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 will pay for durable medical equipment that is mainly used to serve a medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly used for medical purposes. Medicare will not pay for:

1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 110.1.

The rules say that the power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. You can find this rule in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504) - Effective January 1, 2018.

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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 coverage for up to three extraction procedures per calendar year. This benefit also includes coverage for necessary anesthesia with covered services. The current procedural terminology (CPT) codes that are covered under the dental anesthesia benefit include D9215, D9222, D9223, D9230, D9239, and D9243. You can find this information in the Plan's 2021 Dental Benefit Schedule and on page 84 of the Plan's 2021 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.

A pneumatic compression device (PCD) coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when all of the following are met:

- The beneficiary has lymphedema of an extremity. 
- The coverage criteria for an E0650 or E0651 PCD are met. 
- The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial.

A four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651 is required. The four-week trial of conservative therapy must include all of the following:

- At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 PCD after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided 
- Compliant use of an appropriate compression bandage system or compression garment to provide adequate graduated compression 
- Regular exercise - Elevation where appropriate 
- Manual lymphatic drainage (where available) and self-manual lymphatic drainage (MLD) for at least 30 minutes per day 
- Evaluation of diet and implementation of any necessary change 
- Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.) 
- Correction (where possible) of anemia and/or hypoproteinemia

You can find this information at Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).

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 pay for durable medical equipment (DME) that is reasonable and necessary for treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment already available to an enrollee. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(C). 

The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your home may be a dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, an institution may not be considered your home if it is an acute hospital or a skilled nursing facility (SNF). You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D).

A patient meeting the requirements specified below may qualify for coverage of a portable oxygen system either (1) by itself, or, (2) to use in addition to a stationary oxygen system. A portable oxygen system is covered for a particular patient if:
1. The claim meets the requirements specified in subsections A-D, as appropriate; and 
2. The medical documentation indicates that the patient is mobile in the home and would benefit from the use of a portable oxygen system in the home. Portable oxygen systems are not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. You can find this information in National Coverage Determination (NCD) for Home Use of Oxygen (240.2).

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 does not pay for nutritional supplements. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determination Manual, Chapter 1, Section 180.2.

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 hospital beds are covered only with a physician's prescription and sufficient documentation in the patient's medical records to establish medical necessity for a hospital bed due to one of the following reasons:

1. The patient's condition requires positioning of the body; e.g., to alleviate pain, promote good body alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or 

2. The patient's condition requires special attachments that cannot be fixed and used on an ordinary bed. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.7.

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 continuous glucose monitors (CGMs) and related supplies are covered by Medicare when all of the following coverage criteria are met:
1. The beneficiary has diabetes mellitus, 
2. The beneficiary has been using a blood glucose monitor (BGM) and performing frequent (four or more times a day) testing, 
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, 
4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results.

You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 

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: 
1. 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); 
2. generally not useful to the individual in the absence of an illness or injury; 
3. appropriate for use in the home; and 
4. 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. CMS-1682-R.

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 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 Article: Billing and Coding: Speech-Language Pathology (A52866) Speech-language pathology services may be considered reasonable and necessary when the following criteria are met:

- The services shall be considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition;
- The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified therapist;
- If the contractor determines the services furnished were of a type that could have been safely and effectively performed only by or under the supervision of such a qualified professional, the contractor shall presume that such services were properly supervised when required. However, this presumption is rebuttable, and, if in the course of processing a claim, the contractor finds that services were not being furnished under proper supervision, it shall deny the claim and bring this matter to the attention of the Division of Survey and Certification of the Regional Office;
- While a beneficiary's particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary's diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a qualified therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel. Medicare coverage does not turn on the presence or absence of a beneficiary's potential improvement from the therapy, but rather on the beneficiary's need for skilled care; and
- The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.

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 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).

At present, the literature and scientific evidence supporting the use of peripheral nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for neuropathies or peripheral neuropathies caused by underlying systemic diseases is insufficient to warrant coverage. These procedures are considered investigational and are not eligible for coverage for the treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases. You can find this information in Local Coverage Determination (LCD): Peripheral Nerve Blocks (L36850).

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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 lists the specific dental services that are covered. Porcelain crown is not listed and therefore is not a covered service. Core build up is not listed and therefore is not a covered service either. You can find this information on pages 90 to 110 of the Plan's 2021 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 long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I). 
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need medical care. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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 3-4 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 dental services beyond Medicare coverage. You can find this information on page 8 of the Plan's 2021 Dental Addendum.
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 effective for dates of service on or after October 9, 2014, The Cologuard test is covered once
every three years for Medicare beneficiaries that meet all of the following criteria:

1. Age 50 to 85 years, and
2. Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal
pain, blood in stool, positive guaiac fecal occult blood test (gFOBT) or fecal immunochemical test (iFOBT)),
and
3. At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal
cancer, or inflammatory bowel disease, including Crohn's Disease and ulcerative colitis; no family history of
colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis
colorectal cancer).

You can find this rule in the National Coverage Determination Manual Chapter 1, Section 210.3.

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.
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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for
a person who meets the following criteria:

1. The person must have a personal mobility deficit;
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such
as toileting, feeding, grooming and bathing in customary locations within the home;
3. The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and
4. The person must be capable of safely operating the PMD.

You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare
National Coverage Determinations Manual, Section 280.3(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.