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 enteral nutrition may be administered by syringe, gravity, or pump. Some enteral 
beneficiaries may experience complications associated with syringe or gravity method of administration. 
 
If a pump (B9002) is ordered, there must be documentation in the beneficiary's medical record to justify its use 
(e.g., gravity feeding is not satisfactory due to reflux and/or aspiration, severe diarrhea, dumping syndrome, 
administration rate less than 100 ml/hr., blood glucose fluctuations, circulatory overload, 
gastrostomy/jejunostomy tube used for feeding). If the medical necessity of the pump is not documented, the 
pump will be denied as not reasonable and necessary. 
 
In-line digestive enzyme cartridges (B4105) are reasonable and necessary for beneficiaries who: 
 
   a. meet the coverage criteria for enteral nutrition; AND, 
   b. have a diagnosis of Exocrine Pancreatic Insufficiency (EPI) (refer to the Group 1 Codes in the LCD-related 
Policy Article for applicable diagnoses). 
 
More than two in-line digestive enzyme cartridges (B4105) per day will be denied as not reasonable and 
necessary. 
 
The feeding supply allowance (B4034, B4035, and B4036) must correspond with the method of enteral 
nutrition administration (syringe, pump, gravity). If a feeding supply kit does not correspond with the method 
in which the enteral nutrition is being administered, then the feeding supply kit will be denied as not reasonable 
and necessary. 
 
For dates of service prior to January 1, 2023, the feeding supply allowance (B4034, B4035, and B4036) must 
correspond to the method of administration indicated in question 5 of the DME Information Form (DIF). If it 
does not correspond, it will be denied as not reasonable and necessary. 
 
If a pump supply allowance (B4035) is provided and if the medical necessity of the pump is not documented, it 
will be denied as not reasonable and necessary. 
 
The codes for feeding supply allowances (B4034, B4035, and B4036) are specific to the route of 
administration. Claims for more than one type of kit code delivered on the same date or provided on an 
ongoing basis will be denied as not reasonable and necessary. 
 
Enteral feeding supply kit allowances (B4034, B4035, and B4036), are all-inclusive, with the exception of 
B4105 in-line digestive enzyme cartridge. Separate billing for any item including an item using a specific 
HCPCS code, if one exists, or B9998 (ENTERAL SUPPLIES, NOT OTHERWISE CLASSIFIED) will be 
denied as unbundling. you can find these rules in the Local Coverage Determination (LCD) Enteral Nutrition 
L38955. 
 
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 thermal destruction of the intraosseous basivertebral nerve (BVN) will be considered 
medically reasonable and necessary for the treatment of chronic low back pain (cLBP) in patients who meet 
ALL the following criteria: 
 
    1. Chronic lumbar back pain of equals 6 months duration that causes functional deficit measured on a pain or 
disability scale*, AND 
   2. Documented failure to respond to equals 6 months of non-surgical management**, AND 
   3. Absence of non-vertebrogenic pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant deformity, 
AND 
   4. Evidence of Type 1 or Type 2 Modic changes on MRI, such as inflammation, edema, vertebral endplate 
changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent marrow, 
hypotensive signals (Type 1 Modic change), and changes to the vertebral body marrow including replacement 
of normal bone marrow by fat, and hypertensive signals (Type 2 Modic change), in 1 or more vertebrae from 
L3-S1. 
 
* Pain assessment and a disability scale must be obtained at baseline to be used for functional assessment. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Thermal Destruction of the 
Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain (L39420). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 up to 48 one-way trips are covered each year (limited to ground transportation only). You are 
responsible for any costs over the trip limit. Each one-way trip must not exceed 50 miles of driving distance. A 
trip is one-way transportation; a round trip is 2 trips. You can find this information in Chapter 4 on pages 4-121 
to 4-122 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 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 on page 61 of the Plans 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 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 if any power operated vehicle (POV) or power wheelchair (PWC) is only for use outside the 
home, it will be denied as noncovered. You can find this information in local Coverage Article: Power Mobility 
Devices (A52498). 
 
