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 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 Appeal Number is: 
1-9510786816 
 
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 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 rule in 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. You can find this rule in Local Coverage Article: Glucose Monitor - Policy 
Article (A52464) - Effective January 1, 2020. The rules say that code A9278 (RECEIVER (MONITOR); 
EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM) 
describes any CGM system that fails to meet the DME Benefit requirements as described in CMS Ruling 
1682R. You can find this rule in Local Coverage Article: Glucose Monitor - Policy Article (A52464) - 
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 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 Plan contract provides a 
list of covered dental services. You can find this information on pages 82-83 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 state that treatment for Symptomatic Chronic Venous Insufficiency or Varicose Veins (VV), in the 
absence of bleeding, phlebitis or skin necrosis, may be covered as medically necessary with: 
&#61623; A documented 3-month trial of conservative therapy including graduated compression stockings with a 
minimum of (12-18 mmHg), weight reduction to BMI less than 35, therapeutic leg elevation, and an 
exercise program of calf muscle pumping activity with compression of the involved veins, which results 
in limited alteration/improvement of symptoms or findings without satisfactory endpoint, and 
&#61623; Duplex venous studies of the involved lower extremity(s), mapping size and course of the greater and 
lesser saphenous vein and prominent tributaries and demonstrating the: 
o Presence and Patency of the Deep Venous System. 
o Absence of Deep Venous Thrombosis, and 
o Documented Incompetence (reflux greater than 500msec) of the Valves of the Saphenous, 
Perforator or Deep venous systems consistent with the patient's symptoms and findings. 
 
You can find these rules in Local Coverage Determination (LCD) Treatment of Varicose Veins and Venous 
Stasis Disease of the Lower Extremities (L34924). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Section 423.578(b)(5)(ii). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. The 
health plan contract says that if the clinical criteria is met for Lucentis, you must also meet these step therapy 
requirements: has had prior therapy, or cannot use bevacizumab (step therapy requirement). You can find this 
rule in the plan's Pharmacy and Therapeutics Lucentis (ranibizumab injection) Coverage Policy.
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 long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of 
stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).   
 
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need 
medical care. You can find this rule in the Medicare Program Integrity Manual, Chapter 6, Section 6.5.2. 
 
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 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. 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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers 60 one-way transportation trips within 75 miles of the pickup location. You can find this information on 
page 4-74 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 home blood pressure monitors (A4660) and home blood pressure cuffs (A4663) are considered home dialysis supplies. These items are only covered for patients on home dialysis. You can find this rule in the Medicare Claims Processing Manual, Chapter 8, Section 90.3.2(A).

The rules also say that ambulatory blood pressure monitoring (ABPM) may be covered in some instances. This service involves the use of a non-invasive device which is used to measure blood pressure in 24-hour cycles. These 24-hour measurements are stored in the device and are later interpreted by the physician. ABPM is only covered for those patients with suspected white coat hypertension. Suspected white coat hypertension is defined as

1. Office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit;
2. At least two documented blood pressure measurements taken outside the office which are <140/90 mm Hg; and
3. No evidence of end-organ damage.

You can find this information in the National Coverage Determination (NCD) for Ambulatory Blood Pressure Monitoring (20.19).
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 nutritional supplements. You can find this rule in the Medicare 
National Coverage Determination Manual, Chapter 1, Section 180.2. 
 
Local Coverage Article: Enteral Nutrition - Policy Article (A52493) - Enteral nutrition products that are 
administered orally and related supplies are noncovered, no benefit. 
 
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). 
 
The rules say that all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. You can find this rule in the Medicare 
Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
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 45 & 46 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 ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Medicare National Coverage Determinations Manual, 
Chapter 1, Section 280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device is made 
based upon the specifics of each person?s medical condition. There must be enough detailed information in the 
medical record to justify the treatment selected. You can find this rule in the Local Coverage Determination 
(LCD): Respiratory Assist Devices (L33800), effective for services performed on or after January 1, 2017. 
 
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 payment will be made for routine changes of the urinary drainage collection system as noted below. Additional charges will be allowed for reasonable and necessary non-routine changes when the documentation substantiates the medical necessity, (e.g., obstruction, sludging, clotting of blood, or chronic, recurrent urinary tract infection):
Usual Maximum Quantity of Supplies per month:
A4357: 2
A4358: 2 You can find these rules in the Local Coverage Determination (LCD): Urological Supplies, L33803. This LCD is effective for services provided on or after July 26, 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 state that WCE is limited to those patients who have undergone upper GI endoscopy and colonoscopy 
and these tests have failed to reveal a source of bleeding. Medicare would not expect to see a WCE provided if 
upper and lower endoscopy has not previously been performed. Documentation in the medical record must 
indicate that the beneficiary has suspected GI blood loss with or without anemia. Appropriate differential 
diagnoses for the evaluation of such bleeding include: 
? Iron deficiency anemia, which is unexplained after upper and lower endoscopy 
You can find these rules in the Local Coverage Determination (LCD): Wireless Capsule Endoscopy, L35089. 
This LCD is effective for services provided on or after November 21, 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 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 32 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 does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(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. The Health 
Plan contract also says that your Medicare and Medicaid covered services must be provided according to the 
rules set by Medicare and Medicaid. You can find this information on page 38 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 elastic stockings are not covered because they are non-reusable supply items. Elastic 
stockings are not durable medical equipment. You can find this rule in the Medicare National Coverage 
Determinations Manual, Chapter 1, Section 280.1.   
  
The rules say that gradient pressure garments may be covered when used as dressings following burn injuries. 
You can find this rule in the Medicare National Coverage Determinations Manual, Chapter 1, Section 270.5.  
 
The rules also say that compression bandages, multi-layer systems, and gradient compression wraps are 
covered only when they are used as dressings over a qualifying wound. A qualifying wound is either a wound 
caused or treated by surgery or a wound that must be debrided. A gradient compression stocking or wrap 
described by codes A6531, A6532, or A6545 is only covered when it is used in the treatment of an open 
venous stasis ulcer. Gradient compression stockings and wraps identified with codes A6531, A6532, and 
A6545 are not covered when they are used to treat the following conditions: 
 Venous insufficiency without stasis ulcers; 
 Prevention of stasis ulcers; 
 Prevention of the reoccurrence of stasis ulcers that have healed; 
 Treatment of lymphedema in the absence of ulcers. 
You can find these rules in Local Coverage Determination (LCD): Surgical Dressings L33831 and Local 
Coverage Article: Surgical Dressings-Policy Article A54563, effective for services performed on or after July 
24, 2017. 
 
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 does not pay for nutritional supplements. You can find this rule in the Medicare
National Coverage Determination Manual, Chapter 1, Section 180.2.
Local Coverage Article: Enteral Nutrition - Policy Article (A52493) - Enteral nutrition products that are
administered orally and related supplies are noncovered, no benefit.
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.