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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
2. The services require the skills or direct supervision of a therapist,  
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. 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 220.2. 
 
The local Medicare Administrative Contractor has published its interpretation of the various outpatient therapy 
rules which provide more specific criteria for certain services. You can find this information in the Local 
Coverage Article (LCA) Billing and Coding: Medical Necessity of Therapy Services A52775. 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The 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 24 of the Plan's 2023 
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for
Medicare Services, Chapter I(A).

The rules say that all outpatient non-diagnostic services, other than ambulance and maintenance renal dialysis
services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the date of
a beneficiary's inpatient admission are deemed related to the admission and are billed with the inpatient stay.
You can find this in the Centers for Medicare & Medicaid Services, Medicare Claims Processing Manual
Chapter 3 - Inpatient Hospital Billing Table of Contents, Section 40. 3 - Outpatient Services Treated as
Inpatient Services

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 provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment. You can find
this rule at 42 CFR 424.5.

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, Section 3.3.2.1.

The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid
information for all these elements may be returned as un-processable. You can find this rule in the Medicare
Claims Processing Manual, Chapter 1, Section 80.3.1.

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 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 Sections 411.15 and 
411.15(o). 
The rules say that cervical traction devices (E0840, E0849, E0850, E0855 and E0860) are covered only if both 
of the following criteria are met: 
1. The beneficiary has a musculoskeletal or neurologic impairment requiring traction equipment; and 
2. The appropriate use of a home cervical traction device has been demonstrated to the beneficiary and the 
beneficiary tolerated the selected device. 
If criteria 1 and 2 are not met, cervical traction will be denied as not reasonable and necessary. 
 
Cervical traction devices described by code E0849 or E0855 are covered only when criteria 1 and 2 above and 
either criterion A, B or C below has been met: 
A. The beneficiary has a diagnosis of temporomandibular joint (TMJ) dysfunction; and has received 
treatment for the TMJ condition; or, 
B. The beneficiary has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that 
a chin halter is unable to be utilized; or, C. The treating practitioner orders and/or documents the medical necessity for greater than 20 pounds of 
cervical traction in the home setting. 
If the criteria for cervical traction are met but the additional criteria for E0849 or E0855 are not met, they will 
be denied as not reasonable and necessary. You can find this rule in Local Coverage Determination (LCD) 
Cervical Traction Devices L33823. 
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 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 
coverage for caps (crown) or partial crown called an onlay - made of metal, porcelain-ceramic, porcelain fused 
to metal, or titanium, made outside of the mouth and then placed into the mouth. Coverage is limited to one 
(D2542-2544, D2642-D2644, D2662-D2664, D2710-D2794, D6205-D6252, D6545-6615, D6710-D6783, 
D6790, D6791, D6792, D6794) per tooth. This benefit includes coverage every 84 months; requires extensive 
loss of tooth structure due to decay or fracture; requires at least 50% remaining bone support. You can find this 
information on page 9 of the Plan's 2023 Dental Benefits Details booklet.
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 genetic testing for the Factor V Leiden (FVL) variant in the F5 gene, the G20210G>A 
(G20210A) variant in the F2 gene, and the MTHFR gene which encodes the 5,10-methylenetetrahydrofolate 
reductase enzyme for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk 
assessment, are non-covered except for pregnant patients. You can find this information in the Centers for 
Medicare & Medicaid Services, Local Coverage Determination (LCD): MolDX: Genetic Testing for 
Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) (L36400). 
 
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 Advantage (MA) plans may specify brands and manufacturers as preferred and
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual
Chapter 4, 10.12.2.

The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions
associated with receipt or use of benefits. 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 Abbott and LifeScan products the Preferred brands. You can find this information on
page 19 of the Plan's 2023 Customer Handbook. The contract also states that non-preferred brands are not
covered. You can find this on page 36 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 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 Sections 411.15 and 
411.15(o).  
 
The rules say that supplier-produced records, even if signed by the treating practitioner, and attestation letters 
(e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment 
purposes. Templates and forms, including CMS CMNs, are subject to corroboration with information in the 
medical record. A prescription is not considered to be part of the medical record. Medical information intended 
to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated 
by information contained in the medical record. The beneficiarys medical record must contain sufficient 
documentation of the beneficiarys medical condition to substantiate the necessity for the type and quantity of 
items ordered and for the frequency of use or replacement (if applicable). The information should include the 
beneficiarys diagnosis and other pertinent information including, but not limited to, duration of the 
beneficiarys condition, clinical course (worsening or improvement), prognosis, nature and extent of functional 
limitations, other therapeutic interventions and results, past experience with related items, etc. 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 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 to be eligible for coverage of a continuous glucose monitor (CGM) and related supplies, the 
beneficiary must meet all of the following initial coverage criteria (1)-(5): 
 
1. The beneficiary has diabetes mellitus; and, 
2. The beneficiarys treating practitioner has concluded that the beneficiary (or beneficiarys caregiver) has  
    sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
3. The CGM is prescribed in accordance with its Food and Drug Administration (FDA) indications for use;  
     and, 
4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the  
    criteria below: 
     A. The beneficiary is insulin-treated; or, 
     B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the  
          following: 
          -     Recurrent level 2 hypoglycemic events that persist despite multiple attempts to adjust  
                medication(s) and/or modify the diabetes treatment plan; or, 
          -     A history of one level 3 hypoglycemic event characterized by altered mental and/or physical state  
                requiring third-party assistance for treatment of hypoglycemia 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare- 
     approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria  
     (1)-(4) above are met. You can find this information in the Local Coverage Determination (LCD): Glucose  
     Monitors (L33822). 
 
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 wheelchair options and accessories are covered under the Durable Medical Equipment 
benefit (Social Security Act 1861(s)(6)). In order for a beneficiary's equipment to be eligible for 
reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage 
Determination must be met. In addition, there are specific statutory payment policy requirements, discussed 
below, that also must be met. 
 
The term interface in the code narrative and definitions describes the mechanism for controlling the movement 
of a power wheelchair. Examples of interfaces include, but are not limited to, joystick, sip and puff, chin 
control, head control, etc.  The term controller describes the microprocessor and other related electronics that 
receive and interpret input from the joystick (or other drive control interface) and convert that input into power 
output which controls speed and direction. A high power wire harness connects the controller to the motor and 
gears. 
An expandable controller is capable of accommodating one or more of the following additional functions: 
Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, 
head control, etc.) 
Non-proportional input devices (e.g., sip and puff, head array, etc.) 
Operate 3 or more powered seating actuators through the drive control. 
A separate display (i.e., for alternate control devices) 
Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control) 
An attendant control 
 
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 state that definitive UDT is considered reasonable and necessary when the clinical information 
supplied supports the definitive testing as in: 
 
-Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT screen; 
-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; 
-Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients 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. 
 
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. To establish that a test is reasonable and necessary, the clinicians rationale for the definitive UDT 
and the tests ordered must be documented in the patients medical record. 
 
Physician-directed definitive profile testing is reasonable and necessary when ordered for a particular patient 
based upon historical use, clinical findings, and community trends. However, the same physician-defined 
profile is not reasonable and necessary for every patient in a physicians practice. Definitive UDT orders 
should be individualized based on clinical history and risk assessment, and must be documented in the medical 
record.  
You can find this information in Local Coverage Determination (LCD): Urine Drug Testing (L36668). 
 
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.