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 protective outer surface covering systems (L5962, L5964, and L5966) are specialized 
covers intended to be worn over an existing prosthesis. They are used by a beneficiary who has special needs 
for protection against unusually harsh environmental situations where it is necessary to protect the lower limb 
prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707. They are not for 
cosmetic or convenience reasons, or for everyday usage in a typical environment. Protective outer surface 
coverings are different from the covering that is already reimbursed as part of L5704, L5705, L5706, 
and L5707. 
 
You can find this information in the Local Coverage Article Lower Limb Prostheses - Policy Article A52496. 
 
When an initial below knee prosthesis (L5500) or a preparatory below knee prosthesis (L5510, L5520,L5530, 
L5540) is provided, prosthetic substitutions and/or additions of procedures and components are covered in 
accordance with the functional level assessment except for codes L5629, L5638, L5639, L5646, L5647, L5704, 
L5785, L5962, and L5980 which will be denied as not reasonable and necessary. When a below knee 
preparatory prefabricated prosthesis (L5535) is provided, prosthetic substitutions and/or additions of 
procedures are covered in accordance with the functional level assessment except for codes L5620, L5629, 
L5645, L5646, L5670, L5676, L5704, and L5962 which will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
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. 
 
 
 
 
  
  Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise 
reasonable and necessary for the patient. Food and Drug Administration (FDA) approved drugs used for 
indications other than what is indicated on the official label may be covered if the use is determined to be 
medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or 
accepted standards of medical practice. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 
50.4.1 and 50.4.2. 
 
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 the implantation of a phrenic nerve stimulator is covered for selected patients with partial or 
complete respiratory insufficiency. You can find this rule in the Center for Medicare Services (CMS) 
Publication 100-03, Medicare National Coverage Determination (NCD) Manual, Section 160.19. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 and Medicaid Services, Internet Only 
Manual, 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. The Plan 
contract says services not covered by Medicare: custodial care. (Care that helps with activities of daily living 
that does not require professional skills or training e.g. bathing and dressing.) Custodial care is personal care 
that does not require the continuing attention of trained medical or paramedical personnel, such as care that 
helps you with activities of daily living, such as bathing or dressing. You can find this information in Chapter 4 
on page 107 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 pay for durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. 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. You can find these rules in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(C). 
 
The rules state that to repair means to fix or mend and to put the equipment back in good condition after  
damage or wear. Repairs to equipment which a beneficiary owns are covered when necessary to make the  
equipment serviceable. If the expense for repairs exceeds the estimated expense of purchasing or renting  
another item of equipment for the remaining period of medical need, no payment can be made for the amount  
of the excess. Replacement refers to the provision of an identical or nearly identical item. Equipment which the  
beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable  
wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot be  
identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful  
lifetime of the equipment. In the absence of program instructions, Medicare contractors may determine the  
reasonable useful lifetime of equipment, but in no case can it be less than 5 years. Replacement due to wear is  
not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime,  
Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary  
equipment owned by the beneficiary. You can find this rule in the Centers for Medicare and Medicaid Services,  
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2. 
 
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 Centers for  
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, 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 that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 53 of the 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. 
 
A second diagnostic facet procedure is considered medically reasonable and necessary to confirm validity of 
the initial diagnostic facet procedure when administered at the same level. The second diagnostic procedure 
may only be performed a minimum of 2 weeks after the initial diagnostic procedure.
 
1. An initial diagnostic facet joint procedure will be considered medically reasonable and 
necessary when the patient meets the criteria outlined under the indications for facet joint 
interventions. 
2. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and 
necessary in patients who meet BOTH of the following criteria: 
 The patient meets the criteria for the first diagnostic procedure; AND 
 After the first diagnostic facet joint procedure, there must be a consistent positive 
response of at least 80% relief of primary (index) pain (with the duration of relief being 
consistent with the agent used). 
You can find this rule in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L34892). 
 
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 therapeutic facet joint procedures are considered medically reasonable and necessary for 
patients who meet ALL of the following criteria: 
 
A. The patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with each 
one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of relief being 
consistent with the agent used) AND 
B. Subsequent therapeutic facet joint procedures at the same anatomic site results in at least consistent 50% 
pain relief for at least three (3) months from the prior therapeutic procedure or at least 50% consistent 
improvement in the ability to perform previously painful movements and ADLs as compared to baseline 
measurement using the same scale; AND 
C. Documentation of why the patient is not a candidate for radiofrequency ablation (such as established spinal 
pseudarthrosis, implanted electrical device) 
 
You can find this information in Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L38765). 
 
