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 covers Bone Mass Measurements (BMMs) under the following conditions: 
 
Is ordered by the physician or qualified nonphysician practitioner who is treating the beneficiary following an 
evaluation of the need for a BMM and determination of the appropriate BMM to be used. 
A physician or qualified nonphysician practitioner treating the beneficiary for purposes of this provision is one 
who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results in 
the management of the patient. For the purposes of the BMM benefit, qualified nonphysician practitioners 
include physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives. 
Is performed under the appropriate level of physician supervision as defined in 42 CFR 410.32(b). 
Is reasonable and necessary for diagnosing and treating the condition of a beneficiary who meets the conditions 
described in Section 80.5.6. 
In the case of an individual being monitored to assess the response to or efficacy of an Food and Drug 
Administration (FDA) -approved osteoporosis drug therapy, is performed with a dual-energy x-ray 
absorptiometry system (axial skeleton). 
In the case of any individual who meets the conditions of 80.5.6 and who has a confirmatory BMM, is 
performed by a dual-energy x-ray absorptiometry system (axial skeleton) if the initial BMM was not performed 
by a dual-energy x-ray absorptiometry system (axial skeleton). A confirmatory baseline BMM is not covered if 
the initial BMM was performed by a dual-energy x-ray absorptiometry system (axial skeleton). 
 
You can find this information in the Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other 
Health Services, Section 80.5.4 - Conditions for Coverage. 
 
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 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 Centers for Medicare & Medicaid 
Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and 
Appeals Guidance Manual, Section 50.12.1.  
 
The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare & Medicaid Services, Internet Only Manual, National Correct 
Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
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 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 this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations (NCD) Manual, Section 280.3(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.
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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare & Medicaid 
Services, Internet Only Manual, Publication 100-16, 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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers 18 one-way trips not exceeding 50 miles per trip. You can find this information Chapter 4: Section 2.1, 
page 88 of the Plans 2023 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 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 also says that there is a $300 deductible which applies to certain items and services. The Plan 
deductible applies to an inpatient stay. You can find this information on page 78 of the Plan's 2023 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 the indications for myocardial perfusion imaging (MPI) are: 
 
1. Acute myocardial infarction (AMI) - MPI is not typically performed during the acute period of myocardial 
infarction (MI), if the diagnosis is established by other means. In selected patients, imaging is appropriate in 
the assessment of: 
 
a. Disease severity 
b. Risk assessment and/or prognosis 
c. Efficacy of acute reperfusion therapy 
d. Evidence of myocardial salvage 
e. Suspected infarction when the combination of history and other tests is not diagnostic 
 
2. Unstable angina - MPI may be useful as an adjunct to other tests in the diagnosis or treatment of unstable 
angina only when the combination of history and other tests is not diagnostic. In selected patients, imaging is 
appropriate for: 
 
a. Identification of ischemia in the distribution of a known lesion or in remote areas 
b. Identification of the severity/extent of disease in patients with medically unstable angina or ongoing 
ischemia 
c. Measurement of left ventricular function (LVF) 
 
3. Chronic ischemic heart disease - The use of MPI is well established in the diagnosis and management of 
CAD and is covered in these situations: 
 
a. Diagnosis of coronary artery disease (CAD), especially in patients with atypical chest pain 
b. Evaluation of abnormal or suspected false positive stress electrocardiogram (ECG) 
c. Evaluation of other symptoms suspicious for the diagnosis of CAD such as syncope and ventricular 
arrhythmia 
d. Assessment of myocardial viability after revascularization or medical management e. Planning percutaneous transluminal coronary angioplasty (PTCA) to identify lesions causing ischemia, if 
unknown 
f. Evaluation of suspected or known CAD prior to high risk surgical procedure 
g. Identification of the presence, location, extent, and severity of myocardial ischemia 
h. Assessment of drug therapy 
i. Assessment of symptoms suggesting restenosis following PTCA 
j. Assessment of symptoms suggesting ischemia following coronary artery bypass graft (CABG) 
k. Follow up of symptomatic ischemic heart disease 
 
4. Congenital heart disease (CHD) - Echo is the method of choice for evaluating patients with known or 
suspected CHD. Selected patients may benefit from MPI when assessing for: 
 
a. Diagnosis of anomalies of the coronary circulation 
b. Kawasakis disease 
 
5. Post-transplant cardiac disease 
 
a. Assessment of coronary arteriopathy 
b. Evaluation for ventricular dysfunction with post-transplant rejection 
 
You can find this rule in the Local Coverage Determination (LCD) - Cardiac Radionuclide Imaging (L33457). 
 
