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 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 repeat polysomnography or sleep testing for diagnosing sleep apnea requires documentation 
justifying the medical necessity for the repeated test. Repeat polysomnography/sleep testing may be indicated: 
- if the first study is technically inadequate due to equipment failure; 
- if the subject could not sleep or slept for an insufficient amount of time to allow a clinical diagnosis; 
- if the results were inconclusive or ambiguous; or 
- if initiation of therapy or confirmation of the efficacy of prescribed therapy is needed. 
You can find this information in the Local Coverage Determination (LCD) for Outpatient Sleep Studies 
(L35050). 
 
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 follow-up polysomnography or sleep studies are not routinely indicated for patients treated 
with CPAP whose symptoms continue to be resolved with CPAP treatment. Follow-up polysomnography 
studies may be indicated, however, for the following conditions: 
- After substantial weight loss has occurred in patients on CPAP for treatment of sleep-related 
breathing disorders to ascertain whether CPAP is still needed at the previously titrated pressure; 
- After substantial weight gain has occurred in patients previously treated with CPAP successfully, 
who are again symptomatic despite the continued use of CPAP, to ascertain whether pressure 
adjustments are needed; or 
- When clinical response is insufficient or when symptoms return despite a good initial response to 
treatment with CPAP. 
You can find this information in the Local Coverage Determination (LCD) for Outpatient Sleep Studies 
(L35050). 
 
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 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. The Plan 
contract says that you may request us to pay you back by sending us a request in writing. If you send a request 
in writing, send your bill and documentation of any payment you have made. Its a good idea to make a copy of 
your bill and receipts for your records. You can find this information on page 84 of the Plans 2023 Evidence 
of Coverage. 
 
The Plan contract says that when we receive your request for payment, we will let you know if we need any 
additional information from you. Otherwise, we will consider your request and make a coverage decision.  
If we decide that the medical care or drug is not covered, or you did not follow all the rules, we will not pay for 
our share of the cost. We will send you a letter explaining the reasons why we are not sending the payment and 
your rights to appeal that decision. You can find this information on page 85 of the Plans 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 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 
coverage or specific dental items/services stated in the Plans contract. A prefabricated abutmentincludes 
modification and placement (D6056) is not covered. Dental implants are not covered. You can find this 
information on pages 70-71 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 a power operated vehicles (POV) or power wheelchair (PWC) which has not been reviewed 
by the Pricing, Data Analysis, and Coding (PDAC) contractor or which has been reviewed by the PDAC and 
found not to meet the definition of a specific POV/PWC will be denied as not reasonable and necessary and 
should be coded as K0899. You can find this information in Local Coverage Determination (LCD): Power 
Mobility Devices (L33789). 
 
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 knee orthosis with joints (L1810, L1812) or knee orthosis with condylar pads and joints 
with or without patellar control (L1820) are covered for ambulatory beneficiaries who have weakness or 
deformity of the knee and require stabilization. 
 
If an L1810, L1812 or L1820 is provided but the criteria above are not met, the orthosis will be denied as not 
reasonable and necessary. You can find this rule at Local Coverage Determination (LCD) L33318: Knee 
Orthoses (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 the patient's medical record must contain documentation that fully supports the medical 
necessity for services included within the Local Coverage Determination (LCD). This documentation includes, 
but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or 
procedures. You can find this information in the Local Coverage Determination (LCD) for Spinal Cord 
Stimulators for Chronic Pain (L37632). 
 
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 a line item denial (LID) indicates there are one or more edits present that cause one or more 
individual line items to be denied. The line item cannot be resubmitted but can be appealed. A line that has a C 
status indicator has a disposition of a line item denial (LID). All other line items on the same day as the line 
with a C status indicator are denied and edit 49 is assigned on all line items. A service reported on the same day 
as a C status indicator (edit 49) has a disposition of line item denial (LID). You can find this rule Integrated 
Outpatient Code Editor (OCE), Centers for Medicare and Medicaid Services Specification V23.2, Section 6.1.1 
and 6.2.  
 
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 Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1.  
 
The rules also 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). 
 
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 procedures that do not usually require anesthesia services, MAC could be covered when 
the patients condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia 
in addition to the physician performing the procedure, and is so documented in the patients medical record. 
You can find this rule at Local Coverage Determination (LCD) L35049: Monitored Anesthesia Care (eff. 
10/17/19). 
 
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 state that Medicare covers cytogenetic studies when they are reasonable and necessary for the 
diagnosis or treatment of the following conditions: 
 
Genetic disorders (e.g., mongolism) in a fetus;  
Failure of sexual development; 
Chronic myelogenous leukemia; 
Acute leukemias lymphoid (FAB L1-L3), myeloid (FAB M0-M7), and unclassified; or 
Mylodysplasia 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, National Coverage Determinations (NCD) Manual: Cytogenetic Studies (190.3). 
 
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 state that therapeutic/non-adjunctive and non-therapeutic/adjunctive implantable continuous glucose 
monitors (I-CGMs) are considered reasonable and necessary by Medicare when all of the following coverage 
criteria (1-5) are met: 
1. The beneficiary has diabetes mellitus (Refer to the related Billing and Coding Article for applicable 
diagnoses); and, 
2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a 
Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and, 
3. The beneficiarys insulin treatment regimen requires frequent adjustment by the beneficiary on the basis 
of blood glucose monitor (BGM) or CGM testing results; and, 
4. Within six (6) months prior to ordering the I-CGM, the treating practitioner has an in-person visit with 
the beneficiary to evaluate their diabetes control and determined that criteria (1-3) above are met; and, 
5. Routine recommended follow-up care is expected. 
 
You can find these rules in Local Coverage Determination (LCD) Implantable Continuous Glucose Monitors 
(I-CGMs) (L38686). 
 
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 Diagnostic breath analyses are tests performed to measure either the hydrogen or carbon 
dioxide content of the breath after the ingestion of certain compounds. The analyses are performed to diagnose 
certain gastrointestinal disease states. 
Indications and Limitations of Coverage 
 
The Following Breath Test is Covered: 
 
    Lactose breath hydrogen to detect lactose malabsorption. 
 
The Following Breath Tests are Excluded from Coverage: 
 
    Lactulose breath hydrogen for diagnosing small bowel bacterial overgrowth and measuring small bowel 
transit time. 
    CO2 for diagnosing bile acid malabsorption. 
    CO2 for diagnosing fat malabsorption. 
 
You can find these rules in the National Coverage Determination (NCD) Diagnostic Breath Analyses 100.5. 
 
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 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 pages 74 to 75 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 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 - Policy Article (A52498). 
 
The rules say that if the power wheelchair (PWC) base is not covered, then related accessories will be denied. 
You can find this information in Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes specific 
dental procedures included in a dental benefits chart. Maxillary complete denture and mandibular complete 
denture are not listed as covered dental benefits. You can find this information on pages 74-76 of the Plans 
2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that an Outpatient Prospective Payment System (OPPS) payment status indicator is assigned to 
every HCPCS code. The status indicator identifies whether the service described by the HCPCS code is paid 
under the OPPS and if so, whether payment is made separately or packaged. The status indicator may also 
provide additional information about how the code is paid under the OPPS or under another payment system or 
fee schedule. You can find this rule in the Centers for Medicare & Medicaid Services, Medicare Claims 
Processing Manual, Chapter 4, Section 10.1.1. 
 
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.