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 cardiovascular nuclear imaging is indicated for diagnostic evaluation of patients with chest 
pain and uninterpretable or equivocal electrocardiogram changes caused by drugs, bundle branch block, or left 
ventricular hypertrophy. Myocardial perfusion studies performed based on the presence of risk factors in the 
absence of cardiac symptoms, cardiac abnormalities on physical examination, or abnormalities on cardiac 
testing (e.g., electrocardiographic tests, echocardiography, etc.) will be considered screening and denied as not 
covered by Medicare. You can find this information in the Local Coverage Determination (LCD) for 
Cardiovascular Nuclear Medicine (L33560). 
 
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 below is a list of individuals and entities that frequently attempt to enroll in Medicare but are 
not eligible to do so. (This list is not all-inclusive, however.). If the contractor receives an enrollment 
application from any of these individuals or entities, the contractor shall deny the application -- with the 
exception of entities eligible to enroll using the Form CMS-20134, which is specific to the furnishing of MDPP 
services. An assisted living facility, for example, that also provides the DPP and is eligible to enroll as an 
MDPP supplier may enroll through the CMS-20134; however, this enrollment only pertains to the rendering of 
MDPP services: Acupuncturist. You can find this information in the Medicare Program Integrity Manual; 
Chapter 10  Medicare Enrollment; 10.2.8 - Providers/Suppliers Not Eligible to Enroll. 
 
he rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, 30.2.2. 
 
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 enteral nutrition is covered for a beneficiary who requires feedings via an enteral access 
device to provide sufficient nutrients to maintain weight and strength commensurate with the beneficiary's 
overall health status and has a permanent: 
 
A. full or partial non-function or disease of the structures that normally permit food to reach the small bowel; 
OR, 
B. disease that impairs digestion and/or absorption of an oral diet, directly or indirectly, by the small bowel. 
You can find this rule in the Local Coverage Determination (LCD) for Enteral Nutrition, L38955. 
 
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 an electronic interface used to control lights or other electrical devices is non-covered 
because it is not primarily medical in nature. 
 
A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are 
not primarily medical in nature. 
 
For power wheelchairs which are capable of being upgraded to an expandable controller (K0835, K0836, 
K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, 
K0854, K0855, K0856 K0857, K0858, K0859, K0860, K0861 K0862, K0863, K0864, K0868, K0869, K0870, 
K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891), E2377 is used if an 
expandable controller is provided at the time of initial issue. Code E2376 is used with complete replacement of 
an expandable controller. 
 
Code E2351 describes an electronic interface used with a speech generating device. An electronic interface that 
is used to allow lights or other electrical devices to be operated using the power wheelchair control interface 
must be billed with code A9270 (non-covered item). 
 
You can find this information 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 say that a CTA is indicated for coverage for the following conditions: 
 
    a. Patient presenting with chest pain syndrome. 
    b. To facilitate the management decision of a patient with an equivocal stress test. 
    c. When the recurrence of symptoms in patients with known coronary artery disease may be related to 
progression/exacerbation of underlying disease. 
    d. When patients with prior bypass surgery or intracoronary artery stent placement present with chest pain or 
dyspnea. 
    e. Suspected congenital anomalies of the coronary circulation. 
    f. The assessment of coronary or pulmonary venous anatomy. 
    g. The patient undergoing non-coronary artery cardiac surgery. 
    h. The test may be medically necessary in patients presenting to the emergency room with complaints 
consistent with cardiac ischemia, but without diagnostic electrocardiography (ECG) or enzymes. 
    i. The test may be considered medically necessary in patients status post revascularization procedures who 
present with recurrent symptoms not clearly identifiable as ischemic. 
 
The rules say that these tests are never covered for screening, i.e., in the absence of signs, symptoms or disease. 
 
You can find this information in the Local Coverage Determination (LCD) for Cardiac Computed Tomography 
(CCT) and Coronary Computed Tomography Angiography (CCTA) (L33559). 
 
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 home blood pressure monitors (A4660) and home blood pressure cuffs (A4663) are 
considered home dialysis supplies. These items are only covered for patients on home dialysis and they are not 
payable to Durable Medical Equipment suppliers. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Transmittal 
250, Change Request 11021, Attachment B, dated November 14, 2018. 
 
The rules also say that ambulatory blood pressure monitoring (ABPM) may be covered in some instances. This 
service involves the use of a non-invasive device which is used to measure blood pressure in 24-hour cycles. 
These 24-hour measurements are stored in the device and are later interpreted by the physician. ABPM is only 
covered for those patients with suspected white coat hypertension. Suspected white coat hypertension is 
defined as 
 
1. Office blood pressure greater than140 over 90 mm Hg on at least three separate clinic/office visits with two 
separate measurements made at each visit; 
2. At least two documented blood pressure measurements taken outside the office which are less than 140 over 
90 mm Hg; and 
3. No evidence of end-organ damage. 
 
You can find this information at National Coverage Determination (NCD) for Ambulatory Blood Pressure 
Monitoring (20.19). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.