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 Centers for Medicare & Medicaid Services, Internet 
Only Manual, Publication 100-16, 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 Plan 
contract says the Plan will provide reimbursement for participation in weight loss programs such as Weight 
Watchers or Jenny Craig, (meals and supplements do not qualify for reimbursement). You can find this 
information on pages 64 to 65 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that a Medicare Advantage (MA) organization may specify a network of providers from whom 
enrollees may obtain services. The MA organization must maintain and monitor a network of appropriate 
providers that is sufficient to provide adequate access to covered services to meet the needs of the enrollee. MA 
organizations must arrange for and cover any medically necessary covered benefit outside of the plan provider 
network, but at in-network cost sharing, when an in-network provider or benefit is unavailable or inadequate to 
meet an enrollee's medical needs. MA organizations offering coordinated care plans must ensure continuity of 
care and integration of services through arrangements with contracted providers. This includes services 
available through contracting or non-contracting providers in the area serviced by the MA plan including 
nursing home and community-based services, and behavioral health services. For enrollees undergoing an 
active course of treatment, approval of a prior authorization request for a course of treatment must be valid for 
as long as medically necessary to avoid disruptions in care. You can find this rule at 42 CFR Section 422.112. 
 
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 on page 8 of the Plan's 2023 
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 sacroiliac joint (SIJ) Denervation (also called Radiofrequency Ablation or RFA) is not 
considered reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Sacroiliac Joint Injections and 
Procedures L39462. 
 
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 an MA organization that offers an MA coordinated care plan may specify the networks of 
providers from whom enrollees may obtain services if the MA organization ensures that all covered services, 
including supplemental services contracted for by (or on behalf of) the Medicare enrollee, are available and 
accessible under the plan. You can find this rule at 42 of Code of Federal Regulation (CFR) Section 422.112. 
 
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 they cover meals delivered to your home immediately following discharge from a network 
hospital as an inpatient due to congestive heart failure, up to two meals per day in a consecutive four-week 
period, once per calendar year. You can find this information on page 62 of the Plan's 2023 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 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare & Medicaid Services, 
Internet Only Manual, Publication 100-02, 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 the 
requested item or service but is limited to one per 60 floating months. You can find this information on pages 
104-106 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that reduction mammaplasty is the surgical removal of a substantial portion of the breast, 
including the skin and underlying glandular tissue, until a clinically normal size is obtained. Breasts are pair 
organs, and breast hypertrophy generally affects both sides, therefore, bilateral surgery is usually performed. 
 
Reduction mammaplasty is performed to reduce the size of the breasts and help ameliorate symptoms caused 
by the hypertrophy and to reduce the size of a normal breast to bring it into symmetry with a breast 
reconstructed after cancer surgery. 
 
Reduction mammaplasty is considered medically necessary: 
1. When the patient has significant symptoms that have interfered with normal daily activities, despite 
conservative management, for at least 6 months, including at least one of the following criteria: 
 
2. History of back and/or shoulder pain which adversely affects activities of daily living (ADLs) 
unrelieved by, e.g.: 
a. conservative analgesia (e.g., such as non-steroidal anti-inflammatory drug (NSAID), compresses, 
massage, etc.) 
b. supportive measures (e.g., such as garments, back brace, etc.), 
c. physical therapy 
d. correction of obesity 
 
3. History of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with 
persistent symptoms and/or significant restriction of activity, e.g.: 
a. Signs and symptoms of ulnar paresthesias 
b. Cervicalgia 
c. Torticollis 
d. Acquired kyphosis 
 
Signs and symptoms of: 
1. intertriginous maceration or infection of the inframammary skin (e.g., hyperpigmentation, bleeding, 
chronic moisture, and evidence of skin breakdown), refractory to dermatologic measures, or 
2. shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by appropriate 
supporting garment AND 
 
Considerable attention has been given to the amount of breast tissue removed in differentiating between 
cosmetic and medically necessary reduction mammoplasty. To be considered a non-cosmetic procedure it is 
expected that at least a minimal amount of breast tissue will be removed. Yet, arbitrary minimum weight breast 
tissue removed criteria do not consistently reflect the consequences of mammary hypertrophy in individuals 
with a unique body habitus. There are wide variations in the range of height, weight, and associated breast size 
that cause symptoms. The amount of tissue that must be removed in order to relieve symptoms will vary and 
depend upon these variations. 
 
Limitations of Coverage: 
1. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit. 
2. Indications of Coverage must be met. 
 
Note: Reconstruction of the affected and the contralateral unaffected breast following a medically necessary 
mastectomy is considered a non-cosmetic procedure. National coverage provides for payment of breast 
reconstruction surgery following removal of a breast for any medical reason. 
 
You can find these rules in Local coverage Determination (LCD) Reduction Mammaplasty (L35001).
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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare & Medicaid Services, 
Internet Only Manual, Publication 100-02, 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 does not include 
D5820. You can find this information on pages 68-69 of the Plans 2023 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 pays for care in a skilled nursing facility (SNF) when all of the following four 
factors are met: 
 
1. The patient requires skilled nursing or skilled rehabilitation services; 
2. The patient requires these services on a daily basis; 
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and 
4. The services are reasonable and necessary for the treatment of the patients illness or injury or the services 
must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from 
getting worse.  
 
You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare & Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30.   
 
The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need 
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of 
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, 
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also 
custodial care services. You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
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.