Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 says that we cover medically-necessary services by a dentist or an oral surgeon for surgery of the jaw 
or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for 
radiation treatment of neoplastic disease, or services that would be covered when provided by a medical 
provider. You can find this information on page 63 of the 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 power seating system -tilt only, recline only, or combination tilt and recline -with or without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; and2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary's seating and positioning needs. The PT, OT, or practitioner may have no financial relationship with the supplier; and3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or6. The power seating system is needed to manage increased tone or spasticity.You can find this rule in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792) -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 physical therapy (PT), occupational therapy (OT), and speech therapy(ST) services are covered only when they are medically reasonable and necessary. Therapy services are considered reasonable and necessary when:1. The services are specific and effective treatment for the patient's condition,2. The services require theskills or direct supervision of a therapist, 3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and  4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, or carry out a maintenance program. Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for skilled care. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 220.2.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 pays for care in a skilled nursing facility (SNF) when all of the following four factors are met:

1. The patient requires skilled nursing or skilled rehabilitation services;
2. The patient requires these services on a daily basis;
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and
4. The services are reasonable and necessary for the treatment of the patient's illness or injury or the services must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from getting worse. 

You can find these rules at 42 CFR Section 409.31 and in the Medicare Benefit Policy Manual, Chapter 8, Section 30.  

The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoing care from trained medical or The rules say that Medicare pays for care in a skilled nursing facility (SNF) when all of the following four factors are met:

1. The patient requires skilled nursing or skilled rehabilitation services;
2. The patient requires these services on a daily basis;
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and
4. The services are reasonable and necessary for the treatment of the patient's illness or injury or the services must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from getting worse. 

You can find these rules at 42 CFR Section 409.31 and in the Medicare Benefit Policy Manual, Chapter 8, Section 30.  

The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also custodial care services. You can find this rule in the Medicare Benefit Policy Manual, Chapter 16, Section 110.

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 $100 copayment for ambulatory surgical center services. You can see 
this on page 79 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 state that documentation is expected to support the ability of the beneficiary to learn and retain instruction. Absence of such documentation may result in a denial of services. If the patient has questionable cognitive skills, a brief cognitive-communication assessment should be performed in order to establish the patient's learning ability. The brief cognitive assessment may also determine the need for more comprehensive cognitive performance testing.You can find this information in the Local Coverage Determination (LCD):  Speech-Language Pathology (L33580).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 patients medical records must establish medical necessity for a hospital bed due to one of the following 
reasons: 
 
1. The patients condition requires positioning of the body; e.g., to alleviate pain, promote good body 
alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or  
 
2. The patient?s condition requires special attachments that cannot be fixed and used on an ordinary bed.  
You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.7(A). 
 
In order to qualify for a semi-electric hospital bed, the patient?s condition must require frequent change in body 
position and/or there may be an immediate need for a change in body position (i.e., no delay can be tolerated) 
and the patient can operate the controls and cause the adjustments. Exceptions may be made to this last 
requirement in cases of spinal cord injury and brain damaged patients. You can find this rule in the Medicare 
National Coverage Determinations Manual, Section 280.7(D). 
 
The rules say 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 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: 
 
a. Use of an appropriate group 1 support surface 
b. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and 
c. Appropriate turning and positioning, and 
d. Appropriate wound care 
e. Appropriate management of moisture/incontinence, and 
f. 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 
 
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 
 
You can find this rule in Local Coverage Determination (LCD): Pressure Reducing Support Surfaces - Group 2 
(L33642) - Effective January 1, 2020. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $40 copayment for specialist services. You can see this on page 62 of 
the 2020 Evidence of Coverage.  
 
The Plan contract says that enrollees must pay a $10 copayment for outpatient diagnostic services. You can see 
this on page 72 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 state that Dorsal column stimulators may be covered as therapies for the relief of chronic intractable 
pain under the following circumstances: 
 
1. To treat chronic pain caused by lumbosacral arachnoiditis that has not responded to medical management 
including physical therapy. (Presence of arachnoiditis is usually documented by presence of high levels of 
proteins in the Cerebrospinal Fluid [CSF] and/or by myelography or Magnetic Resonance Imaging [MRI]). 
2. To treat intractable pain caused by nerve root injuries, post-surgical or post-traumatic including that of post-
laminectomy syndrome (failed back syndrome). 
3. To treat intractable pain caused by complex regional pain syndrome I & II. 
4. To treat intractable pain caused by phantom limb syndrome that has not responded to medical management. 
5. To treat intractable pain caused by end-stage peripheral vascular disease, when the patient cannot undergo 
revascularization or when revascularization has failed to relieve painful symptoms and the pain has not 
responded to medical management. 
6. To treat intractable pain caused by post-herpetic neuralgia. 
7. To treat intractable pain caused by plexopathy. 
8. To treat intractable pain caused by intercostal neuralgia that did not respond to medical management and 
nerve blocks. 
9. To treat intractable pain caused by cauda equina injury. 
10. To treat intractable pain caused by incomplete SPINAL CORD injury. 
 
This information can be found in Local Coverage Determination (LCD): Spinal Cord Stimulation (Dorsal 
Column Stimulation) (L35450). 
 
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

Medicare rules say that the Plan must give the member a subscriber agreement. It is a contract between the Plan and the member. It is usually called the "Evidence of Coverage" (EOC) or "Member Agreement."We read this contract carefully to see what the Plan is supposed to cover.The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41.The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. Youcan find this rule in the Medicare Managed Care Manual, Chapter 4, Section 30.3.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit coversroutine transportation to plan approved health-related locations for up to 50 one-way trips per calendar year (limited to ground transportation only). You can find this information on pages79-80 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 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 in 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 state Medicare payment for ambulance services is based on the lesser of the actual charge or the 
applicable fee schedule amount. The fee schedule payment for ambulance services equals a base rate for the 
level of service plus payment for mileage and applicable adjustment factors. Except for services furnished by 
certain critical access hospitals or entities owned and operated by them, as described in ? 413.70(b) of this 
chapter, all ambulance services are paid under the fee schedule specified in this subpart (regardless of the 
vehicle furnishing the service). You can find this rule at 42 Code of Federal Regulations (CFR) Section 
414.610(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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 49 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 contractor shall verify that the face-to-face encounter documentation includes information supporting that 
the beneficiary was evaluated or treated for a condition that supports the DME item(s) ordered. If this 
information is not included, the contractor shall deny the claim. If the physician completed the written order 
before the face-to-face encounter, the contractor shall deny the claim. You can find these rules in the Medicare 
Program Integrity Manual, Chapter 5 - Items and Services Having Special DME Review Considerations 
Section 5.2.5.1 - Face-to-Face Encounter. 
 
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 harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that 
are required for the operation of an expandable controller. It also includes all the necessary fasteners, 
connectors, and mounting hardware. Code E2313 is separately billable in addition to an expandable controller 
both at initial issue and with complete replacement of the expandable controller. Code K0108 must not be used 
for any component or feature of an expandable controller at the time of initial issue. The reimbursement for any 
type of complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. 
However, if individual components of the harness are replaced, code K0108 should be used. 
 
A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are 
not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or 
E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will 
be denied as non-covered. 
 
You can find this information 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.