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 Medicare will pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). 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(D). 
 
The rules say that Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
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 280.3(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 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 and 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 E0652, is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen when all of the following are met: 
 
    -The beneficiary has lymphedema of an extremity as defined above 
    -The coverage criteria for an E0650 or E0651 are met 
    -The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the  
      limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to  
      improve with a four-week trial. (See below for trial guidelines.) 
 
A PCD coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen that does not 
meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable 
and necessary. 
 
A PCD coded as E0652 used to treat lymphedema not extending onto the chest, trunk and/or abdomen or CVI 
is not eligible for reimbursement. Claims will be denied as not reasonable and necessary. 
PCD related accessories (E0671) are eligible for reimbursement only when the appropriate, related base PCDs 
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 information in the 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 based on information in the scientific literature, intra-operative testing may be considered 
reasonable and necessary for the following: 
 
1. Surgery of the aortic arch, its branch vessels, or thoracic aorta, including carotid artery surgery, when there is 
risk of cerebral or spinal cord ischemia 
2. Resection of epileptogenic brain tissue or tumor 
3. Resection of brain tissue close to the primary motor cortex and requiring brain mapping 
4. Protection of cranial nerves: 
 
-Resection of tumors involving the cranial nerves 
-Cavernous sinus tumors 
-Microvascular decompression of cranial nerves 
-Skull base surgery in the vicinity of the cranial nerves and surgeries of the foramen magnum 
-Oval or round window graft 
 
5. Endolymphatic shunt for Meniere's disease 
6. Vestibular section for vertigo 
7. Correction of scoliosis or deformity of spinal cord involving traction of the cord 
8. Protection of spinal cord where work is performed in close proximity to cord as in the placement or removal 
of old hardware or where there have been numerous interventions 
9. Spinal instrumentation requiring pedicle screws or distraction 
10. Decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or claudication 
where function of spinal cord or spinal nerves is at risk 
11. Spinal cord tumors and spinal fractures (with the risk of cord compression) 
12. Neuromas of peripheral nerves of brachial plexus, when there is risk to major sensory or motor nerves 
13. Surgery or embolization for intracranial AV malformations 
14. Surgery for arteriovenous malformation of spinal cord 
15. Embolization of bronchial artery AVMs or tumors 
16. Cerebral vascular aneurysms 
17. Surgery for intractable movement disorders 
18. Arteriography, during which there is a test occlusion of the carotid artery 
19. Circulatory arrest with hypothermia (does not include surgeries performed under circulatory bypass [e.g., 
CABG, ventricular aneurysms]) 
20. Distal aortic procedures, where there is risk of ischemia to spinal cord 
21. Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks 
22. Basal ganglia movement disorders 
23. Surgery as a result of traumatic injury to spinal cord/brain 
24. Deep brain stimulation, and 
25. Certain thyroid surgeries (see below for additional guidance) 
 
You can find this rule in the Local Coverage Determination (LCD) - Intraoperative Neurophysiological Testing 
(L35003) - Effective November 14, 2019. 
 
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 $250 copayment for each in and out-of-network outpatient hospital visit. 
You can find this information on page 120 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 PBT is considered reasonable in instances where sparing the surrounding normal tissue 
cannot be adequately achieved with photon-based radiotherapy and is of added clinical benefit to the patient. 
  
  Examples of such an advantage might be: 
 
    The target volume is in close proximity to one or more critical structures and a steep dose gradient outside 
the target must be achieved to avoid exceeding the tolerance dose to the critical structure(s). 
    A decrease in the amount of dose inhomogeneity in a large treatment volume is required to avoid an 
excessive dose "hotspot" within the treated volume to lessen the risk of excessive early or late normal tissue 
toxicity. 
    A photon-based technique would increase the probability of clinically meaningful normal tissue toxicity by 
exceeding an integral dose-based metric associated with toxicity. 
    The same or an immediately adjacent area has been previously irradiated, and the dose distribution within 
the patient must be sculpted to avoid exceeding the cumulative tolerance dose of nearby normal tissue. 
 
