there is: 
    -Intermediate pre-test probability of CAD* and 
    -No electrocardiogram (EKG) changes to suggest acute myocardial injury or ischemia and 
    -Normal initial cardiac markers. 
    -Patients with intermediate risk and a discordant clinical situation (e.g., ongoing ischemic symptoms, normal 
stress test). 
 
2. Evaluation of chest pain syndrome when there is: 
    -Intermediate pre-test probability of CAD* and 
    -Uninterpretable EKG** or patient is unable to exercise or 
    -Uninterpretable or equivocal stress test (exercise, perfusion or stress echocardiogram (echo)). 
 
You can find this information in Medicare's Local Coverage Determination (LCD) L33423: Cardiac Computed 
Tomography & Angiography (CCTA). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.