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 Plan 
contract includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. Complete mandibular overdenture (D5865) is not included on this list and 
is not a covered supplemental benefit. You can find this information on pages 4-54 to 4-67 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 417.414. 
 
The rules say that except for emergency and urgently needed services, Cost plans are not required to make 
payments for any services received by enrollees that are not provided directly by the Plan or through 
arrangements made by the Plan. You can find this rule at 42 CFR Section 417.448(a). 
 
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 you generally must receive your care from a network provider. If the Plan does not 
cover services you receive from an out-of-network provider, the services will be covered by Original Medicare 
if they are Medicare-covered services. Except for prior authorized and emergency or urgently needed services, 
if you receive services covered by Original Medicare from an out-of-network provider then you must pay 
Original Medicare's cost-sharing amounts. You can find this information on pages 33-36 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. 
 
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion 
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the 
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find 
this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 290(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 for people with diabetes who have severe diabetic foot disease: one (1) pair per plan year of 
therapeutic custom-molded shoes (including inserts provided with such shoes) and two (2) additional pairs of 
inserts, or one pair of depth shoes and three (3) pairs of inserts (not including the non-customized removable 
inserts provided with such shoes). Coverage includes fitting. You can find this information in Chapter 4 on 
pages 4-13 to 4-16 of the plan's 2020 Evidence of Coverage. 
 
The health plan contract says orthopedic shoes are covered if shoes are a part of a leg brace and are included in 
the cost of the brace, or the shoes are for a person with diabetic foot disease. Supportive devices for the feet 
(orthopedic or therapeutic shoes) are for people with diabetic foot disease. You can find this information in 
Chapter 4 on page 4-71 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). 
 
Medicare guidance says The supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies 
(DMEPOS) is required to keep on file a physician prescription (order). A supplier must have an order from the 
treating physician before dispensing any DMEPOS item to a beneficiary. In addition; All DMEPOS items 
other than those referenced in 42 CFR 410.38(c)(4) and 410.38(g)(2) require detailed written orders prior to 
billing. Detailed written orders may take the form of a photocopy, facsimile image, electronically maintained, 
or original ""pen-and-ink"" document. (See chapter 3, section 3.3.2.4). The written order must be sufficiently 
detailed, including all options or additional features that will be separately billed or that will require an 
upgraded code. The description can be either a narrative description (e.g., lightweight wheelchair base) or a 
brand name/model number. All orders must clearly specify the start date of the order. Also, A written order 
prior to delivery is required for certain DMEPOS items as specified in 42 CFR 410.38(c)(4) and 410.38(g)(2). 
For these items, the supplier must have received a written order that has been both signed and dated by the 
treating physician/practitioner before dispensing the item. If a supplier bills for an item without a written order 
prior to delivery, the item will be denied.For a covered DME item, outlined in 42 CFR 410.38(g), the 
contractor shall ensure that the written order is consistent with requirements in 42 CFR 410.38(g)(4). This 
order must include, the beneficiary's name, the item of DME ordered, the NPI of the prescribing 
physician/practitioner, the signature of the prescribing physician/practitioner and the date of the order. If this 
information is not included on the written order, the claim will be denied. Medicare requires that the written 
order is completed after the face-to-face encounter. If the date of the written order is prior to the date of the 
face-to-face encounter, the contractor shall deny the claim. You can find this guidance in the Medicare 
Program Integrity Manual Chapter 5 Items and Services Having Special DME Review Considerations, 5.2.1 - 
Physician Orders, 5.2.3  Detailed Written Orders and 5.2.4  Written Orders Prior to Delivery (A and C).C11. 
 
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 health 
plan contract says that enrollees must pay a $750 copayment per stay for each in-network medically necessary 
covered inpatient stay after you pay your $1,000 deductible. You can find this information in Chapter 4 on 
page 66 of the plan's 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 Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
 
You can find these rules in the Medicare National Coverage Determinations Manual, Section 280.3(B) and 
Local Coverage Determination (LCD): Power Mobility Devices (L33789) 
 
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 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 the Plan covers items and services in accordance with Medicare rules. The health 
plan contract says, "we reimburse you up to $40 per month for qualifying fitness expenses. You will be 
responsible for paying the qualifying expenses upfront. You must submit an itemized receipt or other proof of 
payment and proof of participation for reimbursement to the Plan." and "Gym Membership: We can reimburse 
you for the monthly cost of your single-person gym membership, as long as the gym is standalone, meaning 
the primary purpose of the facility is to provide exercise equipment. Other membership-based facilities such as 
spas, golf clubs, or country clubs do not qualify for reimbursement, even if the facility includes gym access. 
Gym membership must include an orientation to the facility and equipment." You can find this information in 
Chapter 4 on pages 64 to 65 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 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 Guidance Manual, Section 50.12.1. 
 
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 health 
plan contract says Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts. 
You can find this information in Chapter 4 on page 91 of the plan's 2020 Evidence of Coverage. 
 
