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 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. A bone replacement graft for 
ridge preservation (D7953) and a pontic (D6245) are not among the services covered under the Plans dental 
benefit. You can find this information in Chapter 4 on pages 86 to 88 and 93 to 94 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay 20% coinsurance for diagnostic procedures and tests. You can find this 
information on page(s) 86 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 claims for services furnished on or after January 1, 2010, must be filed no later than the close 
of the period ending 1 calendar year after the date of service. You can find this rule at 42 CFR Section 
424.44(a). 
 
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 non-emergency transportation by ambulance is appropriate if it is documented that the 
members condition is such that other means of transportation could endanger the persons health and that 
transportation by ambulance is medically required. You can find this information on page 56 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 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 
preventive and comprehensive services. Core buildup (D2950) is excluded from this benefit. You can find this 
information 70 to 72 and 82 to 82 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 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. 
 
The rules say that items that do not contribute meaningfully to the treatment of an illness or injury or the 
functioning of a malformed body member are not covered. You can find this rule in the Centers for Medicare 
and Medicaid Services (CMS), Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, 
Chapter 16, Section 80. 
 
The rules say that Medicare payment can be made for reasonable and necessary maintenance and service of 
beneficiary-owned DME that is not under a manufacturers or suppliers warranty. You can find this rule in the 
Center for Medicare Services (CMS) Internet-Only Manual, Publication 100-02, Medicare Benefit Policy 
Manual, Chapter 15, Section 110.2.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 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 the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules say that modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(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.
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 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 patient's 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.  
 
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 at Local Coverage Article (A52504): Wheelchair Options/Accessories - Policy Article 
(eff. 1/1/20).  

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 for home health aide services to be covered, the services provided by the home health aide 
must be part-time or intermittent. You can find this information in the Centers for Medicare and Medicaid 
Service, Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 50.2 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that total knee replacement surgery is considered medically necessary in the following 
circumstances: 
 
Advanced joint disease demonstrated by: 
 
 Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance 
imaging (MRI) and/or computed tomography (CT) (in situations when MRI is non-diagnostic or not able to be 
performed) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint 
subluxation, joint space narrowing, avascular necrosis); and 
 
 Pain or functional disability from injury due to trauma or arthritis of the joint; and 
 
 If appropriate, history of unsuccessful conservative therapy (non-surgical medical management) that is clearly 
addressed in the pre-procedure medical record. (If conservative therapy is not appropriate, the medical 
record must clearly document why such approach is not reasonable). Non-surgical medical management is 
usually but not always implemented prior to scheduling total joint surgery. Non-surgical treatment as clinically 
appropriate for the patients current episode of care typically includes one or more of the following: 
 
 anti-inflammatory medications or analgesics, or 
 
 flexibility and muscle strengthening exercises, or 
 
 supervised physical therapy [Activities of daily living (ADLs) diminished despite completing a plan of care], 
or 
 
 assistive device use, or 
 
 weight reduction as appropriate, or 
 
 therapeutic injections into the knee as appropriate. 
 
In some circumstances, for example, if the patient has bone on bone articulation, severe deformity, pain or 
significant disabling interference with activities of daily living, the surgeon may determine that nonsurgical medical management would be ineffective or counterproductive, and that the best treatment option, after 
explaining the risks, is surgical. If medical management is deemed inappropriate, the medical record should 
indicate the rationale for and circumstances under which this is the case. 
 
 Failure of a previous osteotomy; or 
 
 Distal femur fracture; or 
 
 Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; or 
 
 Failure of previous unicompartmental knee replacement; or 
 
 Avascular necrosis of the knee; or 
 
 Proximal tibia fracture 
 
You can find this rule at Local Coverage Determination (LCD) L36575: Total Knee Arthroplasty (eff. 12/1/19). 
 
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. You can find this information 
on pages 86-88, 93-96 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 state that for these items of durable medical equipment (DME), A/B Medicare Administrative 
Contractor (MACs) and DME MACs pay the fee schedule amounts on a monthly rental basis not to exceed a 
period of continuous use of 15 months. In the tenth month of rental, the beneficiary is given a purchase option. 
If the purchase option is exercised, A/B MACs and DME MACs continue to pay rental fees not to exceed a 
period of continuous use of 13 months and ownership of the equipment passes to the beneficiary. If the 
purchase option is not exercised, A/B MACs and DME MACs continue to pay rental fees until the 15-month 
cap is reached and ownership of the equipment remains with the supplier.  

You can find this rule in the Centers for Medicare and Medicaid Services, Medicare Claims Processing 
Manual, Chapter 20, Section 30.5. 
 
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 wheelchair seat and back cushion codes are all-inclusive. Use of HCPCS code K0108 or any 
other HCPCS code to separately bill for added components such as the foam blocks, gel packs, air cells, or 
equivalent material is incorrect coding. You can find this rule in the Local Coverage Article Wheelchair 
Seating - Policy Article A52505. 
 
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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) 
procedures will be considered medically reasonable and necessary for the following indications: 
 
    Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have not 
responded to non-surgical medical management (e.g. narcotic and/or non- narcotic medication, physical 
therapy modalities) with and without methods of immobility (e.g. rest, bracing). 
        Both PVP and PVA will be considered reasonable and necessary when ALL of the following criteria are 
met: 
            Acute (less than 6 wks) or subacute (6-12 wks) osteoporotic VCF (T1 L5), based on symptom onset, 
and documented by advanced imaging demonstrating bone marrow edema on MRI or bone-scan/SPECT/CT 
uptake and 
            The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or 
Visual Analog Scale [VAS] pain score equals 8) or is non-hospitalized with moderate to severe pain (NRS or 
VAS equals 5) despite optimal non-surgical management (NSM) with one of the following: 
                Worsening Pain or 
                Stable to improved pain (but NRS or VAS equals 5) when 2 or more of the following are present: 
                    Progression of vertebral body height loss 
                    Greater than 25% vertebral body height reduction 
                    Kyphotic deformity 
                    Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] 
greater than 17) 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L35130). 
 
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 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 only 
those items and services specifically listed in your Plan contract. Endodontic therapy, molar tooth (D3330) is 
not covered under the Plan's dental benefits. You can find this information on pages 92-93 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 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 
intraoral - periapical first radiographic image (D0220) but is limited to 1 every 3 years. This benefit also 
includes the limited oral evaluation - problem focused (D0140) but is limited to 1 oral evaluation every 6 
months. You can find this information on pages 69-70 of the Plan's 2022 Evidence of Coverage (EOC).