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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.  
The Plan contract says that the only covered chiropractic service is manual manipulation of the spine to correct 
a subluxation. You can find this information on page 4-13 of the Plans 2022 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 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 and 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 
preventive and comprehensive services. Scaling in presence of generalized moderate or severe gingival 
inflammation (D4346) is excluded from this benefit. You can find this information on pages 4-65 to 4-77 of the 
Plans 2022 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 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 A/B Medicare Administrative Contractors (MACs) (B) may not pay for the technical 
component (TC) of radiology services furnished to hospital patients. Payment for physicians radiological 
services to the hospital, e.g., administrative or supervisory services, and for provider services needed to 
produce the radiology service, is made by the A/B MAC (A) to the hospital as a provider service. A/B MACs 
(A) include the TC of radiology services for hospital inpatients, except Critical Access Hospitals (CAHs), in 
the prospective payment system (PPS) payment to hospitals. Hospital bundling rules exclude payment to 
suppliers of the TC of a radiology service for beneficiaries in a hospital inpatient stay. The TC of radiology and 
other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment 
System (OPPS) to the hospital. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual Publication 100-04, Medicare Claims Processing Manual Chapter 13, Section 20.2.1. 
 
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 a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height 
adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. 
Side rails (E0305, E0310) or safety enclosures (E0316) are covered when they are required by the beneficiary's 
condition and they are an integral part of, or an accessory to, a covered hospital bed. You can find this 
information in Medicare's Local Coverage Determination (LCD): Hospital Beds And Accessories (L33820). 
 
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 codes E2310 and E2311 describe the electronic components that allow the beneficiary to 
control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or 
non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power 
leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the 
beneficiary to select the motor that is being controlled and an indicator feature to visually show which function 
has been selected. When the wheelchair drive function has been selected, the indicator feature may also show 
the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate 
display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for 
fixed mounting hardware for the control box and for the display box (if present). 
 
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the 
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting 
hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and 
with complete replacement of the expandable controller. Code K0108 must not be used for any component or 
feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete 
expandable controller is included in the allowance for codes E2377/E2376 plus E2313. However, if individual 
components of the harness are replaced, code K0108 should be used. 
 
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. The interfaces described by codes E2312, E2321, E2322, E2325, E2327, E2328, E2329, E2330, E2373, E2374, E2375, E2376, E2377 must have programmable control parameters for speed 
adjustment, tremor dampening, acceleration control, and braking. 
 
You can find these rules 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. 
 
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 non-invasive peripheral arterial examinations, performed to establish the level and/or degree of
arterial occlusive disease, are medically necessary if (1) clinical evidence of limb ischemia is present and (2)
the patient is a candidate for invasive/surgical therapeutic interventions. Acute ischemia is often characterized
by the sudden onset of severe pain, coldness, numbness and pallor of the extremity. Chronic ischemia can be
manifested by intermittent claudication, pain at rest, diminished pulse, ulceration, and gangrene.
A routine history and physical examination, which includes ankle/brachial indices (ABIs), can readily
document the presence or absence of ischemic disease in the majority of cases. An ABI is not a reimbursable
procedure by itself; rather, ABI may be reimbursed when derived from a more comprehensive procedure which
includes a permanent chart copy of the measured pressures and waveforms in the examined vessels.
An ABI should be abnormal, e.g., <0.9 at rest, and accompanied by other appropriate indications before
proceeding to additional studies.
You can find these rules in Local Coverage Determination (LCD) Non-Invasive Vascular Studies L33627.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that a lower limb prosthesis is covered when the beneficiary:
1. Will reach or maintain a defined functional state within a reasonable period of time; and
2. Is motivated to ambulate.
A determination of the medical necessity for certain components/additions to the prosthesis is based on the
beneficiary's potential functional abilities. Potential functional ability is based on the reasonable expectations
of the prosthetist, and treating practitioner, considering factors including, but not limited to:
1. The beneficiary's past history (including prior prosthetic use if applicable); and
2. The beneficiary's current condition including the status of the residual limb and the nature of other medical
problems; and
3. The beneficiary's desire to ambulate.
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.
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. 
 
