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 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 a MA plans may specify brands and manufacturers as preferred and charge lower costsharing
for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as
long as during an enrollee's first year of enrollment in an MA plan, if the enrollee requests, the plan will
provide a 90-day transition period (commencing with the initial time of enrollment) during which the plan
provides (and repairs, as applicable) non-preferred DME brands furnished in the previous year. You can find
this rule in the Medicare Managed Care Manual, Chapter 4, Section 10.12.2.
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 pay a $0 copay for Medicare-covered preferred brand diabetic test strips, monitors,
and continuous glucose monitoring devices. Non-preferred brands are not covered. You can find this
information on page 43 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 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 50 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 genetic testing identified with code 81545 is non-covered.
You can find these rules in the Local Coverage Article for Billing and Coding: Molecular Pathology
Procedures, A56199. This Local Coverage Article is effective for services provided on or after July 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.
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).
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 only covered for people with diabetic foot disease.
Orthopedic shoes are only covered 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 146 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).
Local Coverage Determination (LCD): Urological Supplies (L33803) - INDWELLING CATHETERS
(A4311, A4312, A4313, A4314, A4315, A4316, A4338, A4340, A4344, and A4346)
No more than one catheter per month is covered for routine catheter maintenance. Non-routine catheter changes
are covered when documentation substantiates medical necessity, such as for the following indications:
1. Catheter is accidentally removed (e.g., pulled out by beneficiary)
2. Malfunction of catheter (e.g., balloon does not stay inflated, hole in catheter)
3. Catheter is obstructed by encrustation, mucous plug, or blood clot
4. History of recurrent obstruction or urinary tract infection for which it has been established that an acute
event is prevented by a scheduled change frequency of more than once per month
CATHETER INSERTION TRAY (A4310, A4311, A4312, A4313, A4314, A4315, A4316, A4353, and
A4354)
One insertion tray will be covered per episode of indwelling catheter insertion. More than one tray per episode
will be denied as not reasonable and necessary.
One intermittent catheter with insertion supplies (A4353) will be covered per episode of reasonable and
necessary sterile intermittent catheterization (see below).
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 continuous glucose monitors (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 Medicarecovered
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 inperson
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 information 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.
The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The
documentation must show that the patient is mobile in the home and would benefit from the use of portable
oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood
gas studies obtained during sleep. You can find this rule in the Medicare National Coverage Determinations
Manual, Section 240.2(E).
To qualify for home oxygen, the patient must meet one of the following blood gas levels:
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during
sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for
patients who have hypoxia symptoms during exercise;
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of
dependent edema, pulmonary hypertension, or erythrocythemia.
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air,
there is a rebuttable presumption of non-coverage. You can find this rule in the Medicare National Coverage
Determinations Manual, Section 240.2(D)(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.
Recertification following initial certification situations 1 and 2:
-For beneficiaries initially meeting Group I criteria, the most recent qualifying blood gas study prior to the
thirteenth month of therapy must be reported on the Recertification CMN.
-For beneficiaries initially meeting Group II criteria, the most recent blood gas study that was performed
between the 61st and 90th day following Initial Certification must be reported on the Recertification CMN. If a
qualifying test is not obtained between the 61st and 90th day of home oxygen therapy but the beneficiary
continues to use oxygen and a test is obtained at a later date, if that test meets Group I or II criteria, coverage
would resume beginning with the date of that test.
-For beneficiaries initially meeting group I or II criteria, the beneficiary must be seen and re-evaluated by the
treating physician within 90 days prior to the date of any Recertification. If the physician visit is not obtained
within the 90-day window but the beneficiary continues to use oxygen and the visit is obtained at a later date,
coverage would resume beginning with the date of that visit. You can find this information in Local Coverage
Determination (LCD): Oxygen and Oxygen Equipment (L33797).
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).
National Coverage Determination (NCD) for Neuromuscular Electrical Stimulation (NMES) (160.12) - Use for
Walking in Patients with Spinal Cord Injury (SCI) - The type of NMES that is use to enhance the ability to
walk of SCI patients is commonly referred to as functional electrical stimulation (FES). These devices are
surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence. Coverage
for the use of NMES/FES is limited to SCI patients for walking, who have completed a training program which
consists of at least 32 physical therapy sessions with the device over a period of three months. The trial period
of physical therapy will enable the physician treating the patient for his or her spinal cord injury to properly
evaluate the person's ability to use these devices frequently and for the long term. Physical therapy necessary to
perform this training must be directly performed by the physical therapist as part of a one-on-one training
program.
The goal of physical therapy must be to train SCI patients on the use of NMES/FES devices to achieve
walking, not to reverse or retard muscle atrophy.
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 CMS developed the National Correct coding Initiative (NCCI) to prevent inappropriate
payment of services that should not be reported together. NCCI edits are placed in "Column One/Column Two
Correct Coding Edit Tables. Each edit table contains edits which are pairs of HCPCS/CPT codes that in general
should not be reported together. Each edit has a column one and column two HCPCS/CPT code. If a provider
reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for
payment. However, if it is clinically appropriate to utilize an NCCI-associated modifier, both the column one
and column two codes are eligible for payment. You can find this rule at Medicare National Correct Coding
Initiative Manual, Chapter I.
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 supplies such as sensors are only covered if they are used with a therapeutic CGM.
You can find these rules in the Local Coverage Article for Glucose Monitor - Policy Article, A52464. This
Local Coverage Article is effective for services provided on or after 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 state 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;
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 Medicarecovered
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 anin-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.
These rules can be found 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.
The rules say that Medicare pays for therapeutic continuous glucose monitors (CGMs) when they are medically
reasonable and necessary. Therapeutic CGMs are defined in CMS Ruling 1682R. You can find these rules in
Local Coverage Article A52464, effective on and after January 12, 2017.
CGMs consist of three components: a glucose sensor, a transmitter, and a receiver. CGMs are considered
therapeutic CGMs if they are:
- approved by the FDA for use in place of a blood glucose monitor for making diabetes treatment decisions (for
example, changes in diet and insulin dosage);
- generally not useful to the individual in the absence of an illness or injury;
- appropriate for use in the home; and
- those which include a durable component that can withstand repeated use, are expected to last at least three
years, and are capable of displaying the trending of the continuous glucose measurements.
The rules also say that a CGM which does not replace a blood glucose monitor for making diabetes treatment
decisions is not covered. You can find these rules in CMS Ruling 1682R.
The rules say 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 Codes that are Covered" section of the LCDrelated
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 Medicarecovered
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 the Local Coverage Determination (LCD): Glucose
Monitors (L33822) effective January 1, 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.
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).
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 specifically listed dental services are covered by the plan. Crown (D2751) is listed as a
covered benefit when medically reasonable and necessary. You can find this information on pages 6 and 24 of
the Plan's 2020 Preventive & Comprehensive Dental Coverage Customer Handbook.
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 routine foot care services are considered medically necessary once (1) in 60 days. More
frequent services will be considered not medically necessary. You can find this rule in Local Coverage Article:
Billing and Coding: Routine Foot Care and Debridement of Nails (A57759).
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.