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. 
 
  
  Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(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. The Plan 
contract also says that you have a $175 allowance for supplemental eyewear every year. Eyeglasses and frames 
or contact lenses up to the plan allowance amount. The Plan specified allowance may be applied to one set of 
the members choice of eyewear, to include the eyeglass frame/lenses/lens options combination or contact 
lenses (to include related professional fees) in lieu of eyeglasses. You can find this information on pages 62-63 
of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that when there is a clinical concern for Clostridium difficile colitis, Medicare will cover up to 11 
targets if Clostridium difficile is one of the organisms tested for. You can find this rule in the Local Coverage 
Determination (LCD) - Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification 
Tests (NAATs) (L37766) - Effective August 5, 2021 (Retired 4/16/22). 
 
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 fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, 
L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is 
covered for beneficiaries whose functional level is 3 or above. 
 
L5859 (addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable 
flexion/extension assist control, includes any type motor(s)) is only covered when the beneficiary meets all of 
the criteria below: 
1. Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee 
2. K3 functional level only 
3. Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or 
quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled knee 
alone 
4. Is able to make use of a product that requires daily charging 
5. Is able to understand and respond to error alerts and alarms indicating problems with the function of the 
unit 
If these coverage criteria for the knee component are not met, L5859 will be denied as not reasonable and 
necessary. You can find this rule in Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.   
The Plan contract says that the only covered chiropractic service is manual manipulation of the spine to correct 
a subluxation. You can find this information on page 66 of the Plans 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that once a beneficiary is admitted to a hospital, critical access hospital (CAH), or skilled 
nursing facility (SNF), it may be necessary to transport the beneficiary to another hospital or other site 
temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. 
This movement of the patient is considered "patient transportation" and is covered as an inpatient hospital or 
CAH service and as a SNF service when the SNF is furnishing it as a covered SNF service and payment is 
made under Part A for that service. (If the beneficiary is a resident of SNF and must be transported by 
ambulance to receive dialysis or certain other high-end outpatient hospital services, the ambulance transport 
may be separately payable under Part B. Also, if the beneficiary is a SNF resident and not in a Part A covered 
stay and must be transported by ambulance to the nearest supplier of medically necessary services not available 
at the SNF, the ambulance transport, including the return trip, may be covered under Part B.) Because the 
service is covered and payable as a beneficiary transportation service under Part A, the service cannot be 
classified and paid for as an ambulance service under Part B. This includes intra-campus transfers between 
different departments of the same hospital, even where the departments are located in separate buildings. Such 
intra-campus transfers are not separately payable under the Part B ambulance benefit. Such costs are accounted 
for in the same manner as the costs of such a transfer within a single building. You can find this rule at 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 10  Ambulance Services, Section 10.3.3. 
 
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.
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 elastic stockings are not covered because they are non-reusable supply items. Elastic 
stockings are not durable medical equipment. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, 
Chapter 1, Section 280.1.   
  
The rules say that gradient pressure garments may be covered when used as dressings following burn injuries. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 270.5.  
 
The rules also say that compression bandages, multi-layer systems, and gradient compression wraps are 
covered only when they are used as dressings over a qualifying wound. However, gradient compression 
stockings described by codes A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, A6541, 
A6544, and A6549 are noncovered because they do not meet the statutory definition of a dressing. You can 
find these rules in the Local Coverage Determination (LCD): Surgical Dressings L33831 and Local Coverage 
Article: Surgical Dressings-Policy Article A54563. 
 
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
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 scratch resistant coating (V2760), mirror coating (V2761), polarization (V2762), deluxe 
lens feature (V2702) and progressive lenses (V2781) will be denied as noncovered. Progressive lens (V2781) is 
a multifocal lens that gradually changes in lens power from the top to the bottom of the lens, eliminating the 
line(s) that would otherwise be seen in a bifocal or trifocal lens. 
 
