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 CFR 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 web site 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. Problem focused limited oral evaluation, first
intraoral periapical x-ray and panoramic x-ray are not included on this list and are not covered supplemental
benefits. You can find this information on pages 91 to 92 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 CFR 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 411.15 and 411.15(o). Local Coverage Determination (LCD): Category III CPT Codes (L33392) - Because of the specific purpose these Category III codes serve, National Government Services will consider the item, service, or procedure represented by these codes to be not medically necessary, unless the item, service, or procedure is listed below under the "Indications and Limitations of Coverage". If a provider believes that any Category III code, included in the attached coding guidance article Category III CPT Codes (A56195)- Groups 1 and 3, qualifies for coverage (is proven to be safe and effective as well as reasonable and necessary), the provider may request coverage and inclusion of the item, service, or procedure in this LCD through the LCD Reconsideration Process or in its own LCD through the LCD Request Process.
If you want to read these Medicare rules, you can go to this web site 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 CFR 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 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 3-4 of the 2019 EOC.
Appeal type: unknown
Decision: unknown

The rules saythat 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 CFR 422.101.The rules say that screening tests are excluded from coverage. The only exceptions are for the following services:1. screening mammography, 2. colorectal cancer screening tests,3. screening pelvic exams, 4. prostate cancer screening tests, 5. glaucoma screening exams, 6. ultrasound screening for abdominal aortic aneurysms (AAA), 7. cardiovascular disease screening tests, 8. diabetes screening tests, and9. screening electrocardiograms10. certain other testing recommended by the United States Preventive Services Task Force and approved by CMSYou can find this rule at 42 CFR 411.15(a)(1) and 42 CFR 410.64.If you want to read these Medicare rules, you can go to this web site 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 CFR 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 person's 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 this rule in the Medicare National Coverage Determinations Manual, Section 280.3(B).
Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site
evaluation of the beneficiary's home to verify that the beneficiary can adequately maneuver the device that is
provided considering physical layout, doorway width, doorway thresholds, and surfaces. There must be a
written report of this evaluation available on request. You can find this rule in Local Coverage Determination
(LCD): Power Mobility Devices (L33789).
A detailed written order (DWO)is required before billing. Someone other than the physician/practitioner may
complete the DWO of the item unless statute, manual instructions, the contractor's LCD or policy articles
specify otherwise. However, the prescribing physician/practitioner must review the content and sign and date
the document. You can find this rule in Local Coverage Article: Standard Documentation Requirements for All
Claims Submitted to DME MACs (A55426)
If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.
The rules say that a Medicare plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR 422.112(a)(3).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 10 of the 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 CFR 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 411.15 and
411.15(o).
A standard walker (E0130, E0135, E0141, E0143) and related accessories are covered if all of the following
criteria (1-3) are met:
1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or
more mobility-related activities of daily living (MRADL) in the home.
A mobility limitation is one that:
a. Prevents the beneficiary from accomplishing the MRADL entirely, or
b. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the
attempts to perform the MRADL, or
c. Prevents the beneficiary from completing the MRADL within a reasonable time frame; and
2. The beneficiary is able to safely use the walker; and
3. The functional mobility deficit can be sufficiently resolved with use of a walker.
You can find these rules in Local Coverage Determination (LCD): Walkers (L33791).
The rules say that 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. Medicare will only pay for durable
medical equipment that is needed for use in the home. Medicare will not pay for equipment used for a patient's
convenience or comfort or for the convenience of a person caring for the patient. 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 additional expenses for "deluxe" equipment or features, or items that are rented or purchased
for aesthetic reasons or added convenience, do not meet the reasonableness test. Thus, where a service or item
is medically necessary and covered under the Medicare program, and the patient or provider wishes to obtain
such deluxe features, the payment is based upon the payment amount for the kind of service or item normally
used to meet the intended purpose (i.e., the standard item or the least costly item). You can find this in the
Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and
Supplies.
If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forwardinformation 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, youcan go to this web site 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 CFR 422.101.
The rules say that continuous passive motion devices (CPM devices) are covered only for patients who have
received a total knee replacement. There is insufficient evidence to justify coverage for other applications. You
can find this rule in the Medicare Coverage Determinations Manual, Section 280.1.
If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.
The rules say that definitive urine drug testing (UDT) is reasonable and necessary for the following circumstances: -Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT; -Definitively identify specific drugs in a large family of drugs; -Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, meperidine, synthetic cannabinoids and other synthetic/analog drugs; -Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., discontinuation of THC use according to a treatment plan); -Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patient's self-report, presentation, medical history, or current prescribed pain medication plan; -Rule out an error as the cause of a presumptive UDT result; -Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and -Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. You can find this rule in Local Coverage Determination (LCD): Lab: Controlled Substance Monitoring and Drugs of Abuse Testing (L36707) - Effective December 27, 2018. The rules say that definitive UDT may be reasonable and necessary based on patient specific indications, including historical use, medication response, and clinical assessment, when accurate results are necessary to make clinical decisions. The clinician's rationale for the definitive UDT and the tests ordered must be documented in the patient's medical record. You can find this rule in Local Coverage Determination (LCD): Lab: Controlled Substance Monitoring and Drugs of Abuse Testing (L36707) - Effective December 27, 2018.
If you want to read these Medicare rules, you can go to this web site 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 CFR 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 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 27 of the Plan's 2018 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 CFR 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 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this web site 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 authorizesthe use of out-of-network providers. You can find this information on page 1-8 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 CFR 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 web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract states that if a dental item or service is not listed in the benefit chart, then it is not covered. The requested codes, D6750 and D6240, are not listed in the benefits chart. You can find this information and a full list of covered dental services on pages 20 to 29 of the Plan's 2020 Preventative & Comprehensive Dental Coverage Customer Handbook.
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 CFR 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 web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also includes a list of covered supplemental dental services. Consultation and apexification/recalcification are not included on this list and are not covered supplemental benefits. You can find this information on pages 62 to 63 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 CFR 422.101.
The rules say that shower and bath chairs are not covered because they are considered hygienic equipment that is not primarily medical in nature. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.1.
The rules also say that raised toilet seats are not covered because they are considered hygienic equipment that is not primarily medical in nature. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.1.
If you want to read these Medicare rules, you can go to this web site 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 CFR 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 person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and4. The person must be capable of safely operating the PMD. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.3(B).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).A positioning seat cushion (E2605, E2606), positioning back cushion (E2613-E2616, E2620, E2621), and positioning accessory (E0953, E0955-E0957, E0960) are covered for a beneficiary who meets both of the following criteria:1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and2. The beneficiary has any significant postural asymmetries that are due to one of the following (a or b):a. A diagnosis code listed in Group 2 of the "ICD-10 Codes that are Covered" section in the LCD-related Policy Article; orb. A diagnosis code listed in Group 3 of the "ICD-10 Codes that are Covered" section in the LCD-related Policy Article.You can find this rule in Local Coverage Determination (LCD): Wheelchair Seating (L33312).A skin protection seat cushion (E2603, E2604, E2622, E2623) is covered for a beneficiary who meets both of the following criteria:1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and2. The beneficiary has either of the following (a or b):a. Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface as reflected in a diagnosis code listed in Group 1 of the "ICD-10 Codes that are Covered" section in the LCD-related Policy Article; orb. Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift as reflected in a diagnosis code listed in Group 2 of the "ICD-10 Codes that are Covered" section in the LCD-related Policy Article.You can find this rule in Local Coverage Determination (LCD): Wheelchair Seating (L33312)