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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
Local Coverage Determination (LCD): Transthoracic Echocardiography (TTE) (L33577): In order to qualify as 
a valid echocardiographic service, the study must be done for an accepted clinical indication by a properly 
trained examiner and must include a permanent record of the findings, data sufficient to support the 
conclusions and an appropriate interpretation and written report. Such a study would meet the standards 
required for a complete echocardiographic examination, regardless of the size or portability of the instrument 
used to perform the study. 
 
This policy addresses the medically necessary and appropriate application of TTE, including stress 
echocardiography. Transesophageal echocardiography (TEE) is the subject of a separate policy statement. 
 
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). 
National Coverage Determination (NCD) for Electrical Nerve Stimulators (160.7): No payment may be made 
for the implantation of dorsal column or depth brain stimulators or services and supplies related to such 
implantation, unless all of the conditions listed below have been met: 
&#61623; The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with 
chronic intractable pain; 
&#61623; With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or 
contraindicated for the given patient; 
&#61623; Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
&#61623; All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be 
available; and 
&#61623; Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
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 F2 and F5 germline mutations will be considered medically reasonable and necessary when 
performed for evaluation of venous thromboembolism. You can find this information in the Local Coverage 
Determination (LCD): Biomarkers Overview (L35062). 
 
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). 
 
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: 
1-9618344436 
 
 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances, 
Organization/Coverage Determinations, and Appeals Grievance Manual, Section 50.12.1. 
 
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. 
 
Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise 
reasonable and necessary for the patient. FDA approved drugs used for indications other than what is indicated 
on the official label may be covered if the use is determined to be medically accepted, taking into consideration 
the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. You 
can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50.4.1 and 50.4.2. 
 
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 417.414. 
 
The rules say that immunizations are not covered unless they are directly related to the treatment of an injury or 
direct exposure to a disease or condition. In the absence of injury or direct exposure, vaccination or inoculation 
is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule. 
You can find this rule at 42 CFR Section 411.15(e). 
 
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 some vaccines such as those for shingles are not covered by your Plan. You can find this 
information on page 54 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 Abdominal Lipectomy/Panniculectomy is surgical removal of excessive fat and skin from 
the abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally, 
chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, such surgery is considered 
reconstructive. Preoperative photographs may be required to support justification and should be supplied upon 
request. 
 
Panniculectomy will be considered medically necessary when the pannus or panniculus hangs below the level 
of the pubis, and the medical records document that the panniculus causes chronic intertrigo (dermatitis 
occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over 
three months while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy 
over a period of three months. 
 
You can find these rules in Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery 
(L35090). 
 
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. 
 
Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the health plan 
sufficient information to determine whether payment is due and the amount of payment. You can find this rule 
at 42 CFR Section 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare 
Program Integrity Manual Chapter 3 Section 3.3.2.1. 
 
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. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes dental 
services beyond Medicare coverage. Dental implants are covered to support the lower full denture on fully 
edentulous lower arch only. Does not include membranes and/or bone replacement or graft. You can find this 
information on page 7 of the Plan?s 2020 Dental Benefits 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 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 non-medical 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 Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
The rules state that a 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). 
 
Medicare rules state that options and accessories for wheelchairs are covered if the beneficiary has a wheelchair 
that meets Medicare coverage criteria and the option/accessory itself is medically necessary. You can find this 
rule in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). 
 
A power tilt seating system and a power recline seating system includes a switch control which is independent 
of the power wheelchair drive control interface. A power leg elevation feature includes a switch control which 
may or may not be integrated with the power tilt and/or recline controls. 
You can find this information in Local Coverage Article: Wheelchair Options/Accessories-Policy Article 
(A52504). 
 
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 dates of service on or after September 19, 2000, and until notified otherwise by CMS, 
Medicare contractors will pay for covered clinical trial services furnished to beneficiaries enrolled in managed 
care plans. The clinical trial coding requirements for managed care enrollee claims are the same as those for 
regular Medicare fee for service claims.  However, for beneficiaries enrolled in a managed care plan, 
institutional providers must not bill outpatient clinical trial services and non-clinical trial services on the same 
claim.  If covered outpatient services unrelated to the clinical trial are rendered during the same day/stay, the 
provider must split-bill so that ONLY the clinical trial services are contained on a single claim and billed as 
fee-for-service (this allows the Medicare claims processing system to not apply deductible when the patient is 
found to be in a managed care plan).  Any outpatient services unrelated to the clinical trial should be billed to 
the managed care plan. You can find these rules in the Medicare Claims Processing Manual, Chapter 32, 
Section 69.9. 
 
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 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 non-medical 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 Medicare Benefit Policy Manual, Chapter 15, Section 110.1.  
 
Medicare will not pay for precautionary equipment. You can find these rules in the Medicare Benefit Policy 
Manual, Chapter 15 - 110.1. 
 
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 Medicare Benefit Policy Manual, Chapter 15, 
Section 110.1(C). 
Equipment which is primarily and customarily used for a non-medical purpose may not be considered "medical" 
equipment for which payment can be made under the medical insurance program. This is true even though the 
item has some remote medically related use.  
You can find this information in Medicare Benefit Policy Manual, Chapter 15, 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 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 Plan 
contract says that prior authorization is required for comprehensive dental services. You can find this 
information on page 59 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
National Coverage Determination (NCD) for FDG PET for Infection and Inflammation (220.6.16): The CMS is 
continuing its national non-coverage of FDG PET for the requested indications. Based upon our review, CMS 
has determined that the evidence is inadequate to conclude that FDG PET for chronic osteomyelitis, infection 
of hip arthroplasty, and fever of unknown origin improves health outcomes in the Medicare populations, and 
therefore has determined that FDG PET for chronic osteomyelitis, infection of hip arthroplasty, and fever of 
unknown origin is not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act. 
 
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). 
 
The criteria in section A (patient signs and symptoms), section B (photographs), and section C (visual field) 
below must be documented to demonstrate medical necessity. You can find this information in Local Coverage 
Determination (LCD): Blepharoplasty, Blepharoptosis and Brow Lift (L34528). 
 
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 coverage for the use of neuromuscular electrical stimulation/functional electrical 
stimulation is limited to spinal cord injury patients for walking. You can find this information in the National 
Coverage Determination (NCD) for Neuromuscular Electrical Stimulation (NMES) (160.12). 
 
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.