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 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 Durable Medical Equipment 
(DME) benefit. A PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
There is insufficient evidence to demonstrate that reimbursement is justified. Claims for E0675 will be denied 
as not reasonable and necessary. You can find this information in the Local Coverage Article: Pneumatic 
Compression Devices - Policy Article (A52488) and in the Local Coverage Determination (LCD): Pneumatic 
Compression Devices (L33829). 
 
Pneumatic Compression Devices (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 information 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.
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 elevators (such as stair lifts) are not covered because they are considered convenience items 
that are 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. The contract 
says that adaptive equipment, structural modifications such as ramps, doorways, and elevators including 
stairway elevators are not covered under any condition. You can find this information on page 104 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 state that Medicare will cover the following reconstructive procedures when medically necessary: 
dermabrasion, abdominal lipectomy and panniculectomy, reconstructive breast surgery and removal of breast 
implants, reduction mammaplasty, mastectomy for gynecomastia, gigantomastia of pregnancy, and rhinoplasty 
and reconstructive nasal surgery.  You can find this rule at Centers for Medicare and Medicaid Services, Local 
Coverage Determination L35090, entitled Cosmetic and Reconstructive Surgery. 
 
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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 29 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 an ambulance transport is covered to the nearest appropriate facility to obtain necessary 
diagnostic and/or therapeutic services. Only local transportation by ambulance is covered, and therefore, only 
mileage to the nearest appropriate facility equipped to treat the patient is covered. However, if two or more 
facilities that meet the destination requirements can treat the patient appropriately and the locality of each 
facility encompasses the place where the ambulance transportation of the patient began, then the full mileage to 
any one of the facilities to which the beneficiary is taken is covered. 
 
The rules say that the term "locality" with respect to ambulance service means the service area surrounding the 
institution to which individuals normally travel or are expected to travel to receive hospital or skilled nursing 
services. The Medicare Administrative Contractors (MACs) have the discretion to define locality in their 
service areas. 
 
The rules also say that the term "appropriate facilities" means that the institution is generally equipped to 
provide the needed hospital or skilled nursing care for the illness or injury involved. In the case of a hospital, it 
also means that a physician or a physician specialist is available to provide the necessary care required to treat 
the patient's condition. The fact that a more distant institution is better equipped, either qualitatively or 
quantitatively, to care for the patient does not warrant a finding that a closer institution does not have 
"appropriate facilities." Such a finding is warranted, however, if the beneficiary's condition requires a higher 
level of trauma care or other specialized service available only at the more distant hospital. An institution is 
also not considered an appropriate facility if there is no bed available. The contractor, however, will presume 
that there are beds available at the local institutions unless the claimant furnished evidence that none of these 
institutions had a bed available at the time the ambulance service was provided.  
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.3, 10.3.5, and 10.3.6. 
 
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 continuous passive motion devices are devices covered for patients who have received a total 
knee replacement. To qualify for coverage, use of the device must commence within 2 days following surgery. 
In addition, coverage is limited to that portion of the 3-week period following surgery during which the device 
is used in the patients home. There is insufficient evidence to justify coverage of these devices for longer 
periods of time or for other applications. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet-Only Manual, Publication 100-03, National Coverage Determination (NCD) for 
Durable Medical Equipment Reference List (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 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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 27 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 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 $50 copayment for in-network Medicare-covered vision services at a 
specialist's office. You can find this information on pages 84 to 85 of the Plan's 2023 Evidence of Coverage 
(EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that effective January 1, 2016 Noridian requires that, when billing intravitreal bevacizumab 
acquired from a compounding source or compounded in the physicians facility/office, the new HCPCS code 
J7999 be used on the claims submission. You can find this rule at Local Coverage Article (LCA) A53008: 
Billing and Coding: Intraocular Bevacizumab (eff. 4/1/23). 
 
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 does not include 
coverage for the dental service code D4341. You can find this information in Chapter 4 on pages 51-52 of the 
Plans 2023 Evidence of Coverage (EOC).