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 state that Therapeutic CGMs and related supplies are covered by Medicare when all ofthe following coverage criteria (1-6) are met:1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses); and,2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and,3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and,4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes controland determined that criteria (1-4) above are met; and,6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.You can find these rules in the Local Coverage Determination (LCD): Glucose Monitors, L33822. This LCD is effective for services provided on or after January 1, 2020.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the 
following conditions are met (42 CFR 422.100(l)): 
 
- The MA plan provides all categories of DME covered under original Medicare Part B; 
- The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
- The MA plan's contracted suppliers provide access to all preferred DME brands; 
- During an enrollee's first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 
90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year; 
- Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
- The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
- The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the EOC and ANOC and on its website; and 
- The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by CMS to require full coverage. 
 
You can find this information at Medicare Managed Care Manual Chapter 4 - Benefits and Beneficiary 
Protections 10.12.2- Specifying Brands or Manufacturers 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 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 physician/practitioner services/in-network/provider 
services/specialist. You can find this information on pages 86-87 of the Plan's 2020.
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 if an attendant control (E2331) is provided in addition to a beneficiary-operated drive 
control system, it will be denied as non-covered. You can find this information in the Local Coverage Article: 
Wheelchair Options/Accessories - Policy Article (A52504). 
 
The rules say that an attendant control is covered in place of a beneficiary-operated drive control system if the 
beneficiary meets coverage criteria for a wheelchair, is unable to operate a manual or power wheelchair and has 
a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair. You can 
find this information in the Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). 
 
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 cosmetic surgery or expenses incurred in connection with such surgery is not covered.  
Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for 
the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the 
functioning of a malformed body member.  For example, this exclusion does not apply to surgery in connection 
with treatment of severe burns or repair of the face following a serious automobile accident, or to surgery for 
therapeutic purposes which coincidentally also serves some cosmetic purpose. You can find this information in 
the Medicare Benefit Policy Manual Chapter 16 - General Exclusions From Coverage, 120 -  Cosmetic 
Surgery. 
 
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 cosmetic surgery or procedures are covered only under specific conditions: Covered in cases 
of an accidental injury or for improvement of the functioning of a malformed body member.Covered for all 
stages of reconstruction for a breast after a mastectomy, as well as for the unaffected breast to produce 
symmetrical appearance. You can find this information in Chapter 4 on pages 100-101 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 Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health 
plan contract says covered drugs include: Drugs that usually aren't self-administered by the patient and are 
injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. 
You can find this information in Chapter 4 on page 91 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 does not pay for gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 
30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that gym membership is covered when provided through the Renew Active fitness 
program. Enrollees must use participating fitness locations. You can see this on page 4-18 and 4-19 of the 2019 
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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR -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 - 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.
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 to qualify for home health services, the patient must be: 
 
1. Confined to the home;  
2. Under the care of a physician or allowed practitioner;  
3. Receiving services under a plan of care established and reviewed by a physician;  
4. In need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) 
continuing occupational therapy.  
You can find this rule at 42 CFR Section 409.42. 
 
The rules say that eligibility for the home health benefit will be determined based on the certifying physician?s 
records. If the enrollee was directly admitted to home health from an acute or post-acute care facility, the 
facility records may be used instead. The medical records for the enrollee must contain information that 
justifies the referral for home health services. 
  
The certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a 
face-to-face encounter with the enrollee within the required timeframe. The records must contain the actual 
clinical note for the face-to-face encounter visit. You can find these rules in the Medicare Benefit Policy 
Manual, Chapter 7, Section 30.5.1, 30.5.1.1, and 30.5.1.2. 
 
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 422.101. 
 
The rules say that a nonadjustable skin protection and positioning seat cushion (E2607, E2608) is a 
prefabricated cushion which has the following characteristics:""4. It has a removable vapor permeable or 
waterproof cover or it has a waterproof surface;" A separate request for a replacement cover for the seat 
cushion should be denied as unbundled. You can find this information in Medicare's Local Coverage Article: 
Wheelchair Seating - Policy Article (A52505). 
 
The rules say that Expandable Controller - An electronic system that is capable of accommodating one or more 
of the following additional functions: a. Proportional input devices (e.g., mini, compact, or short throw 
joysticks, touchpads, chin control, head control, etc.) other than a standard proportional joystick. b. Non-
proportional input devices (e.g., sip and puff, head array, etc.) 
 
c. Operate 3 or more powered seating actuators through the drive control. (Note: Control of the powerseating 
actuators though the Control Input Device would require the use of an additional component,E2310 or E2311.) 
 
An expandable controller may also be able to operate one or more of the following: d. A separate display (i.e., 
for alternate control devices), e. Other electronic devices (e.g., control of an augmentative speech device or 
computer through thechair's drive control), f. An attendant control 
 
A power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a solid back; any 
frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway 
detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable 
speed programmability; a switch control which is independent of the power wheelchair drive control interface.  
 
A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or 
without variable speed programmability which allows the legrest to be raised and lowered independently of the 
recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with 
the power tilt and/or recline control(s). 
 
 You can find this guidance in the 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.
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 before submitting a claim to the DME MAC the supplier must have on file a dispensing 
order, the detailed written order, the CMN (if applicable), the DIF (if applicable),information from the treating 
physician concerning the patient's diagnosis, and any information required for the use of specific modifiers or 
attestation statements as defined in certain DMEMAC policies. The supplier should also obtain as much 
documentation from the patient's medical record as they determine they need to assure themselves that 
coverage criteria for an item have been met. If the information in the patient's medical record does not 
adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved 
unless a properly executed ABN of possible denial has been obtained. You can find this information in the 
Medicare Program Integrity Manual, Chapter 5 - Items and Services Having Special DME Review 
Considerations, Section 5.7 Documentation in the Patient's Medical Record and Section 5.8 - Supplier 
Documentation. 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 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 20% coinsurance for Medicare Part B drugs. You can see this on page 59 
of the 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.  
 
The rules state that a pneumatic compression device (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 enrollee has a diagnosis of lymphedema as defined above, and 2. 
The enrollee has persistence of chronic and severe lymphedema as identified by the documented presence of at 
least one of the following clinical findings: marked hyperkeratosis with hyperplasia and hyperpigmentation, 
papillomatosis cutis lymphostatica, deformity of elephantiasis, skin breakdown with persisting lymphorrhea, 
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. 
 
You can find this in the Medicare National Coverage Determinations Manual, Chapter 1, Section 280.6. 
 
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 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). 
 
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 for mammography, if you receive a separate additional non-preventive evaluation and/or 
service, a copayment will apply. The copayment amount depends on the provider type or place of service. You 
can see this on page 62 of the 2020 Evidence of Coverage.  
 
The Plan contract says that enrollees must pay a $40 copayment for outpatient diagnostic services. You can see 
this on page 84 of the 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.  
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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.  
 
The rules say that 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 information in Medicare's 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.