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 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. 
 
The rules say that Epoetin alfa is covered for Food and Drug Administration (FDA) approved labeled 
indications.  Please see the FDA drug label for the FDA approved indications and dosages. In addition to the 
FDA labeled indications, epoetin alfa is covered for the following off-label indications: 
? For the treatment of anemia associated with myelodysplastic syndrome (MDS). Patients usually 
present with variable clinical features depending on the MDS classification and the degree of disordered 
hematopoiesis with anemia. Common complaints or symptoms are fatigue, pallor, infection and 
bleeding or bruising. Diagnosis is usually confirmed by bone marrow aspiration and/or biopsy. For the 
purposes of this LCD, Chronic Myelomonocytic Leukemia (CMML) will be considered a form of MDS 
and as such the anemia associated with it may be eligible for coverage if the indications and limitations 
outlined in this LCD for MDS are met. Providers must use the ICD-10 codes listed in the LCD for MDS 
to code for CMML. If the physician cannot classify the patient with one of the MDS diagnosis codes, 
then the patient does not meet the criteria for CMML and coverage will not have been met.  
? For the treatment of anemia associated with the management of hepatitis C. The use of epoetin alfa 
has been shown to be effective in treatment of anemia in patients with hepatitis C virus infection who 
are being treated with the combination of ribavarin and interferon alfa or ribavarin and peginterferon 
alfa 
? For the treatment of chronic anemia associated Rheumatoid Arthritis (RA). The patient must have 
been previously diagnosed with RA using the American College of Rheumatology criteria. Patients are 
usually on antimetabolite (e.g., Methotrexate), which causes the anemia. 
 
Prior to and during ESA therapy for CKD patients, the patient?s iron stores, including transferrin saturation and 
serum ferritin, should be evaluated. Transferrin saturation should be at least 20%, and ferritin should be at least 
100 ng/mL. At this time, there is no clearly established dosing regimen for off label indications. You can find 
this rule in the Local Coverage Determination for Erythropoiesis Stimulating Agents; L36276 (eff 10/29/19). 
 
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 total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. You can find this information in Medicare's Local Coverage Determination (LCD): Hospital Beds And Accessories (L33820).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 to qualify for home health services, the patient must be:1. Confined to the home; 2. Under the care of a physician or allowed practitioner; 3. Receiving services under a plan of care established and reviewed by a physician; 4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) continuing occupational therapy. You can find this rule at 42 CFR Section 409.42.The rules say that eligibility for the home health benefit will be determined based on the certifying physician's records. If theenrollee was directly admitted to home health from an acute or post-acute care facility, the facility records may be used instead. The medical records for the enrollee must contain information that justifies the referral for home health services.The certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face encounter visit. You can find these rules in the Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1, 30.5.1.1, and 30.5.1.2.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 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 $300 copayment for surgery provided in an outpatient hospital. You can 
find this information on page 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. 
 
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion 
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the 
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find 
this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 290(3). 
 
The rules say that (L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, 
L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3300, L3310, L3320, L3330, L3332, L3334, L3340, 
L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3465, L3470, L3480, 
L3485, L3500, L3510, L3520, L3550, L3560, L3570, L3580, L3590 and L3595) are covered if they are on a 
shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of 
the brace. Shoes and related modifications, inserts, heel/sole replacements or shoe transfers billed without a KX 
modifier will be denied as noncovered because coverage is statutorily excluded.  You can find this information 
in Medicare's Local Coverage Article: Orthopedic Footwear - Policy Article (A52481). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health 
plan contract says supportive devices for the feet are covered only for people with diabetic foot disease. 
Orthopedic shoes are covered only if shoes are part of a leg brace and are included in the cost of the brace, or 
the shoes are for a person with diabetic foot disease. You can find this information in Chapter 4 on page 4-71 
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 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 page 52 of the Plan?s 2019 
Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that for the purposes of this policy, these surgeries (either individually or in the minimum 
combination required to achieve a satisfactory surgical outcome) are functional when overhanging skin or 
upper lid position secondary to dermatochalasis, blepharochalasis, blepharoptosis, or pseudoptosis is 
sufficiently low to produce a visually-significant field restriction considered by this policy to be approximately 
30 degrees or less from fixation. Published literature correlates this amount of field restriction with a Margin 
Reflex Distance of 2.0 mm or less. You can find this rule at Local Coverage Determination (LCD): 
Blepharoplasty, Eyelid Surgery, and Brow Lift (L34194) (eff. 10/1/19). 
 
