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 PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when all of the following three requirements are met:
1. The beneficiary has a diagnosis of lymphedema as defined above, and
2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence of at least one of the following clinical findings:
o Marked hyperkeratosis with hyperplasia and hyperpigmentation,
o Papillomatosis cutis lymphostatica,
o Deformity of elephantiasis,
o Skin breakdown with persisting lymphorrhea,
o Detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a likely etiology, and
3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other clinical treatment over the course of a required four-week trial.
A 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 as defined above
- The coverage criteria for an E0650 or E0651 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.
You can find this rule at Local Coverage Determination (LCD) L33829: Pneumatic Compression Devices (eff. 1/1/20).
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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, 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 routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers 24 one-way trips are covered per calendar year. You can see this on page 4-53 of the Plans 2021 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 indications for transthoracic echocardiogram indications for Ventricular Function, Cardiomyopathies and Heart Failure include:
1. "When the etiology is in doubt, echocardiography can document or rule out the common cardiac causes of pulmonary congestion: left-sided valvular disease, depressed systolic or diastolic function, and cardiomyopathy. In this regard, echocardiography is the preferred initial diagnostic test when the history, physical examination, and routine laboratory tests suggest (or cannot eliminate) cardiac disease." (ACC/AHA/ASE 2003 Guideline Update, pg. 35)
2. "Echocardiography is recommended for patients with edema with clinical signs of elevated central venous pressure when a potential cardiac etiology is suspected or when central venous pressure cannot be estimated with confidence and clinical suspicion of heart disease is high." TTE is also recommended for patients experiencing "dyspnea with clinical signs of heart disease."(ACC/AHA/ASE 2003 Guideline Update, pg. 37)
3. "Echocardiography is not recommended in patients with edema when the jugular venous pressure does not appear to be elevated." (ACC/AHA/ASE 2003 Guideline Update, pg. 35).
You can find this information in the Local Coverage Determination (LCD) Transthoracic Echocardiography (TTE) L33577.
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 wounds and ulcers described under A or B above, a NPWT pump and supplies will be
denied as not reasonable and necessary when 4 months (including the time NPWT was applied in an inpatient
setting prior to discharge to the home) have elapsed using a NPWT pump in the treatment of the most recent
wound. You can find these rules in the Local Coverage Determination (LCD) Negative Pressure Wound
Therapy Pumps, L33821.
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 equipment that is primarily and customarily used for nonmedical purposes or for equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples self-help devices or precautionary equipment. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 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 health plan contract says that dental services are covered as long as you get them from a network provider. You can find this information on page 31 of the 2021 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, Publication 100-02, 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 specifically excludes bridges from coverage. You can find this information on page 69 of the Plan's 2021 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 Coverage is not available for LINX Reflux Management System, which is not a true endoluminal treatment but is also not considered reasonable and necessary for the diagnosis or treatment of an injury or disease. You can find these rules in the Local Coverage Determination (LCD) Select Minimally Invasive GERD Procedures, L35080.
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, Publication 100-02, 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 extraction is covered per calendar year and residual tooth root removal is not a covered benefit. You can find this information on pages 67 and 68 of the Plan's 2021 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 an electrical bone growth or osteogenesis stimulator (E0747) is covered if there is nonunion of a long bone fracture, failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last surgery, or congenital pseudarthrosis. Nonunion of a long bone fracture must be documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each including multiple views of the fracture site, and with a written interpretation by a treating practitioner stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs. You can find this rule in the Medicare Local Coverage Determination (LCD) for Osteogenesis Stimulators (L33796).

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 also say that compression bandages, multi-layer systems, and gradient compression wraps described by code A6531 are covered only covered when used in the treatment of an open venous stasis ulcer. You can find these rules in the Local Coverage Article: Surgical Dressings-Policy Article A54563.
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, Publication 100-02, 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 root canal therapy on permanent teeth, including pulpotomies, indirect pulp-cap, and root canal re-treatment (mutually exclusive of final restoration) is only covered once per tooth per lifetime. The cone beam CT capture is not listed as a covered benefit. You can find this information on pages 69 to 74 of the Plan's 2021 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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, 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 routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers 30 one-way trips at a maximum of 60 miles per one way trip. You can see this on page 61 of the Plans 2021 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, Publication 100-02, 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. Comprehensive dental
services covered by this benefit include white and silver fillings, simple extractions, denture repairs, root
canals, crowns or caps, gum disease treatment services (periodontal services), and dentures. You can find this
information on pages 58-59 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 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, Publication 100-02, 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 does not list bone graft at time of implant placement or surgical access to implant body as covered services. You can find this information on pages 53-54 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 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, Publication 100-02, 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. Partial upper denture with flexible base is not listed and therefore is not a covered service. You can find this information on pages 285 to 288 of the Plan's 2021 Office Reference Manual.
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 hygienic items that are non-reusable are not covered by Medicare. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.1.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that indications for wireless capsule endoscopy: For investigating suspected small intestinal bleeding in persons with objective evidence of recurrent, obscure GI bleeding (e.g., persistent or recurrent iron-deficiency anemia and/or persistent or recurrent positive fecal occult blood test (FOBT), or visible bleeding) who have had upper and lower GI endoscopies within the past 12 months (esophagogastroduodenoscopy (EGD) and colonoscopy) that have failed to identify a bleeding source.
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 infusion pump implantation is contraindicated with other implanted programmable devices since crosstalk between devices may inadvertently change the prescription. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 280.14.
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 Appeal Number is:
1-10565804346
The rules say that computed tomography (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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 220.1(A). The rules say that magnetic resonance imaging (MRI) is covered when medically necessary and reasonable for the diagnosis or treatment of the specific patient involved. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 220.2(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.