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). You can find this rule at 42 CFR Section 422.111.  
 
The rules say that a copayment is a fixed amount 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 $225 copayment for each ambulance trip. You can find this information 
on page 63 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 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 the 
placement of a fixed prosthetic appliance will only be considered for those exceptional cases where there is a 
documented physical or neurological disorder that would preclude placement of a removable prosthesis. You 
can find this information in the Plan's 2020 2020 dental contract.
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 patient's 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 a grab bars. You 
can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
The rules say that Medicare covers gloves only when included as part of another covered service or kit. You 
can find this information in the Medicare Benefit Policy Manual (Chapter 7, Section 50.4.1.2 and Chapter 11, 
Section 20.4). 
 
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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules state that a power seat elevation feature (E2300) and power standing feature (E2310) are non-covered 
because they are not primarily medical in nature. You can find this rule in Local Coverage Article (LCA) 
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 if the POV or PWC is a replacement during the 5-year useful lifetime of an item in the same 
performance group that was previously covered by Medicare, a face-to-face encounter is not required. Note: 
Replacement during an item?s useful lifetime is limited to situations involving loss or irreparable damage from 
a specific accident or natural disaster (e.g., fire, flood, etc.). 
 
The treating practitioner may conduct the entire mobility face-to-face encounter or may refer the beneficiary to 
a licensed/certified medical professional (LCMP), such as a physical therapist (PT) or occupational therapist 
(OT), who has experience and training in mobility evaluations to perform part of the face-to-face encounter. 
This person may have no financial relationship with the supplier. (Exception: If the supplier is owned by a 
hospital, the PT or OT working in the inpatient or outpatient hospital setting may perform part of the face-to-
face encounter.) 
 
To accommodate the requirements at 42 CFR 410.38, when the treating practitioner sees the beneficiary, 
regardless of whether a referral to an LCMP is made, that visit date starts the six (6) month timeline for 
completion of the SWO for the wheelchair base. If the treating practitioner chooses to refer the beneficiary to 
an LCMP for a mobility evaluation, the treating physician's co-signature, dating and indicating agreement or 
disagreement with the LCMP evaluation must occur within this six (6) month timeframe. In cases where the 
LCMP evaluation is being adopted into the physician's documentation to substantiate the need for the base 
item, the SWO may not be written until the LCMP report is signed, dated and agreement/disagreement 
indicated. 
 
MISCELLANEOUS: 
 
A custom motorized/power wheelchair base (K0013) must be uniquely constructed or substantially modified 
for a specific beneficiary according to the description and orders of the beneficiary's treating practitioner. The 
beneficiary's needs must not be able to be accommodated by any other existing PMD and accessories, 
including customized seating arrangements. See 42 CFR Section 414.224(a). 
 
A seat elevator is a statutorily noncovered option on a power wheelchair. If a PWC with a seat elevator 
(K0830, K0831) is provided, it will be denied as noncovered. 
 
If any power operated vehicle (POV) or power wheelchair only for use outside the home, it will be denied as 
noncovered. 
 
You can find this information in Medicare's Local Coverage Article: Power Mobility Devices - Policy Article 
(A52498). 
 
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 although not intended as a comprehensive list, the following metabolic, neurologic, and 
peripheral vascular diseases (with synonyms in parentheses) most commonly represent the underlying 
conditions that might justify coverage for routine foot care. Diabetes mellitus  *Arteriosclerosis obliterans 
(A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis) Buerger's disease 
(thromboangiitis obliterans)Chronic thrombophlebitis  * Peripheral neuropathies involving the feet -Associated 
with malnutrition and vitamin deficiency * Malnutrition (general, pellagra) Alcoholism Malabsorption 
(celiac disease, tropical sprue) Pernicious anemia Associated with carcinoma  *Associated with diabetes 
mellitus  *Associated with drugs and toxins  *Associated with multiple sclerosis  *Associated with uremia 
(chronic renal disease)  *Associated with traumatic injury Associated with leprosy or neurosyphilisAssociated 
with hereditary disorders Hereditary sensory radicular neuropathy Angiokeratoma corporis diffusum 
(Fabry's) Amyloid neuropathy 
 
When the patient's condition is one of those designated by an asterisk (*), routine procedures are covered only 
if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.  
 
You can find this information in the Medicare Benefit Policy Manual Chapter 15 - Covered Medical and Other 
Health Services. 
 
For Medicare to consider coverage and payment for any item or service, the information submitted by the 
supplier or provider must corroborate the documentation in the beneficiary's medical documentation and 
confirm that Medicare coverage criteria have been met. Physicians must report services correctly. This manual 
discusses general coding principles in Chapter I and principles more relevant to other specific groups of 
HCPCS/CPT codes in the other chapters. There are certain types of improper coding that physicians must 
avoid. Procedures should be reported with the most comprehensive CPT code that describes the services 
performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services 
described by that code have been performed.  You can find this guidance in the Medicare Program Integrity 
Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Action, Section 3.3.2.1; NCCI Policy 
Manual, Chapter 1, Introduction, page I-7 and I-8. 
 
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 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 
periodontic scaling and root planing and full mouth debridement are covered unlimited every year. Prior 
Authorization (approval in advance) may be required. You can find this information on pages 85 and 86 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. 
 
Medicare guidance says that upgraded electronics (expandable controller, harness and electronic connector to 2 
power options) are not medically necessary. They cannot be covered. You can find this guidance in the 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.
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 a lifetime maximum of 190 days on inpatient psychiatric hospital services available 
to any beneficiary. Therefore, once an individual receives benefits for 190 days of care in a psychiatric 
hospital, no further benefits of that type are available to that individual. You can find this information in the 42 
Code of Federal Regulations (CFR), Section 409.62. 
 
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 
also indicates that there is a 190-day lifetime limit for inpatient psychiatric services. You can find this on page 
77 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 that Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL of the following criteria: 
- Duration of pain of at least three (3) months 
- Pain is intermittent or continuous with average pain levels of 6 or greater on a visual-numerical 
analogue pain scale (VNAS) of 0 to 10 (primary [index] pain), or functional disability 
- Documented failure to respond to conservative care such as nonsteroidal anti-inflammatory drugs 
(NSAIDS), acetaminophen, physical therapy for a minimum of 6 weeks (as tolerated) 
- History of pain that is predominantly axial and, with the possible exception of facet joint cysts, not 
associated with radiculopathy or neurogenic claudication 
- Physical examination with documented signs that the facet joint is the primary suspected source of pain  
- There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patient's pain, including but not limited to fracture, tumor, infection, or significant 
deformity 
You can find this rule at Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management 
(L34892) (eff. 11/21/19). 
 
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 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.  
 
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 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 pages 75 and 189 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 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.  
 
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 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 pages 91 and 214 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 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 patient's 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 a grab bars. You 
can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
The rules say that a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height 
adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. 
You can find this information in Medicare's Local Coverage Determination (LCD): Hospital Beds And 
Accessories (L33820). 
 
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 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.  
 
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 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 pages 71 to 72 and 177 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 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 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 3-3 to 3-7 of the Plan's 
2020 Evidence of Coverage.