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 physical exams for the following reasons: employment, licensing, insurance coverage 
(e.g., pilot license, commercial driver license, etc.) are not covered under any condition. You can find this 
information on page 108 of the Plan's 2022 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that your deductible is $750. This is the amount you have to pay out-of-pocket before the Plan 
will pay the Plan's share for your covered medical services. Until you have paid the deductible amount, you 
must pay the full cost for most of your covered services. You can find this information in Chapter 4 on page 55 
of the Plan's 2022 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 if a supplier utilizes a shipping service or mail order, suppliers have two options for the date 
of service (DOS) to use on the claim: 
1. Suppliers may use the shipping date as the DOS. The shipping date is defined as the date the  
delivery/shipping service label is created or the date the item is retrieved by the shipping service for  
delivery. However, such dates should not demonstrate significant variation. 
2. Suppliers may use the date of delivery as the DOS on the claim. 
 
You can find these rules in Local Coverage Article (LCA) Standard Documentation Requirements for All 
Claims Submitted to DME MACs (A55426). 
 
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 following HCPCS codes are to be billed for Cardiovascular Disease Screening: 80061 - Lipid Panel 82465 - Cholesterol, serum or whole blood, total 83718 - Lipoprotein, direct measurement, high density cholesterol 84478 - Triglycerides Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services, 100.1
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 in Chapter 4 of the Plans 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 additional expenses for "deluxe" features, or items that are rented or purchased for aesthetic reasons or added convenience, do not meet the reasonableness test. You can find this in the Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. 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, Section 110.1.
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 state that A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related 
electronics with or without variable speed programmability which allows the legrest to be raised and lowered 
independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not 
be integrated with the power tilt and/or recline control(s). It includes either articulating or non-articulating 
legrests. The unit of service of code E1010 is a pair. The unit of service for code E1012 is each. 
 
HCPCS code E1012 includes all components of the leg rest, including fixed angle footplates and foot 
platforms. Adjustable angle footplates coded K0040 (ADJUSTABLE ANGLE FOOTPLATE, EACH) are 
separately payable when provided with leg rests coded as E1012. 
 
A remote joystick is one in which the joystick is in one box that is typically mounted on the arm of the 
wheelchair and the controller electronics are located in a different box that is typically located under the seat of 
the wheelchair. The joystick is connected to the controller through a low power wire harness. A remote joystick 
may be used for either hand control, chin control, or attendant control. 
 
Code E2323 includes prefabricated joystick handles that have shapes other than a straight stick - e.g., U shape 
or T shape - or that have some other nonstandard feature - e.g., flexible shaft.  
You can find this rule in the Local Coverage Determination (LCD) for Wheelchair Options/Accessories, 
L33792. 
 
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 the Local Coverage Article for Wheelchair Options/Accessories - Policy Article, 
A52504. 
 
The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). 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(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.
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 Codes A4230 (INFUSION SET FOR EXTERNAL INSULIN PUMP, NON-NEEDLE 
CANNULAS TYPE) and A4231 (INFUSION SET FOR EXTERNAL INSULIN PUMP, NEEDLE TYPE) are 
not valid for claim submission to the DME MAC because they are included in code A4224. 
 
Code K0552 describes a syringe-type reservoir that is used with the K0455 pump when it is used to administer 
epoprostenol/treprostinil, or with an E0779 pump used to administer subcutaneous immune globulin. The 
reservoir may be either glass or plastic and includes the needle for drawing up the drug. This code does not 
include the drug for use in the reservoir. Code A4232 is invalid for submission to Medicare and should not be 
used for this purpose. You can find these rules in the Local Coverage Article (LCA) External Infusion Pumps - 
Policy Article A52507. 
 
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 effective for services performed on or after March 16, 2018, the Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally when certain requirements are met. This coverage is provided for testing that has Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic and an FDA-approved or -cleared indication for use in that patient's cancer. You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-03, National Coverage Determinations Manual, Section 90.2.
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.