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 ventilators are covered for treatment of neuromuscular diseases, thoracic restrictive 
diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease. You can find 
this rule in the National Coverage Determination (NCD) for Durable Medical Equipment Reference List 
(280.1). 
 
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 Thermal Medial Branch Radiofrequency Neurotomy is covered for the following 
indications :  
 
   - If adequate, but short term, pain relief occurs following MBB facet joint injections (see Diagnostic Facet 
Joint Injections), RF neurotomy may be a reasonable treatment option. Thermocoagulation with radiofrequency 
energy may achieve long-lasting pain relief via axonotmesis of the sensory afferent medial branch nerve. 
   - Dual MBBs are the ideal prognostic test to select patients for thermal RF neurotomy. 
   - Only when dual MBBs provide = 80% relief of the primary or index pain, with ability to perform previously 
painful movements consistent with the expected physiological effects of the agents utilized RF medial branch 
neurotomy be considered. 
   - Repeat denervation procedures involving the same joint for the same region will only be considered 
medically necessary if the patient experienced = 50% improvement of pain and improvement in patient specific 
ADLs documented for at least 5-6 months. 
   - Repeat RF neurotomy to treat recurrent facet joint pain in a patient who has failed other conservative 
measures may be covered without repeating MBB injections if the patient has experienced significant and 
prolonged (= 5-6 months) relief of pain and improvement of function in the past following RF ablation. 
 
You can find this rule in the Local Coverage Determination (LCD) for Facet Joint Injections, Medial Branch 
Blocks, and Facet Joint Radiofrequency Neurotomy (L34832). 
 
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 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 
doctors 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 health 
plan contract says covered services include: routine transportation for up to 24 one-way transportation trips per 
calendar year. You can find this information in Chapter 4 on pages 4-67 to 4-68 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). 
 
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). 
 
The rules say that for a patient with low back pain only, a simple disc bulge or annular tear/fissure is 
insufficient to justify performance of an epidural. You can find this information in the Local Coverage 
Determination (LCD): Lumbar Epidural Injections (L35937). 
 
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 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). 
 
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 claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing 
information. You can find this rule at Local Coverage Article: Patient Lifts - Policy Article (A52516) (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 thelens 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 erroronly. 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 provides up to $300 for eyeglasses (frames and lenses) or up to $300 for contact lenses every two years. This information can be found on page 92 of the 2020 Evidence of Coverage
Appeal type: unknown
Decision: unknown

The rules say that the PACE benefit package must include the following:  
(a) All Medicare-covered items and services;  
(b) All Medicaid-covered items and services, as specified in the State's approved Medicaid plan; and  
(c) Other services determined necessary by the interdisciplinary team to improve and maintain the enrollee's 
overall health status.  
You can find this rule at 42 Code of Federal Regulations (CFR) Section 460.92. 
 
The rules say that PACE (Program of All-inclusive Care for the Elderly) benefits must include all services and 
items covered by Medicare and Medicaid. The benefits must also include all other services determined 
necessary by the interdisciplinary team (IDT) to improve and maintain the enrollee's overall health status. You 
can find this rule at 42 CFR Section 460.92.  
 
The rules also say that enrollees in a PACE program must have a written plan of care. This plan must meet 
their needs in all care settings 24 hours a day every day of the year. You can find this rule at 42 CFR Section 
460.98. 
 
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 PACE 
Enrollment Agreement describes all of the PACE services available and how to get services from the PACE 
organization. This Agreement also describes how to get emergency and urgently needed services out-of-
network.
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 plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1.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. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes coverage for intraoral-complete series or panoramic film once every 36 months. You can find this information on page 47 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 a semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if the 
beneficiary meets one of the criteria for a fixed height bed and requires frequent changes in body position 
and/or has an immediate need for a change in body position. 
 
A fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or more of the 
following criteria (1-4) are met: 
 
    1. The beneficiary has a medical condition which requires positioning of the body in ways not feasible with 
an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a 
hospital bed, or 
    2. The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to 
alleviate pain, or 
    3. The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration, or 
   4. The beneficiary requires traction equipment, which can only be attached to a hospital bed. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Hospital Beds And 
Accessories (L33820). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.