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 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.  
 
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 Section 423.578(b)(5)(ii). 
 
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 75 of the Plan's 2020 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 Part B drugs. A separate physician office 
copayment may apply.  In addition, the contract says that enrollees must pay a $20 copayment for specialist 
visits. You can find this information on pages 73 and 79 of the Plan's 2020 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 whirlpool bath equipment is covered if patient is homebound and has a (standard)condition 
for which the whirlpool bath can be expected to provide substantial therapeutic benefit justifying its cost. 
Where patient is not homebound but has such a condition, payment is restricted to the cost of providing the 
services elsewhere; e.g., an outpatient department of a participating hospital, if that alternative is less costly. 
You can find this rule 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 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 SSA, Section 1862(a)(12) and 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 says that 1 
complete or partial denture is covered every 5 years. You can find this information on page 78 of the Plans 
2020 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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 51 of the Plan's 2020 
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 providers must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(A). 
 
The rules say if one laboratory procedure evaluates multiple genes utilizing a next generation sequencing 
procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 
If no CPT code accurately describes the procedure performed, the laboratory shall report CPT code 81479 
(unlisted molecular pathology procedure) with one unit of service. The laboratory shall not report multiple 
individual CPT codes describing the component test results. If a single procedure is performed, only one 
HCPCS/CPT code with one unit of service may be reported for the procedure. You can find this rule in the 
National Correct Coding Initiative Policy Manual Chapter X. 
 
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 the only covered chiropractic service is manual manipulation of the spine to correct subluxation. 
Other services performed by a chiropractor are not covered. You can find this information on page 62 of the 
Plan's 2019 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 the clinical use of contrast echocardiography (ECHO) is appropriate in selected patients to: 
-Evaluate myocardial ischemia  
-Quantify myocardial perfusion during stress  
-Identify the area at risk during acute myocardial infarction (AMI)  
-Determine the success of reperfusion interventions 
-Assess myocardial viability 
 
The plethora of structural and functional information provided by transthoracic echocardiogram (TTE) is 
unique among diagnostic testing modalities. The rapid and noninvasive acquisition of this information has 
contributed to exponential application, and to potential overutilization. This policy addresses the medically 
necessary and appropriate application of TTE.  
 
A. Ventricular Function and Cardiomyopathies  
 
Changes in myocardial thickness (hypertrophy and thinning) in derived parameters of contractility, and in 
chamber volume and morphology, can be quantitated and charted over time by TTE. Cardiac responses to 
volume perturbations, chronic pressure excess and therapeutic interventions can be monitored. Recognition of 
the relative contributions of myocardial and valvular functional perturbations to a clinical presentation is 
facilitated. TTE aids in the recognition of myopathies and their classification into hypertrophic, dilated and 
restrictive types. Without clinically documented, discrete (abrupt change in signs and symptoms) episodes of 
deterioration, it is not generally medically necessary to repeat TTE assessments more frequently than annually, 
unless done to evaluate the response to therapeutic intervention. 
 
Although TTE is used in the assessment of ventricular diastolic function, reproducible pathognomonic findings 
are not well established. In individuals with signs and/or symptoms suggestive of ventricular dysfunction, the 
demonstration by TTE of normal systolic function and/or ventricular hypertrophy may suggest the presence of 
diastolic functional abnormalities. Because the TTE findings suggesting diastolic dysfunction are less well 
established, when this application of TTE is the primary indication for the test, it will be expected to be 
performed by examiners recognized as experts in assessment and treatment of ventricular diastolic dysfunction.  
 
Evaluation of diastolic filling parameters by Doppler ECHO is being used to help establish the prognosis in 
patients with congestive heart failure (CHF) and systolic dysfunction as well as to evaluate appropriate 
parameters of medical treatment. 
 
You can find this rule in the Local Coverage Determination (LCD): Echocardiography (L37379) effective 
September 17, 2017. 
 
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 $750 deductible that the enrollee must pay out-of-pocket before the plan will 
pay their share for the enrollee's covered medical services. You can find this information on page 57 of the 
Plan's 2020 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay 40% coinsurance for out-of-network chiropractic services. 
You can find this information on page 66 of the Plan's 2020 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 your deductible is $500 for services from both in-network and out-of-network providers. You 
can find this information on page 55 of the Plan's 2020 Evidence of Coverage (EOC). 
 
The Plan contract also says that enrollees must pay a 25% coinsurance for in-network and out-of-network 
outpatient surgery services provided in an outpatient hospital. You can find this information on page 80 of the 
Plan's 2020 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 ankle-foot orthoses (AFO) described by codes L1900, L1902, L1904, L1906, L1907, 
L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2106, 
L2108, L2112, L2114, L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory 
beneficiaries with weakness or deformity of the foot and ankle, who: 
 
        Require stabilization for medical reasons, and, 
 
        Have the potential to benefit functionally. 
 