PBT may offer dosimetric advantages as well as added complexity over conventional radiotherapy, 3D 
Conformal Radiation Therapy (3-D CRT) or Intensity Modulated Radiation Therapy (IMRT). Before applying 
PBT techniques, a comprehensive understanding of the benefits and consequences is required. In addition to 
satisfying at least one of the four selection criteria noted above, the radiation oncologist's decision to employ 
PBT requires an informed assessment of the benefits and risks including: 
 
    Determination of patient suitability for PBT allowing for reproducible treatment delivery 
    Adequate definition of the target volumes and OARs 
    Equipment capability, including ability to account for organ motion when relevant 
    Physician, physicist and staff training 
    Adequate quality assurance procedures. 
 
 
It is important to note that normal tissue dose volume histograms (DVHs) must be demonstrably improved with 
a PBT plan to validate coverage. Therefore, coverage decisions must extend beyond ICD-10 codes to 
incorporate additional considerations of clinical scenario and medical necessity with appropriate 
documentation. The final determination of the appropriateness and medical necessity for PBT resides with the 
treating radiation oncologist who should document the justification for PBT for each patient. 
 
You can find this information in the Local Coverage Determination (LCD) Proton Beam Therapy L35075. 
 
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 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 $150 copayment for outpatient diagnostic tests and therapeutic services 
and supplies (advanced imaging services). You can find this information on page(s) 60 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 below is a list of common disorders where an electromyography (EMG), in tandem with a 
properly conducted nerve conduction study (NCS), will be helpful in diagnosis: 
 
1. Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions. 
2. Radiculopathy - cervical, lumbosacral. 
3. Mono/polyneuropathy - metabolic, degenerative, hereditary. 
4. Myopathy - including poly-and dermatomyositis, myotonic and congenital myopathies. 
5. Plexopathy - idiopathic, trauma, infiltration. 
6. Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG is of special value here. 
7. At times, immediately prior to botulinum toxin injection, for localization. 
8. At times, immediately prior to injection of phenol or other substances for nerve blocking or 
chemodenervation. 
 
There may be other instances, not detailed here, where EMG may be of use. You can find this rule in the Local 
Coverage Determination (LCD) - Nerve Conduction Studies and Electromyography (L35048) - Effective July 
15, 2021. 
 
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 Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
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 covered drugs include: Drugs that usually arent self-administered by the patient and are 
injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. 
You can find this information in Chapter 4 on page 82 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 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(s) 56 - 57 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 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(s) 3-4 of the Plan's 2022 
Schedule of Cost Sharing.
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 Medically Unlikely Edits (MUEs) for HCPCS codes with an MAI of 3 are per day edits 
based on clinical benchmarks. MUEs assigned an MAI of 3 are based on criteria (e.g., nature of service, 
prescribing information) combined with data such that it would be possible but medically highly unlikely that 
higher values would represent correctly reported medically necessary services. If contractors have evidence 
(e.g., medical review) that UOS in excess of the MUE value were actually provided, were correctly coded and 
were medically necessary, the contractor may bypass the MUE for a HCPCS code with an MAI of 3 during 
claim processing, reopening, or redetermination, or in response to effectuation instructions from a 
reconsideration or higher-level appeal. 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(V). 
 
 
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 below is a list of common disorders where an electromyography (EMG), in tandem with a 
properly conducted nerve conduction study (NCS), will be helpful in diagnosis: 
 
1. Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions. 
2. Radiculopathy - cervical, lumbosacral. 
3. Mono/polyneuropathy - metabolic, degenerative, hereditary. 
4. Myopathy - including poly-and dermatomyositis, myotonic and congenital myopathies. 
5. Plexopathy - idiopathic, trauma, infiltration. 
6. Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG is of special value here. 
7. At times, immediately prior to botulinum toxin injection, for localization. 
8. At times, immediately prior to injection of phenol or other substances for nerve blocking or 
chemodenervation. 
 
There may be other instances, not detailed here, where EMG may be of use. You can find this rule in the Local 
Coverage Determination (LCD) - Nerve Conduction Studies and Electromyography (L35048) - Effective July 
15, 2021. 
 
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 in-network surgery services received in an 
outpatient hospital setting. You can find this information on page 81 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 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 specific 
dental items/services stated in the Plans contract. Bone replacement grafts for ridge preservation-per site 
(D7953) are not a covered benefit. You can find this information on pages 4-83 to 4-98 of the Plans 2022 
Evidence of Coverage (EOC).