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

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that all of the following basic criteria must be met for a power mobility device (K0800) to be 
covered. 
 
    A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. A mobility limitation is one that: 
        -Prevents the beneficiary from accomplishing an MRADL entirely, or 
        -Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to 
the attempts to perform an MRADL; or 
        -Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
    B. The beneficiary?s mobility limitation cannot be sufficiently and safely resolved by the use of an 
appropriately fitted cane or walker. 
    C. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured 
manual wheelchair in the home to perform MRADLs during a typical day. 
        -Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or 
absence of one or both upper extremities are relevant to the assessment of upper extremity function. 
        -An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating 
options, and other appropriate nonpowered accessories. 
 
You can find these rules in Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
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). 
 
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 that there is $750 deductible for all items and services except those specifically excluded by 
the Plan contract. While some laboratory tests and diagnostic procedures are excluded from the deductible, 
diagnostic imaging is not excluded from the deductible. You can find this information in Chapter 4 on pages 67 
to 68 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 effective October 1, 2007, Medicare providers should begin to submit a Present On 
Admission (POA) Indicator for every diagnosis on your inpatient acute care hospital claims. A POA Indicator 
of 1 is used to indicate the diagnosis is exempt from POA reporting. This code is the equivalent of a blank on 
the UB-04, but blanks are not desirable when submitting data via the 4010A1. You can find these rules in MLN 
Matters Number: MM5499. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 1 
panoramic x-ray every 3 plan years. You can find this information on page 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 at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that a manual wheelchair for use inside of the home is covered if:Criteria A, B, C, D, and Eare met; andCriterion F or G is met.A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:1. Prevents the beneficiary from accomplishing an MRADL entirely, or2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or3. Prevents the beneficiary from completing an MRADL within a reasonable time frame.B. The beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.C. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.D. Use of a manual wheelchair will significantly improve the beneficiary's ability to participate in MRADLsand the beneficiary will use it on a regular basis in the home.E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.You can find this rule in Local Coverage Determination (LCD):Manual Wheelchair Bases (L33788) -Effective January 1, 2020.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.ThePlan contract says that the Plancovers 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 20% coinsurance for Medicare Part B prescription drugs. You can find 
this information in Chapter 4 on pages 89 - 90 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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR ?424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare 
Program Integrity Manual Chapter 3 ? 3.3.2.1. 
 
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 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. 
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
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). 
 
The rules say that procedures with the status indicator of ?I? is not valid for Medicare purposes. Medicare uses 
another code for the reporting of, and payment for, these services. You can find this rule in the Medicare 
Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
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.
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 wireless capsule endoscopy (WCE) is indicated or the diagnosis of occult gastrointestinal 
bleeding (i.e., likely involving the small intestine), the site of which has not previously been identified by any 
of the following: upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging or 
radiological procedures. Other indications include the management of celiac disease (e.g., surveillance for 
small-intestinal cancer) and of Crohn?s disease (that is, either Crohn?s disease is suspected, but not diagnosed, 
or colonic involvement of Crohn?s disease is known, but it is necessary to determine whether there is also 
involvement of the small bowel). In addition, WCE is indicated where an indeterminate type of colitis exists, 
but where a more specific diagnosis is being sought via small bowel evaluation. You can find this rule in Local 
Coverage Determination (LCD): Wireless Capsule Endoscopy (L35089) - Effective November 21, 2019. 
 
The rules say 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: 
 
-Angiodysplasia 
-Neoplasm 
-Iron deficiency anemia, which is unexplained after upper and lower endoscopy 
-Zollinger-Ellison syndrome 
-Tuberculosis 
-Vasculitis 
-Radiation enteritis 
-Meckels diverticulum 
-Jejunal diverticula 
-Chronic mesenteric ischemia 
 
You can find this rule in Local Coverage Determination (LCD): Wireless Capsule Endoscopy (L35089) - 
Effective November 21, 2019. 
 
The rules say that contraindications to WCE include pregnancy, cardiac pacemaker and other implanted 
electro-medical devices, swallowing disorders, known or suspected GI obstruction, strictures or fistulas based 
on the clinical picture or preprocedure testing. You can find this rule in Local Coverage Determination (LCD): 
Wireless Capsule Endoscopy (L35089) - Effective 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 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. Covered dental services are 
listed on pages 87-88 of the plan's 2020 Evidence of Coverage. Any service not listed is not covered.
Appeal type: unknown
Decision: unknown

Please note, the Local Coverage Article (A57256) the plan used in their decision to deny services is not binding 
in this case. The article does not have jurisdiction where the services will be provided.  
 
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. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract also includes a 
list of the covered supplemental dental benefits. Deep sedation is not on this list and is not a covered 
supplemental benefit. You can find this information on page 84 of the Plan?s 2020 Evidence of Coverage 
(EOC).
Appeal type: unknown
Decision: unknown

The rules saythat 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 immunizations are not covered unless they are directlyrelated to the treatment of an injury or direct exposure to a disease or condition. In the absence of injury or direct exposure, vaccination or inoculation is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule. You can find this rule at 42 CFR Section 411.15(e).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that shower and bath chairs are not covered because they are considered hygienic equipment that 
is not primarily medical in nature. You can find this rule in the Medicare National Coverage Determinations 
Manual, Section 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 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 37 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 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 for each admission enrollees pay $20 per day, for days 1-20 of a benefit period and $100 per 
day, for days 21?44 of a benefit period. Additionally, enrollees pay $0 per day, for days 45-100 of a benefit 
period. A benefit period begins on the first day you go to a Medicare-covered inpatient hospital or a skilled 
nursing facility (SNF). The benefit period ends when you haven?t been an inpatient at any hospital or SNF for 
60 days in a row. If you go to the hospital or SNF after one benefit period has ended, a new benefit period 
begins. There is no limit to the number of benefit periods you can have. You can find this information on page 
97 of the Plan's 2020 Evidence of Coverage (EOC).