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 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 20% coinsurance for in-network home infusion therapy, including 
supplies. You can find this information on page 67 of the Plan's 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 state that Medicare covers pneumatic devices when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. You can find 
this in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-03, Medicare 
National Coverage Determinations Manual, Chapter 1, Section 280.6. 
 
The rules say that a pneumatic compression device (PCD) coded as E0650 or E0651 is covered for both 
primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when all of the 
following three requirements are met: 
1. The beneficiary has a diagnosis of lymphedema as defined above, and 
2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented 
presence of at least one of the following clinical findings:  
a) Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
b) Papillomatosis cutis lymphostatica, 
c) Deformity of elephantiasis, 
d) Skin breakdown with persisting lymphorrhea, 
e) Detailed measurements over time confirming the persistence of the lymphedema with a history 
evidencing a likely etiology, and 
3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to 
other clinical treatment over the course of a required four-week trial. (See below for trial guidelines.) 
A PCD coded as E0650 or E0651 used to treat lymphedema that does not meet all of the requirements above is 
not eligible for reimbursement. Claims will be denied as not reasonable and necessary. You can find the rules 
in Local Coverage Determination (LCD) Pneumatic Compression Devices L33829. 
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 repeat thermal facet joint radiofrequency ablation (RFA) at the same anatomic site is 
considered medically reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six (6) months 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. You can 
find this information in the Local Coverage Determination (LCD) L35936: Facet Joint Interventions for Pain 
Management. 
 
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 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 $345 copayment for inpatient hospital care. The enrollee must pay a 
$345 copayment per day, for days one to five, for each inpatient hospital stay. You can find this information on 
page(s) 75 to 76 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 when applying for a Medicare provider number, a clinical psychologist (CP) must submit to 
the carrier a signed Medicare provider/supplier enrollment form that indicates an agreement to the effect that, 
contingent upon the patient's consent, the CP will attempt to consult with the patient's attending or primary care 
physician in accordance with accepted professional ethical norms, taking into consideration patient 
confidentiality. The CP must document, in the patient's medical record, the date the patient consented or 
declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date 
and manner of notification to the physician. The only exception to the consultation requirement for CPs is in 
cases where the patient's primary care or attending physician refers the patient to the CP. You can find this 
information in the Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 15, Section 160 and 42 CFR Section 410.71. 
 
The rules say that a licensed clinical social worker (LCSW) must comply with the consultation requirements 
set forth at 410.71(f). You can find this information at 42 CFR 410.73(c). 
 
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 a pneumatic compression device (PCD) that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a 
preventative service or function are excluded from coverage under the Medicare DME benefit. Therefore, 
claims for E0676 will be statutorily denied as no Medicare benefit. You can find this rule in the Local 
Coverage Article for Pneumatic Compression Devices, A52488. 
 
The rules say that E0118, crutch substitute, lower leg platform, with or without wheels, each, will be denied not 
medically necessary. The determination is that there is insufficient published clinical literature demonstrating 
safety and effectiveness in the Medicare population to establish the medical necessity for these products. You 
can find this in the Durable Medical Equipment Medicare Advantage Contractor (DME MAC) Article entitled 
"PLATFORM CRUTCH CLARIFICATION". 
 
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 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 coinsurance and deductible are not applicable for preventive services. Rural Health Clinics 
(RHCs) must provide detailed Healthcare Common Procedure Coding System (HCPCS) coding for preventives 
services to ensure coinsurance and deductible are not applied. An additional line with the appropriate site of 
service revenue code in the 052X series should be submitted with the approved preventive service HCPCS 
code and the associated charges. For vaccines, RHCs do not report charges for influenza virus or pneumococcal 
pneumonia vaccines on the 71x or 73x/77x claims. Costs for the influenza virus or pneumococcal pneumonia 
vaccines are included in the cost report and no line items are billed. Neither co-insurance nor deductible apply 
to either of these vaccines. You can find this rule in the Centers for Medicare & Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 120. 
 
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 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 20% coinsurance for durable medical equipment (DME) and related 
supplies.  You can find this information on page(s) 53 to 54 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 chronic wounds are defined as wounds that do not respond to standard wound treatment for 
at least a 30-day period during organized comprehensive conservative therapy. 
 