When billing claims for progressive lenses, use the appropriate code for the standard bifocal (V2200, V2201, 
V2202, V2203, V2204, V2205, V2206, V2207, V2208, V2209, V2210, V2211, V2212, V2213, V2214, 
V2215, V2218, V2219, V2220, V2221, V2299) or trifocal (V2300, V2301, V2302, V2303, V2304, V2305, 
V2306, V2307, V2308, V2309, V2310, V2311, V2312, V2313, V2314, V2315, V2318, V2319, V2320, 
V2321, V2399) lenses and a second line item using code V2781 for the difference between the charge for the 
progressive lens and the standard lens. 
 
You can find this information in the Local Coverage Article (LCA): Refractive Lenses - Policy Article 
(A52499). 
 
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 three on pages 39 to 
40 of the Plan's 2022 Member Handbook.
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 peripheral nerve blocks will be considered medically reasonable and necessary for normally 
temporary conditions such as the following diagnostic and therapeutic purposes: 
1. When the patients pain appears to be due to a classic mononeuritis but the neuro-diagnostic studies have 
failed to provide a structural explanation, selective peripheral nerve blockade can usually clarify the situation 
but this is only for diagnostic purposes and not long term treatment. 
2. When peripheral nerve injuries/entrapment or other extremity trauma leads to complex regional pain 
syndrome. 
3. When selective peripheral nerve blockade is used diagnostically in those cases in which the clinical picture is 
unclear but this is only for diagnostic purposes and not long term treatment. 
4. When an occipital nerve block is used to confirm the clinical impression of the presence of occipital 
neuralgia. 
5. When the suprascapular nerve block is used to confirm the diagnosis of suspected entrapment of the nerve.  
6. When the trigeminal nerve is blocked centrally at the trigeminal ganglion, or along one of the three divisions 
or at one of the many peripheral terminal branches (i.e., supraorbital nerve). 
7. Nerve blocks as preemptive analgesia 
   A. When a single injection peripheral nerve block provides post-surgical pain control 
      1. during the transition to oral analgesics 
      2. in those procedures which cause severe pain normally uncontrolled by oral analgesics 
      3. in cases otherwise requiring control with intravenous or parenteral narcotics. 
      4. in cases where the patient cannot tolerate treatment with narcotics due to allergy or side effects, etc. 
   B. When a continuous peripheral nerve block provides the same as above, and furthermore may provide 
extended (i.e. one to five or more days) relief as a result of chronic administration of anesthetic. 
Additional management using medications, behavioral therapy, and physical therapy should be used (when 
appropriate) in conjunction with peripheral nerve block. You can find this information in the Local Coverage 
Determination (LCD): Peripheral Nerve Blocks (L36850). 
 
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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(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. The Plan 
contract also says that supplemental vision services must be received from a participating vision care provider. 
You can find this information on page 89 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 to report a Molecular Diagnostic Test service, please submit the following claim 
information: 
 
   - Select appropriate CPT code 
   - Enter 1 unit of service (UOS) 
   - Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for 
the following Part B claim field/types:\ 
       -- Loop 2400 or SV101-7 for the 5010A1 837P 
       -- Item 19 for paper claim 
   - Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for 
the following Part A claim field/types: 
       -- Line SV202-7 for 837I electronic claim 
       -- Block 80 for the UB04 claim form 
 
You can find this rule in the Local Coverage Article (LCA) for Billing and Coding: MolDX: Molecular 
Diagnostic Tests (MDT) (A57527). 
 
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 pages 3-3 to 3-9 of the Plan's 
2021 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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. You can find this rule in the Local 
Coverage Determination (LCD): MolDX: Molecular Diagnostic Tests (MDT) (L36021). 
 
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 claims for E0675 will be denied as not reasonable and necessary. PCD related accessories 
(E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673) are 
eligible for reimbursement only when the appropriate, related base PCDs (E0650, E0651, E0652, E0675) meets 
the applicable coverage criteria for that type of PCD. If the base PCD is not covered, related accessories are not 
eligible for reimbursement. Claims for related items will be denied as not reasonable and necessary. You can 
find this rule in the Local Coverage Determination (LCD) for 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.