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 manual wheelchair for use inside the home (E1037, E1038, E1039, E1161, K0001, K0002, 
K0003, K0004, K0005, K0006, K0007, K0008, K0009) is covered if: 
 
    Criteria A, B, C, D, and E are met; and 
    Criterion F or G is met. 
 
    A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. A mobility limitation is one that: 
 
      1.  Prevents the beneficiary from accomplishing an MRADL entirely, or 
 
      2.  Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to 
the attempts to perform an MRADL; or 
 
      3.  Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
 
    B. The beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted 
cane or walker. 
 
    C. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for 
use of the manual wheelchair that is provided. 
 
    D. Use of a manual wheelchair will significantly improve the beneficiary's ability to participate in MRADLs 
and the beneficiary will use it on a regular basis in the home. 
 
    E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the 
home. 
 
    F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed 
to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of 
strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both 
upper extremities are relevant to the assessment of upper extremity function. 
 
   G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the 
wheelchair. 
 
ADDITIONAL CRITERIA FOR SPECIFIC MANUAL WHEELCHAIRS (E1037, E1038, E1039, E1161, 
K0002, K0003, K0004, K0005, K0006, K0007, K0008) 
 
 
 
 
In addition to the general manual wheelchair criteria above, the specific criteria below must be met for each 
manual wheelchair. If the specific criteria are not met, the manual wheelchair will be denied as not reasonable 
and necessary. 
 
A transport chair (E1037, E1038 or E1039) is covered as an alternative to a standard manual wheelchair 
(K0001) and if basic coverage criteria A-E and G above are met. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Manual Wheelchair Bases 
(L33788). 
 
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 this contractor will consider high-sensitivity C-reactive protein (hsCRP) testing reasonable 
and necessary when ALL of the following criteria are met: 
1. When the hsCRP would add substantial incremental information in the decision making process to 
optimize/maximize lipid lowering pharmacologic therapy, (e.g., use of statins), in a patient who has 
been identified as being at intermediate risk for CAD (10-year risk of coronary heart disease between 
10-20% per the ATPIII Guidelines). This is to be used for a one time decision point and is not intended 
to monitor therapy. 
2. The test is performed in patients considered to be metabolically stable and without obvious 
inflammatory or infectious conditions. 
The American Heart Association (AHA) recommends the following cutpoints for hsCRP corresponding to 
three levels of risk: 
&#61623; Low risk less than 1.0 mg/L 
  
&#61623; Average risk greater than 1.0 to less than 3.0 mg/L 
  
&#61623; High risk greater than 3.0 mg/L 
You can find this rule at Local Coverage Determination (LCD): C-Reactive Protein High Sensitivity Testing 
(hsCRP) (L34856) (eff. 11/7/19). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that they provide a total of $175 every 12 months for eyeglasses, frames, lenses, or contact 
lenses from participating network providers. You can find this information on page 88 of the Plan's 2020 
Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(A). 
 
The rules state that if an independent lab bills for services, the place where the sample was taken is reported as 
the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of 
service. You can find this information in the Medicare Claims Processing Manual, Chapter 26, Section 10.6.  
 
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 44 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 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. This benefit does not cover 
dental services provided by out-of-network providers. You can find this information on page 14 of the Plan's 
2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that codes for Chemotherapy administration and nonchemotherapy injections and infusions 
include the following three categories of codes in the American Medical Association's Current Procedural 
Terminology (CPT): 
 
1. Hydration; 
2. Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy); and 
3. Chemotherapy administration. 
 
The hydration codes are used to report a hydration IV infusion which consists of a pre- packaged fluid and /or 
electrolytes (e.g. normal saline, D5-1/2 normal saline +30 mg EqKC1/liter) but are not used to report infusion 
of drugs or other substances. A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than 
hydration, is for the administration of substances/drugs. The fluid used to administer the drug (s) is incidental 
hydration and is not separately payable. 
 
You can find this information in the Medicare Claims Processing Manual, Chapter 12, Section 30.5.  
 