A failed response is defined as an ulcer or skin deficit that has failed to respond to documented appropriate 
wound-care measures, has increased in size or depth, or has not changed in baseline size or depth and has no 
indication that improvement is likely (such as granulation, epithelialization or progress towards closing). 
 
Medicare covers application of Cellular and/or Tissue Based Products (CTPs) to ulcers or wounds with failed 
response that are: 
- Partial- or full-thickness ulcers, not involving tendon, muscle, joint capsule or exhibiting exposed bone 
or sinus tracts, with a clean granular base unless the CTP package label indicates the CTP is approved for use 
involving tendon, muscle, joint capsule or exhibiting exposed bone or sinus tracts, with a clean granular base ; 
- Skin deficit at least 1.0 cm2 in size; 
- Clean and free of necrotic debris or exudate; 
- Have adequate circulation/oxygenation to support tissue growth/wound healing as evidenced by 
physical examination (e.g., Ankle-Brachial Index (ABI) of no less than 0.60, toe pressure greater than 30mm 
Hg); 
- For diabetic foot ulcers, the patients medical record reflects a diagnosis of Type 1 or Type 2 Diabetes 
and also reflects medical management for this condition. 
 
Application of a CTP graft for lower extremity chronic wound (diabetic foot ulcers (DFU) and venous leg 
ulcers (VLU)) will be covered when the following conditions are met for the individual patient: 
- Presence of neuropathic ulcers and diabetic foot ulcer(s) having failed to respond to documented 
conservative wound-care measures of greater than four weeks, during which the patient is compliant with 
recommendations, and without evidence of underlying osteomyelitis or nidus of infection. 
- Presence of a venous stasis ulcer for at least 3 months but unresponsive to appropriate wound care for at 
least 30 days with documented compliance. 
- Presence of a full thickness skin loss ulcer that is the result of abscess, injury or trauma that has failed to 
respond to appropriate control of infection, foreign body, tumor resection, or other disease process for a period of 4 weeks or longer. 
 
You can find this information in the Local Coverage Determination (LCD): Wound Application of Cellular 
and/or Tissue Based Products (CTPs), Lower Extremities (L36690). 
 
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 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 $5 copayment for physician/practitioner services, including doctors 
office visits.  You can find this information on page(s) 87 to 88 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 a long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of 
stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).   
 
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need 
medical care. You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, 
Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2. 
 
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.
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 group 2 support surface is covered if the beneficiary meets at least one of the following 
three Criteria (1, 2 or 3): 
1. The beneficiary has multiple stage 2 pressure ulcers located on the trunk or pelvis (refer to the ICD-10 
code list section in the LCD-related Policy Article for applicable diagnoses) which have failed to 
improve over the past month, during which time the beneficiary has been on a comprehensive ulcer 
treatment program including each of the following: 
a. Use of an appropriate group 1 support surface, and 
b. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and 
c. Appropriate turning and positioning, and 
d. Appropriate wound care, and 
e. Appropriate management of moisture/incontinence, and 
f. Nutritional assessment and intervention consistent with the overall plan of care 
2. The beneficiary has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis (refer to the 
ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses), 
3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within 
the past 60 days, and has been on a group 2 or 3 support surface immediately prior to discharge from a 
hospital or nursing facility within the past 30 days. 
 
When the stated coverage criteria for a group 2 mattress or bed are not met, a claim will be denied as not 
reasonable and necessary. You can find this rule in the Local Coverage Determination for Group 2 Pressure 
Reducing Support Surfaces, L33642. 
 
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 & 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 the Plan has a Point-of-Service (POS) option for the enrollee to receive care from out-of-
network providers, including those in the Plans service area, for most services. The Plan will cover services 
from either network or out-of-network providers if the services are covered benefits and are medically 
necessary. You can find this information on page 33 of the Plan's 2023 Evidence of Coverage (EOC). 
 
The Plan contract also says that out-of-network routine chiropractic care under the POS benefit is not covered. 
You can find this information on page 52 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 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 $55 copayment for outpatient diagnostic tests/Medicare-
coveredstandard x-ray and ultrasound.  You can find this information on page(s) 74 of the Plan's 2023 
Evidence of Coverage.