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. This benefit includes 
preventive and comprehensive services. Gingival irrigation (D4921) for the upper right quadrant and upper left 
quadrant is excluded from this benefit. You can find this information on pages 53-54 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 products reviewed by the Pricing, Data Analysis and Coding contractor (PDAC) which do 
not meet the durable medical equipment (DME) benefit category requirements must be coded with procedure 
codes A9276, A9277, A9278, or A9279 and will deny as non-covered. You can find this information in the 
Local Coverage Article: Glucose Monitor - Policy Article (A52464). 
 
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 MRIs are covered when medically necessary and reasonable for the diagnosis or treatment of 
the specific patient involved. 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 220.2(B).  
 
The rules say that a lumbar magnetic resonance imaging (MRI) may be indicated for a patient with a red-flag 
condition, such as a suspected tumor, infection, herniated intervertebral disc with nerve compression, or a 
major neurological problem. The MRI test result may be needed to evaluate these conditions to determine the 
need for surgery or other aggressive therapy, such as a work-up for metastatic cancer. 
Red flags" are identified through an appropriate history plus a physical examination that typically includes 
evaluating muscle strength, limb circumference, reflexes, sensation, straight leg raise, and sitting knee 
extension tests. "Red flags" include: 
 
1.Major trauma 
2.Minor trauma in a potentially osteoporotic patient 
3.History of cancer 
4.Fever 
5.Chills 
6.Unexplained weight loss 
7.Recent bacterial infection 
8.IV drug abuse 
9.Immune suppression 
10.Pain that worsens when supine or at night 
11.Saddle anesthesia 
12.Recent onset of bladder dysfunction 
13.Clinically significant or progressive neurologic deficit in the lower extremity 
14.Unexpected laxity of the anal sphincter 
15.Perianal or perineal sensory loss, 
16.Clinically significant motor weakness, or  
17.Other nerve root compromise. You can find this information in the Local coverage Determination (LCD) Lumbar MRI L37281. 
 
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 an event monitor, or event recorder, is a patient-activated or event-activated 
electrocardiographic (EKG) device that intermittently records cardiac arrhythmic events as they occur. The 
EKG is recorded on magnetic tape or other digital medium. Upon detecting symptoms, the wearer presses a 
button, which activates the recorder to save (i.e., memorize) an interval of pre-symptom EKG data along with 
data during and subsequent to the symptomatic event. Self-sensing recorders (also known as event-activated or 
automatic trigger) do not require patient input to capture these data. Single or multiple events may be recorded. 
The device is worn at all times, usually for up to 30 days. These are considered memory loop recorders (MLR). 
 
Another type of pre-symptom loop recorder is implanted subcutaneously in a patient's upper left chest and may 
remain implanted for many months. An ILR is used when syncope is thought to be cardiac-related but is too 
infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom MLR. 
 
Covered uses are to: 
a. Detect, characterize, and document symptomatic transient arrhythmias; 
b. Initiate, revise, or discontinue arrhythmic drug therapy; or,  
c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); (only 
if 24-hour coverage is provided). You can find this information in the Centers for Medicare and Medicaid 
Services, Internet-Only Manual, Publication Number 100-03, Medicare National Coverage Determinations 
Manual, Section 20.15. 
 
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 
D6751 or D6241. You can find this information on page 125 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 state that an expandable controller is capable of accommodating one or more of the following 
additional functions: 
1. Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin 
control, head control, etc.) 
2. Non-proportional input devices (e.g., sip and puff, head array, etc.) 
3. 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: 
1. A separate display (i.e., for alternate control devices) 
2. Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's 
drive control) 
3. An attendant control 
 
The rules state that a power tilt and recline seating system (E1006, E1007, E1008) includes: a solid seat 
platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height 
armrests; fixed or swingaway detachable legrests; fixed or flip-up footplates; two motors and related 
electronics with or without variable speed programmability; a switch control which is independent of the power 
wheelchair drive control interface. 
 
 The rules state that a power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related 
electronics with or without variable speed programmability which allows the legrest to be raised and lowered 
independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not 
be integrated with the power tilt and/or recline control(s). 
 
You can find these rules in the Local Coverage Article for Wheelchair Options/Accessories - Policy Article, 
A52504. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that wheelchair seat and back cushion codes are all-inclusive. Use of code K0108 or any other 
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 these rules 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).   
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that the only covered chiropractic service is manual manipulation of the spine to correct 
subluxation. You can find this information on page 55 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 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 say that a contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
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 160. 
 
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 
anesthesia . You can find this information in Chapter 4 on page 50 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. 
 
Medicare Part B pays for pulmonary rehabilitation (PR) programs for those with moderate to very severe 
Chronic Obstructive Pulmonary Disease (COPD). The patient must be referred by the doctor treating the 
disease. The services must be provided in a doctors office or an outpatient hospital setting. The PR program 
must include:  
 
1. Physician-prescribed exercise; 
 
2. Education or training; 
 
3. Psychosocial assessment; 
 
4. Outcomes assessment; and 
 
5. An individualized treatment plan established, reviewed, and signed by a doctor every 30 days.  
 
Benefits are limited to a maximum of 36 sessions. An additional 36 sessions over an extended period of time 
may be covered if approved by the Medicare Administrative Contractor. You can find these rules at 42 CFR 
Sections 410.47(b), (d), and (e). 
 
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 
D9243, D9239, D7953, or D7210. You can find this information on pages 90-91 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 to qualify for home health services, the patient must be:

1. Confined to the home; 
2. Under the care of a physician or allowed practitioner; 
3. Receiving services under a plan of care established and reviewed by a physician; 
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) continuing occupational therapy. 
You can find this rule at 42 CFR Section 409.42.

The rules say that eligibility for the home health benefit will be determined based on the certifying physician or allowed practitioner's records. If the enrollee was directly admitted to home health from an acute or post-acute care facility, the facility records may be used instead. The medical records for the enrollee must contain information that justifies the referral for home health services.
 
The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face encounter visit. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and 30.5.1.2.

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 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 wheelchair options and accessories are covered under the Durable Medical Equipment 
benefit (Social Security Act Section1861(s)(6)). In order for a beneficiarys equipment to be eligible for 
reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage 
Determination must be met. An option/accessory that is beneficial primarily in allowing the beneficiary to 
perform leisure or recreational activities is non-covered. You can find this rule in the Local Coverage Article 
for Wheelchair Options/Accessories, A52504. 
 
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 $30 copayment for Medicare-covered urgently needed services.  You 
can find this information on page(s) 87 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 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 
requested item or service but is limited to 1 per 60 floating months. You can find this information in Chapter 4 
on page 57 of the Plan's 2023 Evidence of Coverage (EOC) and in the 2023 dental quick reference guide.