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 state that a power seating system - tilt only, recline only, or combination tilt and recline - with or without power elevating legrests will be covered if any of the following criteria are met:

The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or

The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or The rules state that a power seating system - tilt only, recline only, or combination tilt and recline - with or without power elevating legrests will be covered if any of the following criteria are met:

The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or

The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or the power seating system is needed to manage increased tone or spasticity.

If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.

You can find these rules in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792)
Codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the beneficiary to select the motor that is being controlled and an indicator feature to visually show which function has been selected. When the wheelchair drive function has been selected, the indicator feature may also show the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for fixed mounting hardware for the control box and for the display box (if present).

You can find these rules in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that there are a wide variety of conditions that can be characterized as Temporomandibular Joint 
(TMJ), and an equally wide variety of methods for treating these conditions.  Many of the procedures fall 
within the Medicare program?s statutory exclusion that prohibits payment for items and services that have not 
been demonstrated to be reasonable and necessary for the diagnosis and treatment of illness or injury 
(?1862(a)(1) of the Act).  Other services and appliances used to treat TMJ fall within the Medicare program?s 
statutory exclusion at 1862(a)(12), which prohibits payment ?for services in connection with the care, 
treatment, filling, removal, or replacement of teeth or structures directly supporting teeth....? For these reasons, 
a diagnosis of TMJ on a claim is insufficient.  The actual condition or symptom must be determined. 
 
You can find this information in the Medicare Benefit Policy Manual, Chapter 15 ? Covered Medical and 
Other Health Services, 150.1 -  Treatment of Temporomandibular Joint (TMJ) Syndrome(Rev. 1, 10-01-03). 
 
The rules say that oral appliances generally are classified as dental devices and are not classified as durable 
medical equipment. The following items (not all-inclusive) are considered to be dental devices and will be 
denied as non-covered, not DME: Oral occlusal appliances used to treat temporomandibular joint (TMJ) 
disorders. You can find this information in Medicare's Local Coverage Article: Oral Appliances for Obstructive 
Sleep Apnea - Policy Article (A52512). 
 
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. 
 
Summary of Citation(s): CMS has not issued specific coverage criteria in the form of an LCD (Local Coverage 
Determination) or NCD (National Coverage Determination) for this particular item or service. However, per 
Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k), Medicare does not pay for any 
items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to 
improve the functioning of a malformed body member. The determination of medical necessity must be 
tailored to the individual patient and their unique clinical scenario. CMS considers services to be medically 
reasonable and necessary if they are:  
  
 Safe and effective; 
 Not mainly for the convenience of the patient or the physician; 
 Not experimental or investigational; and 
 Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of 
whether it is: 
   - Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the 
patient's condition or to improve the function of a malformed body member; 
   - Furnished in a setting appropriate to the patient's medical needs and condition; 
   - Ordered and furnished by qualified personnel; 
   - One that meets, but does not exceed, the patient's medical need; and 
   - At least as beneficial as an existing and available medically appropriate alternative. 
You can find this rule in the Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 
 
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). 
 
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 for 
periodontal scaling and root planing to be covered there must be a minimum of four (4) teeth affected in the 
quadrant and periodontal charting must indicate abnormal pocket depths in multiple sites. Additionally, there 
must be radiographic evidence of root surface calculus or radiographic evidence of noticeable loss of bone 
support. You can find this information on page 30 of the Plan?s 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 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 also includes a 
list of the covered supplemental dental benefits. The core buildup (D2950) is not on this list and is not a 
covered supplemental benefit. You can find this information on pages 91 to 102 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 pages 43-44 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 Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You 
can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1.  
 
The rules also say that Medicare will pay for durable medical equipment that is needed for use in the home. 
Your home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 
110.1(D). 
 
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 Genomic Sequential Analysis Panel will be considered reasonable and necessary in the 
evaluation of tumor tissue in the following clinical circumstances:  
 
-Newly diagnosed patients with advanced (stage IIIB or IV) NSCLC, who are not treatable by resection or 
radiation with curative intent, and who are suitable candidates for therapy at the time of testing. 
-Previously diagnosed patients with advanced (stage IIIB or IV) NSCLC, who have not responded to at least 
one systemic therapy, or who have progressed following resection. The patient must be a candidate for 
treatment at the time of the testing. 
-Previously diagnosed patients with advanced (stage IIIB or IV) NSCLC, who have been resistant to at least 
one targeted therapy, are able to undergo tumor tissue biopsy for testing, and who are suitable candidates for 
additional treatment at the time of testing.  
 
You can find this rule in Local Coverage Determination (LCD): Genomic Sequence Analysis Panels in the 
Treatment of Solid Organ Neoplasms (L37810) - Effective October 3, 2019. 
 
The rules say that Genomic Sequential Analysis Panel will be considered reasonable and necessary when the 
test is performed in a CLIA-certified laboratory qualified to perform high complexity testing, ordered by a 
treating physician, and the patient has:  
-metastatic CRC; and 
-is a candidate for intensive chemotherapy with an anti-EGFR biologic agent; and 
-has not had prior RAS/BRAF testing (except after initiation of anti-EGFR therapy with evidence of acquired 
resistance). 
 
You can find this rule in Local Coverage Determination (LCD): Genomic Sequence Analysis Panels in the 
Treatment of Solid Organ Neoplasms (L37810) - Effective October 3, 2019. 
 
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. This benefit includes 
dentures and are limited to 1 complete or partial denture every 5 years. You can find this information on page 
82 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 EPI is covered once prior to initial biopsy. You can find this rule in Local Coverage 
Determination (LCD): Biomarker Testing (Prior to Initial Biopsy) for Prostate Cancer Diagnosis (L37733) - 
Effective December 1, 2019. 
 
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 continued coverage of a PAP device (E0470 or E0601) beyond the first three months of 
therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the 
treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is benefiting from 
PAP therapy. For PAP devices with initial dates of service on or after November 1, 2008, documentation of 
clinical benefit is demonstrated by: 1. In-person clinical re-evaluation by the treating practitioner with 
documentation that symptoms of obstructive sleep apnea are improved; and, 2. Objective evidence of 
adherence to use of the PAP device, reviewed by the treating practitioner. Adherence to therapy is defined as 
use PAP 4 or more hours per night on 70% of nights during a consecutive thirty day period anytime during the 
first three months of initial usage. You can find this rule in Local Coverage Determination (LCD): Positive 
Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718) - 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 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). 
 
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 to be eligible for the special supplemental benefits for Chronically ill, you must have 
one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit 
your health or general functioning, or you must have a high risk of hospitalization or other adverse health 
outcomes; and must require intensive care coordination. You can find this information on pages 110-114 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 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). 
 
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 Special Supplemental Benefits for the Chronically Ill includes: transportation for non-
medical needs, allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit 
card), and home assistance services (repairs). The beneficiary must have a qualifying diagnosis to be eligible 
for these benefits. This information can be found on pages 113 to 116 of the 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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for dentures once every 5 plan years. You can find this information on page 4-58 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 does not pay for gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. You can find this rule in the 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 health 
plan provides supplemental coverage for gym benefits. The services must be obtained through a
fitness program that is provided by a contracted facility. This information can be found on page 4-19 
of the 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 asgrab 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.