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 continued coverage of PAP device (E0470) beyond the first three months of therapy requires 
that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating practitioner 
must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy. For 
PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is 
demonstrated by: 
 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved; and, 
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. 
 
You can find this rule in Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for 
the Treatment of Obstructive Sleep Apnea (L33718) - Effective January 1, 2020. 
 
The rules that adherence to therapy is defined as use of PAP for four hours of more per night on 70% of nights 
during a consecutive thirty day period anytime during the first three months of initial usage. If the above 
criteria are not met, continued coverage of a PAP device and related accessories will be denied as not 
reasonable and necessary. You can find this rule in Local Coverage Determination (LCD): Positive Airway 
Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718) - 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.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion 
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the 
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find 
this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 290(3). 
 
The rules also say that shoes, inserts, and modifications are covered in limited circumstances. They are covered 
in selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers. However, 
different codes are used for footwear provided under this benefit. You can find this information in the Local 
Coverage Article: Orthopedic Footwear - Policy Article (A52481). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Medicare National Coverage Determinations Manual, 
Chapter 1, Section 280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure (BiPAP) device is 
made based upon the specifics of each person?s medical condition. There must be enough detailed information 
in the medical record to justify the treatment selected. You can find this rule in the Local Coverage 
Determination (LCD): Respiratory Assist Devices (L33800), effective for services performed on or after 
January 1, 2017. 
 
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 an expandable controller is defined as an electronic system that is capable of 
accommodating one or more of the following additional functions: 
 
a.  Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head 
control, etc.) other than a standard proportional joystick. 
b.  Non-proportional input devices (e.g., sip and puff, head array, etc.) 
c.  Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating 
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) 
 
An expandable controller may also be able to operate one or more of the following: 
 
d.  A separate display (i.e., for alternate control devices) 
e.  Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's 
drive control) 
f.  An attendant control 
 
These rules can be found in Local Coverage Article: Power Mobility Devices - Policy Article (A52498). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41. 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Medicare Managed Care Manual, 
Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health 
plan contract says that 6 one-way trips every year to plan approved locations. You can find this information in 
Chapter 4 on pages 101-102 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 radiofrequency ablation is covered for the following indications. 
 
   - Patient must have history of at least 3 months of moderate to severe pain with functional impairment and 
pain is inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical therapy (as 
tolerated). 
 
   - Pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with 
radiculopathy or neurogenic claudication. 
 
   - There is no non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor, 
infection, or significant deformity. 
 
   - Clinical assessment implicates the facet joint as the putative source of pain. 
 
You can find this rule in the Local Coverage Determination (LCD) for Facet Joint Injections, Medial Branch 
Blocks, and Facet Joint Radiofrequency Neurotomy (L35936). 
 
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 for the treatment of metastatic lesions, there must be: 
a. the expectation of a long-term benefit (> 2y) that could not have been attained with conventional therapy 
b. the expectation of a complete eradication of the metastatic lesion that could not have been safely 
accomplished with conventional therapy, as evidenced by a dosimetric advantage for proton beam radiotherapy 
over other forms of radiation therapy 
You can find these rules in the Local Coverage Determination (LCD) for Proton Beam Radiotherapy, L33937. 
This LCD is effective for services provided on or after December 16, 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 if medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG) 
Positron Emission Tomography (PET) scan to determine the initial level of cancer treatment needed for an 
enrollee. After the completion of the initial anti-cancer therapy, Medicare may also cover up to three FDG PET 
scans when used to guide subsequent management of cancer treatment after completion of initial anti-cancer 
therapy. Additional FDG PET scans may be covered at the discretion of Medicare. You can find this rule in the 
National Coverage Determinations Manual, Section 220.6.17. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
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 health plan contract lists 
all of the covered dental services on page 43 of the 2020 Evidence of Coverage. Any service not listed here is 
not covered.
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. The health 
plan contract says that plan covers six one-way routine transportation trips per calendar year. You can find this 
information on page 100 and 101 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 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 in Chapter 3 on page 32 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 coverage indications for acute idiopathic thrombocytopenic purpura (ITP) include: 
 Management of acute bleeding due to severe thrombocytopenia (platelet counts less than 30,000/mm3); 
 To increase platelet counts prior to invasive major surgical procedures (splenectomy); or 
 In patients with severe thrombocytopenia (platelet counts less than 20,000/mm3) considered to be at risk for 
intracerebral hemorrhage. 
 
Chronic Refractory ITP: 
First line treatment 
o Pediatric ITP; 
o In combination with steroids if rapid platelet response justified or to avoid splenectomy; or 
o Contraindications to steroids 
Second line treatment 
o Following treatment with corticosteroids with splenectomy; or 
o Platelet counts persistently at or below 20,000/mm 3. 
You can find this rule in the Local Coverage Determination for Immune Globulin Intravenous (IVIg), L34314 
(eff 02/01/20). 
 
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 8 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 tumor treatment field therapy (E0766) is covered for the treatment of newly diagnosed 
Glioblastoma Multiforme (GBM) only when all of the following criteria are met: 
1. The beneficiary has histologically confirmed (World Health Organization (WHO) grade IV 
astrocytoma), newly diagnosed, supratentorial GBM; and, 
2. The beneficiary has received initial treatment with maximal debulking surgery (when feasible), 
followed by chemotherapy and radiotherapy; and, 
3. Tumor treatment field therapy is initiated within 7 weeks from the last dose of concomitant 
chemotherapy or radiotherapy, whichever is later; and, 
4. The beneficiary has no evidence of progression by Response Assessment in Neuro-Oncology (RANO) 
criteria; and, 
5. The beneficiary has a Karnofsky Performance Score (KPS) of at least 70; and, 
6. The beneficiary will use TTFT for an average of 18 hours per day. 
If all of the coverage criteria above are not met, claims for code E0766 will be denied as not reasonable and 
necessary. You can find this rule in the Local Coverage Determination for Tumor Treatment Field Therapy 
(TTFT), L34823 (eff 01/01/20). 
 
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 in Chapter 3, Section 2.4 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 that Codes A9276 (SENSOR; INVASIVE (E.G., SUBCUTANEOUS), DISPOSABLE, FOR 
USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM, ONE UNIT = 1 DAY 
SUPPLY) and A9277 (TRANSMITTER; EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS 
GLUCOSE MONITORING SYSTEM) describe the supplies used with a non-therapeutic CGM. Codes A9276 
and A9277 are not used to bill for supplies used with code K0554. 
 
Code K0553 describes a supply allowance used with a therapeutic CGM device. The supply allowance includes 
all items necessary for the use of the device and includes, but is not limited to: CGM sensor, CGM transmitter, 
home BGM and related BGM supplies (test strips, lancets, lancing device, calibration solutions) and batteries. 
K0553 must not be used for supplies used with CGM coded as A9278. 
 
Code A9278 (RECEIVER (MONITOR); EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS 
GLUCOSE MONITORING SYSTEM) describes any CGM system that fails to meet the DME Benefit 
requirements as described in CMS Ruling 1682R. 
 
You can find this information in Medicare's Local Coverage Article: Glucose Monitor - Policy Article 
(A52464). 
 
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 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 Plan contract says that 
extractions are covered when medically reasonable and necessary.  You can find this information on page 82 of 
the Plan's 2020 Evidence of Coverage (EOC).