The health plan contract says that enrollees must pay any amount over $75 for out-of-network routine eye exam 
(1 per calendar year) eye exam will include refraction and dilation. Your routine exam charge will not exceed 
$75 at a Network supplemental optical provider. Please inform the network provider that you are part of the 
supplemental vision vendor network. When using an out-of-network provider, you will be responsible for costs 
above the plan approved amount. You are responsible for submitting a supplemental vision vendor out-of-
network claim form with itemized receipt when seeing a non-supplemental vision provider. You can find this 
information in Chapter 4 on page 96 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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Medicare Managed Care Manual, Chapter 1, Section 20.2. 
 
The rules say that Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 in Chapter 3 on page 3-6 of the 
plan's 2020 Evidence of Coverage. 
 
The health plan contract says that hearing aids ordered through a provider other than a network Plan provider is 
not covered. You can find this information in Chapter 4 on page 4-21 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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Medicare Managed Care Manual, Chapter 1, Section 20.2. 
 
The rules say that hospital beds are covered only with a physician's prescription and sufficient documentation 
in the patient's medical records to establish medical necessity for a hospital bed due to one of the following 
reasons: 
 
1. The patient's condition requires positioning of the body; e.g., to alleviate pain, promote good body 
alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or   
 
2. The patient's condition requires special attachments that cannot be fixed and used on an ordinary bed.  
You can find this rule in the Medicare National Coverage Determinations Manual, Chapter 1, Section 280.7. 
 
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. 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 in Chapter 3 on page 35 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 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. 
 
A four-week trial of conservative therapy demonstrating failed response to treatment is required. The four-
week trial of conservative therapy must include all of the following: regular and compliant use of an 
appropriate compression bandage system or compression garment to provide adequate graduated compression, 
adequate compression is defined as (1) sufficient pressure at the lowest pressure point to cause fluid movement 
and (2) sufficient pressure across the gradient (from highest to lowest pressure point) to move fluid from distal 
to proximal. (the compression used must not create a tourniquet effect at any point. The garment may be 
prefabricated or custom-fabricated but must provide adequate graduated compression starting with a minimum 
of 30 mmHg distally), regular exercise and elevation of the limb. 
 
You can find this information at Local Coverage Determination (LCD): Pneumatic Compression Devices 
(L33829). 
 
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 the indications for coverage of facet joint injections, medial branch blocks, and facet joint 
radiofrequency neurotomy are: 
 Patient must have history of at least 3 months of moderate to severe pain with functional impairment 
and pain is inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical 
therapy (as tolerated). 
 Pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with 
radiculopathy or neurogenic claudication. 
 There is no non-facet pathology that could explain the source of the patient's pain, such as fracture, 
tumor, infection, or significant deformity. 
 Clinical assessment implicates the facet joint as the putative source of pain. 
 
You can find these rules in Local Coverage Determination (LCD) Facet Joint Injections, Medial Branch 
Blocks, and Facet Joint Radiofrequency Neurotomy (L35936). 
 
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 elastic stockings are not covered because they are non-reusable supply items. Elastic 
stockings are not durable medical equipment. You can find this rule in the Medicare National Coverage 
Determinations Manual, Chapter 1, Section 280.1.   
  
The rules say that gradient pressure garments may be covered when used as dressings following burn injuries. 
You can find this rule in the Medicare National Coverage Determinations Manual, Chapter 1, Section 270.5.  
 
The rules also say that compression bandages, multi-layer systems, and gradient compression wraps are 
covered only when they are used as dressings over a qualifying wound. A qualifying wound is either a wound 
caused or treated by surgery or a wound that must be debrided. A gradient compression stocking or wrap 
described by codes A6531, A6532, or A6545 is only covered when it is used in the treatment of an open 
venous stasis ulcer. Gradient compression stockings and wraps identified with codes A6531, A6532, and 
A6545 are not covered when they are used to treat the following conditions: 
-Venous insufficiency without stasis ulcers; 
- Prevention of stasis ulcers; 
- Prevention of the reoccurrence of stasis ulcers that have healed; 
- Treatment of lymphedema in the absence of ulcers. 
 
You can find these rules in Local Coverage Determination (LCD): Surgical Dressings L33831 and Local 
Coverage Article: Surgical Dressings-Policy Article A54563, effective for services performed on or after July 
24, 2017. 
 
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 the evidence of clinical utility to support the use of the GeneSight assay is limited to patients 
diagnosed with major depressive disorder (MDD) who are suffering with refractory moderate to severe 
depression (based upon DSM-V criteria) after at least one prior neuropsychiatric medication failure when 
ordered by a licensed psychiatrist or neuropsychiatrist contemplating an alteration in neuropsychiatric 
medication. Claims submitted by non-physician providers (NPPs) and physician extenders as ?incident to? 
services will be denied. The GeneSight assay is limited to once in a life-time. You can find this rule in the 
Local Coverage Determination for MolDX: GeneSight ? Assay for Refractory Depression, L35443 (eff 
10/31/19). 
 
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.