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 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. (Note: Control of the power seating 
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) 
 
An expandable controller may also be able to operate one or more of the following: 
 
-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 this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective 
January 1, 2020. 
 
The rules say that code E2311 describes an electronic component that allows the patient to control two or more 
of the following motors from a single interface; e.g. proportional joystick, touchpad or nonproportional 
interface: 
 
-Power tilt 
-Power recline, with or without shear reduction 
-Combination power tilt and recline, with or without shear reduction 
-Power leg elevation with or without articulation, power center mount elevating foot platform with or without 
articulating properties 
 
You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective 
January 1, 2020. 
 
The rules say that a harness (E2313) describes all the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller (E2377). It also includes all the necessary fasteners, 
connectors, and mounting hardware. You can find this rule in Local Coverage Article: Power Mobility Devices 
- Policy Article (A52498) - Effective January 1, 2020. 
 
The rules say that the 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 Local Coverage Article: 
Wheelchair Options/Accessories - Policy Article (A52504) - 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 state that radiofrequency ablation (RFA) used for sacro-iliac (SI) joint pain is considered not 
medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. 
You can find this information in Local Coverage Determination (LCD): Pain Management (L33622). 
 
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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers 48 one-way transportation trips when each one-way trip does not exceed 50 miles. You can find this 
information on pages 113-114 of the Plans 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 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 there are specific diagnosis codes which support the medical necessity of CPT code 87086. 
Any diagnosis codes that are not listed do not support the medical necessity of CPT code 87086. You can find 
this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, 
National Coverage Determinations (NCD) Manual, Urine Culture, Bacterial (NCD 190.12), Coding Policy 
Manual and Change Report (ICD-10-CM). 
 
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 lymphocyte mitogen response assay measures the immune response of patient peripheral 
blood lymphocytes. It is a covered test under Medicare when it is medically necessary to assess lymphocytic 
function in diagnosed immunodeficiency diseases and to monitor immunotherapy. It is not covered when it is 
used to monitor the treatment of cancer, because its use for that purpose is experimental. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, 
National Coverage Determinations (NCD) Manual, Lymphocyte Mitogen Response Assays, NCD 190.8. 
 
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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that for each episode of covered catheterization, Medicare will cover one catheter (A4351) and an 
individual packet of lubricant (A4332). The usual maximum quantity of supplies for code A4351 is 200 per 
month. The -KX modifier indicates the requirements specified in the medical policy have been met. You can 
find this rule in the Local Coverage Determination for Urological Supplies, L33803. 
 
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 on page 64 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 417.414. 
 
The rules state that a commode is covered when the beneficiary is physically incapable of utilizing regular 
toilet facilities. This would occur in the following situations: 
1. The beneficiary is confined to a single room, or 
2. The beneficiary is confined to one level of the home environment and there is no toilet on that level, or 
3. The beneficiary is confined to the home and there are no toilet facilities in the home. 
 
A commode chair with detachable arms (E0165) is covered if the detachable arms feature is necessary to 
facilitate transferring the beneficiary or if the beneficiary has a body configuration that requires extra width. If 
coverage criteria are not met payment will be denied as not reasonable and necessary. You can find this 
information in Local Coverage Determination (LCD): Commodes (L33736). 
 
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 pay for an (IRF) admission when the services are reasonable and medically 
necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing 
rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of 
the therapies must be physical therapy or occupational therapy. The patient must need and be expected to 
actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive 
rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per 
week. The patient does not need to be expected to achieve complete independence in self-care nor be expected 
to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation 
physician. The physician must see the patient at least three days per week throughout the stay. You can find 
these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622. 
 
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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with 
BOTH the following: 
 
1.Inclusion criteria (ALL are required): 
   a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1  L5), 
based on symptom onset, and documented by advanced imaging (bone marrow edema on magnetic resonance 
imaging (MRI) or bone-scan/single-photon emission computerized tomography (SPECT)/computed 
tomography (CT) uptake). (1- 3,10,25,27)  
 
   b. Symptomatic (ONE): 
            i. Hospitalized with several pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain   
score   8) (4-7)  
            ii. Non-hospitalized with moderate to severe pain (NRS or VAS 5) despite optimal non-surgical  
management (NSM) (10) (ONE): 
              1. Worsening pain 
              2.Stable to improved pain (but NRS or VAS still 5) (with  2 of the following): 
                    A. Progression of vertebral body height loss 
                    B. > 25% vertebral body height reduction 
                    C. Kyphotic deformity Severe impact of VCF on daily functioning (Roland Morris Disability  
Questionnaire (RDQ) >17 
                    D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
>17 
   c. Continuum of care (10) (Both) 
               i. All patients presenting with VCF should be referred for evaluation of bone mineral density (BMD) 
and osteoporosis education for subsequent treatment as indicated. 
              ii. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment 
program.  
 
2. Exclusion criteria (2,5,8-10) (Can have NONE of the following): 
        a. Absolute contraindication 
                i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
               ii. Osteomyelitis, discitis, active systemic or surgical site infection 
              iii. Pregnancy         b. Relative contraindication 
              I. Greater than three vertebral fractures per procedure 
             II. Allergy to bone cement or opacification agents 
            III. Uncorrected coagulopathy 
            IV. Spinal instability 
            V. Myelopathy from the fracture 
           VI. Neurologic deficit 
           VII. Neural impingement 
          VIII. Fracture retropulsion/canal compromise 
 
You can find this information at Local Coverage Determination- Percutaneous Vertebral Augmentation (PVA) 
for Osteoporotic Vertebral Compression Fracture (VCF) (L33569). 
 
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 Item 24J on the CMS-1500 form must be billed with the rendering provider's NPI number. 
You can find this rule in the Center for Medicare Services (CMS) Publication 100-04, Claims Processing 
Manual, Chapter 26, Section 10.4. 
 
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 Medicare plan may restrict members 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 a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
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 in Chapter 3 on page 38 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 state that a flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 
or above. You can find this information in Local Coverage Determination (LCD): Lower Limb Prosthesis 
(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. 
 
The rules say that walk-in tubs are not covered because they are considered hygienic equipment that is not 
primarily medical in nature. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.1. 
 
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 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 the 
complete maxillary and mandibular denture but is limited to one procedure every five years. You can find this 
information on page 86 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 state that if an ambulance is called/dispatched but the beneficiary dies on the scene prior to the arrival 
of the ambulance (dead on arrival or DOA): payment may be made for basic life support (BLS) service is a 
ground vehicle is dispatched or at the fixed wing or rotary wing base rate, as applicable, if an air ambulance is 
dispatched. Neither mileage nor a rural adjustment would be paid. Providers or supplies report the A0428 BLS 
non-emergency or A0429 emergency transport code if an emergency response and modifier -QL for ground 
vehicles. You can find this rule in Medicare Claims Processing Manual Chapter 15, Section 30.2(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.