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. This benefit includes fillings, 
extractions, crowns, root canals, and dentures. You can find this information on page 82 of the Plan?s 2020 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
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 Appeal Number is: 
1-9740416806 
 
 
The rules say that Home Health Aide (HHA) services may be covered only if the enrollee needs one or more of 
the following qualified skilled services:  
 
1. Skilled nursing care;  
2. Physical therapy;  
3. Occupational therapy; or  
4. Speech pathology services.  
 
HHA services are no longer covered for enrollees once the qualifying skilled service has ended. To be covered, 
home health aide services must be reasonable and necessary. You can find this rule at 42 CFR Sections 409.44 
and 409.45. 
 
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 state that institutional providers, including home health agencies, use one of two institutional claim 
formats to bill Original Medicare. In the great majority of cases, these providers are required to use the 
electronic HIPAA standard institutional claim transaction, the 837I. The minority of providers that are eligible 
for an exception to electronic claim submission use the paper Form CMS-1450, also known as the UB-04. You 
can find this information in the Medicare Claims Processing Manual, Chapter 10, Section 10. 
 
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 
 
Medical Conditions for Which Testing is Covered 
 
Sleep apnea, Obstructive Sleep Apnea, Narcolepsy, Impotence, Parasomnia 
 
 Non-covered Services 
 
    Polysomnography for Chronic Insomnia Is Not Covered. 
    The use of polysomnography for diagnosis of patients with chronic insomnia is not covered under Medicare 
because it is not reasonable and necessary under ?1862(a)(1)(A) of the Act. 
 
    Actigraphy Testing: 
 
    Actigraphy measures movement of a limb. 
 
    It can be measured as part of a sleep test but will not be paid for separately. 
    Polysomnography or a MSLT is not covered in the following situations: 
 
    for the diagnosis of patients with chronic insomnia; 
    to preoperatively evaluate a patient undergoing a laser assisted uvulopalatopharyngoplasty without clinical 
evidence that obstructive sleep apnea is suspected; 
    to diagnose chronic lung disease (Nocturnal hypoxemia in patients with chronic, obstructive, restrictive, or 
reactive lung disease is usually adequately evaluated by oximetry. However, if the patient's symptoms suggest a 
diagnosis of obstructive sleep apnea, polysomnography is considered medically necessary); 
    in cases where seizure disorders have not been ruled out; 
    in cases of typical, uncomplicated, and non-injurious parasomnias when the diagnosis is clearly delineated; 
    for patients with epilepsy who have no specific complaints consistent with a sleep disorder; 
    for patients with symptoms suggestive of the periodic limb movement disorder or restless leg syndrome 
unless symptoms are suspected to be related to a covered indication; 
    for the diagnosis of insomnia related to depression; 
    for the diagnosis of circadian rhythm sleep disorders (i.e., rapid time-zone change [jet lag], shift-work sleep 
disorder, delayed sleep phase syndrome, advanced sleep phase syndrome, and non 24-hour sleep wake 
disorder). 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Polysomnography and 
Other Sleep Studies (L36839). 
 
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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
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 must pay a $30 copayment for Specialist office visit. You can find this information 
on page 83 of the Plan's 2020 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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
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 must pay a $0 copayment each day for days 1 to 20, a $160 copayment each day for 
days 21 to 58 for skilled nursing facility care. You can find this information on pages 4-61 to 4-63 of the Plan's 
2020 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 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. This benefit includes 
coverage for one denture relining a year. You can find this information on page 85 of the Plan's 2020 Evidence 
of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
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 must pay a $40 copayment for visits to specialists. You can find this information on 
page 85 of the Plan's 2020 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Cologuard testing is covered when enrollees meet all of the following criteria:  
61623; Age 50 to 85 years, and, 
61623; 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, 
61623; At average risk of developing colorectal cancer (no personal history of 
adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohns Disease and 
ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous 
polyposis, or hereditary nonpolyposis colorectal cancer). 
 
You can find these rules in the Medicare National Coverage Determination (NCD) for Colorectal Cancer 
Screening Tests, 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.