Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will 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 1 partial 
denture every 5 plan years. You can find this information on page 4-58 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 Botulinum toxins (Botox?, Dysport?, Xeomin? and Myobloc?), will be considered 
medically reasonable and necessary when administered for treatment of the following FDA-labeled indications 
and other indications as specified below: 

FDA Indications for Botox: 
&#61623; strabismus and blepharospasm associated with dystonia  
&#61623; benign essential blepharospasm  
&#61623; facial nerve (cranial nerve VII) disorders in patients 12 years of age and older 
&#61623; cervical dystonia to reduce the severity of abnormal head position and neck pain (i.e., spasmodic 
torticollis) 
&#61623; severe primary axillary hyperhidrosis inadequately managed with topical agents. Patients should be 
evaluated for potential causes of secondary hyperhidrosis (e.g., hyperthyroidism) to avoid symptomatic 
treatment of hyperhidrosis without the diagnosis and/or treatment of the underlying disease. 
&#61623; upper limb spasticity in adult patients, to decrease the severity of increased muscle tone in elbow 
flexors (biceps), wrist flexors (flexor carpi radialis and flexor carpi ulnaris) and finger flexors (flexor 
digitorum profundus and flexor digitorum sublimis). 
&#61623; prophylaxis of headaches in adult patients with chronic migraine (> 15 days per month with headache 
lasting 4 hours a day or longer). 
&#61623; Treatment of urinary incontinence due to detrusor overactivity associated with a neurologic condition 
[e.g., spinal cord injury (SCI), multiple sclerosis (MS)] in adults who have an inadequate response to or 
are intolerant of anticholinergic medication. 
&#61623; Treatment of overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and 
frequency, in adults who have an inadequate response to or are intolerant of an anticholinergic 
medication. 
&#61623; Lower limb spasticity in adult patients to decrease the severity of lower limb spasticity (i.e., increased 
muscle tone) in ankle and toe flexors (gastrocnemius, soleus, tibialis posterior, flexor hallucis longus, 
and flexor digitorum longus):  
- spastic hemiplegia 
- spasticity related to stroke 

You can find this rule at Local Coverage Determination (LCD): Botulinum Toxins (L33274) (eff. 1/8/19). 
 
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. 
 
The rules say that Medicare will pay for durable medical equipment (DME) 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. You can find these rules in the Medicare Benefit Policy Manual, 
Chapter 15, Section 110.1.  
 
The rules also say that prosthetic devices (other than dental) which replace all or part of an internal body organ 
(including contiguous tissue), or replace all or part of the function of a permanently inoperative or 
malfunctioning internal body organ are covered when furnished on a physician's order. You can find this in the 
Medicare Benefit Policy Manual, Chapter 15, Section 120. 
 
Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 280.1 provides a list of items 
that are non-covered with the reason for denial. Wig, any type, (A9282), will be denied as non-covered when 
submitted to the DME MAC. Does not meet the definition of DME. 
 
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 
extractions. Any service not listed is not covered. You can find this information on pages 4-69 to 4-79 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 Appeal Number is: 1-9629652481 
 
The rules say that an inpatient admission is generally appropriate when the admitting physician expects the 
patient to need hospital care that crosses at least two midnights. The expectation should be based on such 
complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and 
medical risk. The factors must be documented in the medical record. The order for inpatient admission must be 
present in the medical record.  
 
If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be 
considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as 
?inpatient only? is generally appropriate, regardless of the length of stay. An inpatient admission may be 
appropriate if the admitting physician expects a patient to require hospital care for only a limited period of 
time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be 
supported by the medical record. You can find this rule at 42 CFR Section 412.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will 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 contract lists the dental 
services that are covered. Dentures are not listed and therefore are not a covered service. Although extractions 
are listed, the contract also says prior authorization rules may apply. You can find this information on pages 85 
and 86 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 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 84 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 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 up to 8 
fixed bridge units per year, per tooth, per lifetime. You can find this information on page 76 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 417.414. 
 
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 Lumbar Artificial Disc Replacement (LADR) (150.10) - Effective 
for services performed from May 16, 2006 through August 13, 2007, the Centers for Medicare and Medicaid 
Services (CMS) has found that LADR with the Charite lumbar artificial disc is not reasonable and necessary 
for the Medicare population over 60 years of age; therefore, LADR with the Charite lumbar artificial disc is 
non-covered for Medicare beneficiaries over 60 years of age. 
Effective for services performed on or after August 14, 2007, CMS has found that LADR is not reasonable and 
necessary for the Medicare population over 60 years of age; therefore, LADR is non-covered for Medicare 
beneficiaries over 60 years of age. 

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). 
 
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: 
?The implantation of the stimulator is used only as a late resort (if not a last resort) 
for patients with chronic intractable pain; 
?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; 
?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); 
?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 
?Demonstration of pain relief with a temporarily implanted electrode precedes 
permanent implantation. 
You can find this information in National Coverage Determination (NCD) for Electrical Nerve Stimulators 
(160.7.) 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patient?s comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You 
can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1.  
 
Equipment which is primarily and customarily used for a nonmedical 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. 
 
Exercise equipment is not primarily medical in nature. 
National Coverage Determination (NCD) for Durable Medical Equipment Reference List (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 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 say that as comprehensive genomic profile (CGP) testing is not defined as a targeted panel by 
MolDX, and it is a test not currently satisfactorily described by any existing CPT? code. Therefore, to report a 
CGP service, test providers should use CPT code 81479 at this time, in addition to the approved DEX Z-Code 
for the test. Coverage of CGP is limited to one test per surgical specimen and precludes the use of any other 
molecular testing on that specimen. You can find this rule in the Local Coverage Article for Billing and 
Coding: MolDX: Targeted and Comprehensive Genomic Profile Next-Generation Sequencing Testing in 
Cancer, A55624 (eff 12/01/19). 
 
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. 
 
The rules say a manual wheelchair for use inside the home (E1037 - E1039, E1161, K0001 - 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. 
You can find this information in 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. 
 
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 Screening computed tomographic colonography (CTC) is non-covered, effective May 12, 
2009. This rule can be found in National Coverage Determination (NCD): Colorectal Cancer Screening Tests 
(210.3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that health plans, physicians, hospitals, and other health care providers must comply with the 
Official ICD-10-CM Coding Guidelines. You can find this rule in the Medicare Claims Processing Manual, 
Chapter 23, Section 10. 
 
The rules also say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on 
the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes 
for both the left and right side. If the side is not identified in the medical record, assign the code for the 
unspecified side. You can find this rule in the ICD-10-CM Official Guidelines for Coding and Reporting, 
Section 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.