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 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 at Local 
Coverage Article: Glucose Monitor - Policy Article (A52464) (eff. 1/1/20). 
The rules say that therapeutic CGMs and related supplies are covered by Medicare when all of the following 
coverage criteria (1-6) are met: 
1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy 
Article for applicable diagnoses); and, 
2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and,  
3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump; and, 
4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis 
of BGM or CGM testing results; and, 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with 
the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and, 
6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.  
When a therapeutic CGM (code K0554) is covered, the related supply allowance (code K0553) is also covered. 
You can find this rule at Local Coverage Determination (LCD): Glucose Monitors (L33822) (eff. 1/1/20).  

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 $105 copayment for Medicare-covered diagnostic radiological 
diagnostic services. You can find this information on page 4-31 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 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 health 
plan contract says that only certain codes/services are covered under the Plan. The EOC lists specific services 
which are a covered benefit and any service not listed in this section is not a covered benefit. You can find this 
information in Chapter 4 on page 67 of the plan's 2020 Evidence of Coverage. 
 
The health plan contract says non-routine dental care (covered services are limited to surgery of the jaw or 
related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation 
treatments of neoplastic cancer disease, or services that would be covered when provided by a physician). You 
can find this information in Chapter 4 on page 86 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. 
 
No provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the 
provider or supplier is enrolled in the Medicare program. Further, it is essential that each provider and supplier 
enroll with the appropriate Medicare fee-for-service contractor. You can find this information in Medicare 
Program Integrity Manual Chapter 15, Section 15.1. 
 
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 state that A group 2 support surface is covered if the beneficiary meets at least one of the following 
three Criteria (1, 2 or 3): 
 
    1.) The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis (refer to the ICD-10 
code list section in the LCD-related Policy Article for applicable diagnoses) which have failed to improve over 
the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program 
including each of the following: 
        Use of an appropriatge group1 support surface, and 
        Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and 
        Appropriate turning and positioning, and 
        Appropriate wound care, and 
        Appropriate management of moisture/incontinence, and 
        Nutritional assessment and intervention consistent with the overall plan of care 
   2.) The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (refer to the 
ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses), 
    3.) The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within 
the past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable 
diagnoses), and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or 
nursing facility within the past 30 days 
 
 
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 a Group 3 power wheelchair can be covered only for enrollees who have a mobility 
limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices L33789 (eff 1/1/17).  
 
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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 one comprehensive eye exam, complete frame, and pair of lenses (contact lenses, if 
medically necessary) are covered per 24-month period for members 21 through 59 years of age. You can find 
this on page 89 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 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 lists the specific 
dental services that are covered. Removal of the torus mandibularis is not listed and therefore is not covered 
service. Conscious sedation is not listed and therefore is not a covered service either. The contract also says 
that any services not listed are not covered. You can find this information on pages 4-74 to 4-82 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 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 that Medicare Guidance states as Comprehensive Genomic Profile (CGP) testing is not defined as 
a targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to 
report a CGP, service providers should use CPT code 81479 (for the entire multi-test panel) at this time, in 
addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not 
unbundled to separate codes. Coverage of CGP is limited to one test per specimen and precludes the use of any 
other molecular testing on the specimen. You can find this Medicare guidance in the Medicare Local Coverage 
Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Sequencing Testing in 
[Solid Tumor] Cancers (A55624); Medicare Local Coverage Article: Billing and Coding: MolDX: Biomarkers 
in Cardiovascular Risk Assessment (A57559); Local Coverage Determination (LCD): MolDX: Biomarkers in 
Cardiovascular Risk Assessment (L36523). 
 
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 a Standard Written Order (SWO) must be communicated to the supplier before a claim is 
submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, 
the claim shall be denied as not reasonable and necessary. 
 
For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a 
Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS 
item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the 
claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the 
bottom of this policy under the Related Local Coverage Documents section. 
 
For DMEPOS base items that require a WOPD, and also require separately billed associated options, 
accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may 
list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the 
items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies 
without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be 
denied as not reasonable and necessary. 
 
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, 
LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be 
denied as not reasonable and necessary/incorrectly coded. 
 
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD 
documentation in their files. Proof of delivery documentation must be made available to the Medicare 
contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be 
denied as not reasonable and necessary. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Oxygen and Oxygen 
Equipment (L33797). 
 
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 a portable oxygen system is covered if the beneficiary is mobile within the home and the 
qualifying blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood 
gas study was performed during sleep, portable oxygen will be denied as not reasonable and necessary. 
 
If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary 
system. See exception in the related Policy Article Non-Medical Necessity Coverage and Payment Rules, 
OXYGEN EQUIPMENT, Initial 36-Months section. 
 
If a portable oxygen system is covered, the supplier must provide whatever quantity of oxygen the beneficiary 
uses; Medicare's reimbursement is the same, regardless of the quantity of oxygen dispensed. 
 
You can find this information in the Local Coverage Determination (LCD):  Oxygen and Oxygen Equipment 
(L33797). 
 
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 stationary and portable oxygen equipment is often provided at the same time therefore the 
RUL for both items runs concurrently. When the RUL of a beneficiary's portable oxygen equipment differs 
from the RUL of the beneficiary's stationary oxygen equipment, the RUL of the stationary oxygen equipment 
shall govern the application of RUL-based rules and processes for both types, stationary and portable, of 
oxygen equipment. You can find this information in Medicare's Local Coverage Article: Oxygen and Oxygen 
Equipment - Policy Article (A52514). 
 
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 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 $5 copayment for provider and professional services at an in-network 
PCP's office. You can find this information on page 86 of the Plan's 2020 EOC.  
 
The Plan contract says that enrollees must pay 20% coinsurance for Medicare Part B covered drugs at an in-
network PCP's office. You can find this information on page 75 of the Plan's 2020 EOC.  
 
The Plan contract also says that enrollees must pay a $150 copayment for advanced imaging services at an in-
network PCP's office, specialist's office or freestanding radiological facility. You can find this information 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 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 3-4 and 3-7 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 a Pneumatic Compression Devices (PCD) coded as E0650 or E0651 is covered for both 
primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when all of the 
following three requirements are met: 
 
    The beneficiary has a diagnosis of lymphedema as defined above, and 
    The beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence 
of at least one of the following clinical findings: 
        Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
        Papillomatosis cutis lymphostatica, 
        Deformity of elephantiasis, 
        Skin breakdown with persisting lymphorrhea, 
        Detailed measurements over time confirming the persistence of the lymphedema with a history evidencing 
a likely etiology, and 
    In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other 
clinical treatment over the course of a required four-week trial. (See below for trial guidelines.) 
 
A PCD coded as E0650 or E0651 used to treat lymphedema that does not meet all of the requirements above is 
not eligible for reimbursement. Claims will be denied as not reasonable and necessary. 
 
A PCD coded as E0650 or E0651 used to treat edema from causes other than lymphedema is not eligible for 
reimbursement. Claims will be denied as not reasonable and necessary. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Pneumatic Compression 
Devices (L33829). 
 
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 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 $12 copayment for laboratory tests. You can find this information on 
page 76 of the Plan's 2020 EOC.