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 proper coding is necessary on Medicare claims because the codes are generally used to 
determine coverage and payment amounts. CMS accepts only HIPPA approved ICD-9-CM or ICD-10-
CM/ICD-10-PCS codes, depending on the date of service. Use the diagnosis code that describes the patient?s 
diagnosis, symptom, complaint, condition or problem. Assign the code to the highest level of specificity. The 
"highest degree of specificity" refers to assigning the most precise code that most fully explains the narrative 
description of the symptom or diagnosis. You can find these rules in the Medicare Claims Processing Manual 
Chapter 23, Sections 10. 
 
The rules say that when certain component codes or mutually exclusive codes are appropriately furnished, such 
as later on the same day or on a different digit or limb, it is appropriate that these services be reported using a 
HCPCS code modifier. Such modifiers are modifiers E1 - E4, FA, F1 - F9, TA, T1 - T9, LT, RT, LC, LD, RC, 
-58, -78, -79, and -94. Application of these modifiers prevent erroneous denials of claims for several 
procedures performed on different anatomical sites, on different sides of the body, or at different sessions on 
the same date of service. The medical record must reflect that the modifier is being used appropriately to 
describe separate services.  You can find these rules in the Medicare Claims Processing Manual, Chapter 12, 
Section 30 (M) ? Use of 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 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 $120 copayment for emergency care/in-network. You can find this 
information on pages 64-65 of the Plan's 2019 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 417.414.The rules say that except for emergency and urgently needed services, Cost plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. You can find this rule at 42 CFR Section 417.448(a).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 Plan covers items and services in accordance with Medicare rules. The Plan contract also says that you generally must receive your care from a network provider for the Plan to cover the services. If we do not cover services you receive from an out-of-network provider, the services will be covered by Original Medicare if they are Medicare-covered services. Except for emergency or urgently needed services, if you get services covered by Original Medicare from an out-of-network provider then you must pay Original Medicare's cost-sharing amounts. You can find this information on pages 27 and 28 of the Plan's 2019 Evidence of Coverage.The Plan contract also says that if your PCP recommends you have services with an out-of-networkprovider, he or she will submit a prior authorization request to the Plan, who will determine if the requested service is covered at the in-network benefit level. It is your responsibility to be sure that prior authorization is obtained and the services are approved by the plan to be eligible for coverage at in-network rates. Generally,this will only occur when the care needed cannot be obtainedthrough in-network providers. You can find this information on page 30 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.Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find this rulein the Medicare Benefit Policy Manual, Chapter 15, Section 290(3).The rules say that heel replacements (L3455, L3460), sole replacements (L3530, L3540), and shoe transfers (L3600, L3610, L3620, L3630 and L3640) involving shoes on a covered brace are also covered. Inserts and other shoe modifications (L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3550, L3560, L3570, L3580, L3590 and L3595) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. Shoes and related modifications, inserts, heel/sole replacements or shoe transfers billed without a KX modifier will be denied as noncovered because coverage is statutorily excluded. You can find this information in Medicare's Local Coverage Article: Orthopedic Footwear -Policy Article (A52481).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules. The health plan contract says benefits not covered by Medicare: Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of the brace, or the shoes are for a person with diabetic foot disease and supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease. You can find this information in Chapter 4 on page 108 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 at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that continuous glucose monitors (CGMs) are class III medical devices, and require premarket approval by the Food and Drug Administration (FDA). For the purpose of this Ruling, all CGMs that are approved by the FDA for use as adjunctive devices to complement, not replace, information obtained from blood glucose monitors in making diabetes treatment decisions are referred to as "non-therapeutic"CGMs. According to the FDA approval letter for the therapeutic CGM: the indications for use of the product have been expanded to include replacement of blood glucose monitors for diabetes treatment decisions; the device is indicated as a glucose monitoring system for the management of diabetes in persons age 2 years and older; interpretation of the results of the device should be based on the glucose trends and several sequential readings over time; the product also aids in the detection of episodes of hyperglycemia and hypoglycemia, facilitating both acute and long-term therapy adjustments; and the device is intended for single patient use and requires a prescription.  The therapeutic CGM must be calibrated twice a day using a blood glucose monitor. Based on this information, the therapeutic CGM is designed and approved to replace a blood glucose monitor currently classified as DME under the Medicare program, but the device must be calibrated twice a day using a blood glucose monitor. You can find this rulein CMS Ruling 1682R.The rules say that codes A9276 (SENSOR; INVASIVE (E.G., SUBCUTANEOUS), DISPOSABLE, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM, ONE UNIT = 1 DAY SUPPLY) and A9277 (TRANSMITTER; EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM) describe the supplies used with a non-therapeutic CGM. Codes A9276 and A9277 are not used to bill for supplies used with code K0554. You can find this rule in Local Coverage Article: Glucose Monitor -Policy Article (A52464) -Effective June 7, 2018.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers 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 an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both Alzheimer's disease (AD) and frontotemporal dementia (FTD). These patients have been evaluated for specific alternate neurodegenerative diseases or other causative factors, but the cause of the clinical symptoms remains uncertain.You can find this information in the National Coverage Determination (NCD) for FDG PET for Dementia and Neurodegenerative Diseases (220.6.13).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

