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 disposable drug delivery systems, including elastomeric infusion pumps (A4305, A4306, 
A9274) are non-covered devices because they do not meet the Medicare definition of durable medical 
equipment. Drugs and supplies used with disposable drug delivery systems are also non-covered items. You 
can find this rule in the Local Coverage Article for 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 an ultrasonic osteogenesis stimulator (E0760) is covered only if all of the following criteria 
are met: 
 
Nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to starting 
treatment with the osteogenesis stimulator, separated by a minimum of 90 days. Each radiograph set must 
include multiple views of the fracture site accompanied by a written interpretation by a treating practitioner 
stating that there has been no clinically significant evidence of fracture healing between the two sets of 
radiographs; and 
The fracture is not of the skull or vertebrae; and 
The fracture is not tumor related. 
An ultrasonic osteogenesis stimulator will be denied as not medically necessary if any of the criteria above are 
not met. 
 
Use of an ultrasonic osteogenesis stimulator for the treatment of a fresh fracture or delayed union will be 
denied as not medically necessary. 
 
Ultrasound conductive coupling gel is covered and separately payable if an ultrasonic osteogenesis stimulator 
is covered. 
 
An ultrasonic osteogenesis stimulator will be denied as not medically necessary if it is used with other 
noninvasive osteogenesis stimulators. 
 
You can find this information in the Local Coverage Determination (LCD) Osteogenesis Stimulators L33796. 
 
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 a determination of the medical necessity for certain components/additions to the prosthesis 
is based on the beneficiarys 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: 
 
The beneficiarys past history (including prior prosthetic use if applicable); and 
 
The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
 
The beneficiarys desire to ambulate. 
 
Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels: 
 
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a 
prosthesis does not enhance their quality of life or mobility. 
 
Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed 
cadence. Typical of the limited and unlimited household ambulator. 
 
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers 
such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
 
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator 
who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise 
activity that demands prosthetic utilization beyond simple locomotion. 
 
An axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or 
above. 
 
A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot 
with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot 
system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. 
 
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. 
 
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 32 of the Plan's 2023 
Evidence of Coverage (EOC). Although the Plan offers a Point-of-Service benefit for coverage of out-of-
network services, this benefit only applies to dental services.
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). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
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 enrollees must pay a 40% coinsurance for out-of-network Medicare Part B 
prescription drugs and drugs administered by a health care professional. You can find this information on page 
93 of the Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $10 copay for x-rays and a 40% coinsurance for out-of-
network lab services. You can find this information on pages 95-96 of the Plans 2023 EOC.  
 
The Plan contract says that enrollees must pay a $285 copay for each Medicare-covered visit to an outpatient 
hospital facility for both in and out-of-network outpatient surgery services. You can find this information on 
page 100 of the Plans 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 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 one D0220 every 
calendar year. This benefit also includes a $2,500 annual dental allowance amount for covered dental benefits. 
This benefit does not include D0364, D0460, or D2955. You can find this information on pages 74-77 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 coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
  
  practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that a determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiarys 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 beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
3. The beneficiarys desire to ambulate. 
You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
The rules say that a level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical 
of the community ambulator who has the ability to traverse most environmental barriers and may have 
vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. You 
can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
The rules say that a flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 
or above. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
The rules say that an axial rotation unit (L5986) is covered for beneficiaries whose functional level is 3 or 
above. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
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 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 and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
The rules say that Certificates of Medical Necessity (CMN), DME Information Forms (DIF), supplier prepared 
statements and physician attestations by themselves do NOT provide sufficient documentation of medical 
necessity, even if signed by the signed by the ordering physician. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1.1(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 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 plan may restrict enrollees to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the plan must 
arrange for specialty care outside of the plan provider network when network providers are unavailable or 
inadequate to meet an enrollees medical needs. You can find this rule at 42 CFR Section 422.112. 
 
The rules say that plans must ensure continuity of care for enrollees. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 4, Section 
110.6. 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the plan ensures that all covered 
services are available and accessible under the plan. The plan 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. Plans 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 health plan including nursing home and community-based services, and behavioral health 
services. 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 Plans 2023 
Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
Please note, the Local Coverage Determination, L36707, the Plan used in their decision to deny services is not 
binding in this case. The rule does not have jurisdiction where the services were provided. 
 
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 definitive urine drug testing (UDT) may be reasonable and necessary based on patient 
specific indications, including historical use, medication response, and clinical assessment, when accurate 
results are necessary to make clinical decisions. The clinicians rationale for the definitive UDT and the tests 
ordered must be documented in the patients medical record. Blanket orders and routine standing orders for all 
patients in a physicians practice are not reasonable and necessary. You can find this rule in the Local Coverage 
Determination for Controlled Substance Monitoring and Drugs of Abuse 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.
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 coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that a determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiarys 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 beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
3. The beneficiarys desire to ambulate. 
You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
The rules say that a level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical 
of the community ambulator who has the ability to traverse most environmental barriers and may have 
vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. You 
can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
The rules say that a flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 
or above. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
The rules say that a fluid, pneumatic, or electronic/microprocessor knee (L5828, L5848, L5856) is covered for 
beneficiaries whose functional level is 3 or above. You can find this rule in Local Coverage Determination 
(LCD): Lower Limb Prostheses (L33787) - Effective January 1, 2020. 
 
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 a Medicare plan may restrict enrollees to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the plan must 
arrange for specialty care outside of the plan provider network when network providers are unavailable or 
inadequate to meet an enrollees medical needs. You can find this rule at 42 CFR Section 422.112. 
 
The rules say that plans must ensure continuity of care for enrollees. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 4, Section 
110.6. 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the plan ensures that all covered 
services are available and accessible under the plan. The plan 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. Plans 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 health plan including nursing home and community-based services, and behavioral health 
services. 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 13 of the Plans 2023 
Evidence of Coverage.