If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not reasonable 
and necessary. 
 
AFOs and KAFOs that are custom-fabricated are covered for ambulatory beneficiaries when the basic coverage 
criteria listed above and one of the following criteria are met: 
 
    The beneficiary could not be fit with a prefabricated AFO; or, 
 
    The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 
6 months); or, 
 
    There is a need to control the knee, ankle or foot in more than one plane; or, 
 
    The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom 
fabricating over a model to prevent tissue injury; or, 
 
    The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric 
proportions. 
 
If a custom fabricated orthosis is provided but basic coverage criteria above and the additional criteria for a 
custom fabricated orthosis are not met, the custom fabricated orthosis will be denied as not reasonable and 
necessary. 
You can find these rules in Local Coverage Determination (LCD): Ankle-Foot/Knee-Ankle-Foot Orthosis 
(L33686). 
 
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 ankle-foot orthoses (AFO) described by codes L1900, L1902, L1904, L1906, L1907, 
L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2106, 
L2108, L2112, L2114, L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory 
beneficiaries with weakness or deformity of the foot and ankle, who: 
 
        Require stabilization for medical reasons, and, 
 
        Have the potential to benefit functionally. 
 
If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not reasonable 
and necessary. 
 
AFOs and KAFOs that are custom-fabricated are covered for ambulatory beneficiaries when the basic coverage 
criteria listed above and one of the following criteria are met: 
 
    The beneficiary could not be fit with a prefabricated AFO; or, 
 
    The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 
6 months); or, 
 
    There is a need to control the knee, ankle or foot in more than one plane; or, 
 
    The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom 
fabricating over a model to prevent tissue injury; or, 
 
    The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric 
proportions. 
 
If a custom fabricated orthosis is provided but basic coverage criteria above and the additional criteria 1-5 for a 
custom fabricated orthosis are not met, the custom fabricated orthosis will be denied as not reasonable and 
necessary. 
L coded additions to AFOs and KAFOs (L2180, L2182, L2184, L2186, L2188, L2190, L2192, L2200, L2210, 
L2220, L2230, L2232, L2240, L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, 
L2335, L2340, L2350, L2360, L2370, L2375, L2380, L2385, L2387, L2390, L2395, L2397, L2405, L2415, 
L2425, L2430, L2492, L2500, L2510, L2520, L2525, L2526, L2530, L2540, L2550, L2750, L2755, L2760, 
L2768, L2780, L2785, L2795, L2800, L2810, L2820, L2830) will be denied as not reasonable and necessary if 
either the base orthosis is not reasonable and necessary or the specific addition is not reasonable and necessary. 
 
You can find these rules in Local Coverage Determination (LCD): Ankle-Foot/Knee-Ankle-Foot Orthosis 
(L33686). 
 
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 an expandable controller is capable of accommodating one or more of the following 
additional functions: - Other types of proportional input devices (e.g., mini-proportional or compact joysticks, 
touchpads, chin control, head control, etc.) - Non-proportional input devices (e.g., sip and puff, head array, etc.) 
- Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating 
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)  
 
An expandable controller may also be able to operate one or more of the following: - A separate display (i.e., 
for alternate control devices) - Other electronic devices (e.g., control of an augmentative speech device or 
computer through the chair's drive control) - An attendant control.  
 
For power wheelchairs which are capable of being upgraded to an expandable controller (K0835, K0836, 
K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, 
K0854, K0855, K0856 K0857, K0858, K0859, K0860, K0861 K0862, K0863, K0864, K0868, K0869, K0870, 
K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891), E2377 is used if an 
expandable controller is provided at the time of initial issue. Code E2376 is used with complete replacement of 
an expandable controller. A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. 
that are required for the operation of an expandable controller. It also includes all the necessary fasteners, 
connectors, and mounting hardware. Code E2313 is separately billable in addition to an expandable controller 
both at initial issue and with complete replacement of the expandable controller. Code K0108 must not be used 
for any component or feature of an expandable controller at the time of initial issue. The reimbursement for any 
type of complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. 
However, if individual components of the harness are replaced, code K0108 should be used.  
 
You can find this rule in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article 
(A52504) effective January 1, 2020. 
 
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). 
 
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 $350 copayment for outpatient surgery/outpatient hospital. You can find 
this information on pages 90-91 of the Plan's 2020 Evidence of Coverage (EOC).