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. 
 
Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise 
reasonable and necessary for the patient. FDA approved drugs used for indications other than what is indicated 
on the official label may be covered if the use is determined to be medically accepted, taking into consideration 
the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. You 
can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50.4.1 and 50.4.2. 
 
Epoetin alfa is covered for Food and Drug Administration (FDA) approved labeled indications. 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). 
You can find this information in Local Coverage Determination (LCD): Erythropoiesis Stimulating Agents 
(L36276). 
 
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 Medicare plan may restrict members to a network of providers. 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 diabetic supplies and services are limited to specified manufacturers. Prior authorization is 
required. You can see this on page 60 and 61 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 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 Medicare covers nursing care provided by or under the supervision of a registered 
professional nurse. However, the services of a private-duty nurse or other private-duty attendant are not 
covered. Private-duty nurses or private-duty attendants are registered professional nurses, licensed practical 
nurses, or any other trained attendant whose services ordinarily are rendered to, and restricted to, a particular 
patient by arrangement between the patient and the private-duty nurse or attendant. You can find this 
information in the Medicare Benefit Policy Manual, Chapter 8, Section 50.1. 
 
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 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 48 one-way trips every year to Plan approved locations. You can find this information on page 106 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 state that CGM devices covered by Medicare under the DME benefit are defined in CMS Ruling 
1682R as therapeutic CGMs. Refer to the Non-Medical Necessity Coverage and Payment Rules in the LCD-
related Policy Article for additional information. 
 
Therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria 
(1-6) are met: 
1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses); and, 
2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and, 
3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump; and, 
4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results; and, 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the 
beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and, 
6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person 
visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
When a therapeutic CGM (code K0554) is covered, the related supply allowance (code K0553) is also covered. 
If any of coverage criteria (1-6) are not met, the CGM and related supply allowance will be denied as not 
reasonable and necessary. 
You can find this rule in 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. 
 
A supplemental benefit is an item or service not covered by original Medicare, that is primarily health related 
and for which the MA plan must incur a non-zero direct medical cost. These criteria are defined below. 
(1) A supplemental benefit may not be a Medicare Part A or Part B covered service; 
(2) The item or service must be primarily health related; that is, the primary purpose of the item or service is to 
prevent, cure or diminish an illness or injury. If the primary purpose of the item or service is comfort, cosmetic 
or daily maintenance, then it is not eligible as a supplemental benefit. The primary purpose of an item or 
service is determined by national typical usages of most people using the item or service, or by community 
patterns of care; and 
(3) The MA plan must incur a non-zero direct medical cost in providing the benefit. If the MA plan only incurs 
an administrative cost, this requirement is not met. 
 
Supplemental benefits need not be provided through Medicare providers nor at Medicare certified facilities. 
Please note, however, MA plans may not make payment to providers who have opted out or been excluded 
from Medicare through 422.220 and 422.204(b)(4)/422.752(a)(8) You can find this rule in the Medicare 
Managed Care Manual, Chapter 4, Section 30.1 
 
The rules say that Medicare does not pay for gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. 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 Plan 
contract also says that the Plan has a fitness program benefit with a monthly basic membership for a 
Fitness program through network fitness centers. You can find this information on page 4-17 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 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 says that prior 
authorization is required for comprehensive dental services. Comprehensive dental services are covered when 
reasonable and necessary. You can find this information on page 59 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 ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and 
payment policy requirements preclude FSS payment for devices used to deliver continuous and/or intermittent 
positive airway pressure, regardless of the illness treated by the device. (Social Security Act 1834(a)(3)(A)) 
This means that products currently classified as HCPCS code E0465 or E0466 when used to provide CPAP or 
bi-level PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be 
paid in the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions 
described in this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-
level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for 
conditions described in this RAD policy will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Respiratory Assist Devices 
(L33800). 
 
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 facet joint interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL of the following criteria: 
o Duration of pain of at least three (3) months 
o Pain is intermittent or continuous with average pain levels of 6 or greater on a visual-numerical 
analogue pain scale (VNAS) of 0 to 10 (primary [index] pain), or functional disability 
o Documented failure to respond to conservative care such as nonsteroidal anti-inflammatory drugs 
(NSAIDS), acetaminophen, physical therapy for a minimum of 6 weeks (as tolerated) 
o History of pain that is predominantly axial and, with the possible exception of facet joint cysts, not 
associated with radiculopathy or neurogenic claudication 
o Physical examination with documented signs that the facet joint is the primary suspected source of pain  
o There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patient's pain, including but not limited to fracture, tumor, infection, or significant 
deformity 
You can find this rule in the Local Coverage Determination for Facet Joint Interventions for Pain Management, 
L34892 (eff 11/21/19). 
 
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 other treatment modalities (pharmacological, surgical, physical, or psychological therapies) 
must have been tried and did not prove satisfactory or are judged to be unsuitable or contraindicated for the 
given patient for an electrical nerve stimulator to be covered. It must only be used as a last resort. You can find 
this rule in National Coverage Determination (NCD) for Electrical Nerve Stimulators (160.7) - Effective 
August 7, 1995. 
 
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 says fixed 
bridges, crowns, post and core or crown buildup are covered once per tooth every 5 calendar years. The 
contract also says that prior authorization is required. You can find this information on page 60 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 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 professional claims modifiers for TMVR for MR Claims Effective for claims with dates of 
service on or after August 7, 2014, contractors shall pay claim lines for TMVR for MR billed with CPT codes 
0343T, 0344T, and 0345T in a clinical trial when billed with modifier -Q0. You can find this rule in the 
Medicare Claims Processing Manual, Chapter 32, section 340. 
  
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 coverage may be allowed for testing of the BRCA genes for enrollees with a personal 
history of breast, ovarian, pancreatic or prostate cancer with certain other risk factors. Enrollees who do not 
have a personal history of these cancers are not covered for this testing. You can find this information in the 
Local Coverage Determination (LCD): BRCA1 and BRCA2 Genetic Testing (L36715). 
 
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 PCD that provides intermittent limb compression for the purpose of prevention of venous 
thromboembolism (E0676) is a preventive service. Items that are used for a preventative service or function are 
excluded from coverage under the Medicare DME benefit. You can find this rule in Local Coverage Article: 
Pneumatic Compression Devices - Policy Article (A52488). 
 
The rules also say that status code "I = Not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment for these services." You can find this rule in the Medicare Claims Processing 
Manual, Chapter 23 - Fee Schedule Administration and Coding Requirements, 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 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 says that one 
root canal (D3310, D3320 or D3320) is covered one per calendar year and periodontal scaling and root planing 
(D4341) is covered once every 3 calendar years per quadrant. You can find this information on page 93 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 Appeal Number is: 
1-9673799116 
 
 
 
The rules say that CT scans are covered if there is literature to support its use for the patient?s condition and the 
scan is reasonable and necessary for the patient. You can find this rule in the Medicare National Coverage 
Determinations Manual, Section 220.1(A). 
 
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 a group 1 power wheelchair coded with HCPCS K0801 is meant for a weight capacity of 
301-450 pounds. You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices 
(L33789) - Effective January 1, 2020. 
 
The rules say that options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that 
meets Medicare coverage criteria and the option/accessory itself is medically necessary. 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.