Medicare rulesThe 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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for a person who meets the following criteria: 1.The person must have a personal mobility deficit; 2.The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, groomingand bathing in customary locations within the home; 3.The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and4.The person must be capable of safely operating the PMD. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.3(B).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers 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 an IRF admission when the services are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week. The patient does not need to be expected to achieve complete independence in self-care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. You can find these rules in the Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section412.622.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 Medicarerules, 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 includes a list of covered supplemental dental services. Gingival irrigation (D4921), application of desensitizing resin (D9911), and consultation (D9310) are not included on this list and are not covered supplemental benefits. You can find this information on pages 90 to 102 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. 
 
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 health 
plan contract says that if you have been diagnosed by a qualified provider with certain chronic conditions and 
meet certain criteria you may be eligible for additional benefits that include allowance for healthy food 
purchases and/or electricity, water and/or phone bill payments, transportation for non-medical needs and home 
assistant services (repairs). You can find this information on pages 120-124 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 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 Plan 
contract lists crown (D2750) as a covered benefit when medically reasonable and necessary. You can find this 
information on pages 94 and 104 of the Plan's 2020 Evidence of Coverage. 
 
The contract also says that the criteria for crown coverage will be met only for permanent teeth needing multi-
surface restorations where other restorative materials have a poor prognosis. Permanent bicuspid teeth must 
have pathologic destruction to the tooth by caries or trauma, and should involve three or more surfaces and at 
least one cusp. You can find this information on page 39 of the Plan's 2020 supplemental dental coverage 
handbook.
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 at42 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 equipmentthat 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 usedfor 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.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers 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 Plan 
contract includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. Gingivectomy or gingivoplasty to allow access for restorative procedure is 
not included on this list and is not a covered supplemental benefit. You can find this information on pages 80 to 
83 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 a seat lift mechanism is covered if all of the following criteria are met: 
 
    1. The beneficiary must have severe arthritis of the hip or knee or have a severe neuromuscular disease. 
    2. The seat lift mechanism must be a part of the treating practitioner?s course of treatment and be prescribed 
to effect improvement, or arrest or retard deterioration in the beneficiary's condition. 
    3. The beneficiary must be completely incapable of standing up from a regular armchair or any chair in their 
home. (The fact that a beneficiary has difficulty or is even incapable of getting up from a chair, particularly a 
low chair, is not sufficient justification for a seat lift mechanism. Almost all beneficiaries who are capable of 
ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.) 
   4. Once standing, the beneficiary must have the ability to ambulate. 
 
Coverage of seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the 
beneficiary, and effectively assist a beneficiary in standing up and sitting down without other assistance. 
Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden, catapult-
like motion and jolts the beneficiary from a seated to a standing position. 
 
The practitioner ordering the seat lift mechanism must be the treating practitioner or a consulting practitioner 
for the disease or condition resulting in the need for a seat lift. The practitioner's record must document that all 
appropriate therapeutic modalities (e.g., medication, physical therapy) have been tried and failed to enable the 
beneficiary to transfer from a chair to a standing position. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Seat Lift Mechanisms 
(L33801). 
 
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. This benefit includes 
coverage for dentures is limited to once every 5 years. You can find this information on page 67 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 the PENS therapy, which involves stimulation of peripheral nerves by a needle electrode 
inserted through the skin, is performed only in a physician's office, clinic, or hospital outpatient department. 
Therefore, it is covered only when performed by a physician or incident to physician's service. If pain is 
effectively controlled by percutaneous stimulation, implantation of electrodes is warranted. 
As in the case of TENS (described in subsection A), generally the physician should be able to determine 
whether the patient is likely to derive a significant therapeutic benefit from continuing use of an implanted 
nerve stimulator within a trial period of 1 month. In a few cases, this determination may take longer to make. 
The medical necessity for such diagnostic services which are furnished beyond the first month must be 
documented. You can find this rule in the National Coverage Determination Manual, Section 160.7.1. 
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.