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 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 $300 copayment for outpatient diagnostic test. You can find this 
information on page(s) 76 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 effective for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement 
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following 
requirements are met: 
   a. Patient has: 
 
    either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
    not been previously tested with the same test using NGS for the same cancer genetic content, and 
    decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
   b. The diagnostic laboratory test using NGS must have: 
 
    Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
    an FDA-approved or -cleared indication for use in that patients cancer; and, 
    results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
You can find this rule in the National Coverage Determination (NCD): Next Generation Sequencing (90.2) 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $225 copayment for outpatient diagnostic test. You can find this 
information on page(s) 96 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 Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. You can find this rule at 42 CFR Section 422.111(a) and (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 also says that the Plan covers any blood glucose monitors and test strips specified within the preferred 
brand list included in the contract. In general, alternate non-preferred brand products are not covered unless the 
enrollee's doctor provides adequate information that the use of an alternate brand is medically necessary in the 
enrollee's specific situation. You can find this information on page 52 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 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 maxillary partial denture  resin base (including, retentive/clasping materials, rests, and teeth) 
(D5211) and mandibular partial denture  resin base (including, retentive/clasping materials, rests, and teeth) 
(D5212) but each is limited to one per 60 floating months. You can find this information page 285 of the Plan's 
2023 quick reference guide.
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 in any circumstance in which a Medicare Advantage (MA) plan provides transplant services at a 
more distant location, the MA plan must provide reasonable transportation for the enrollee and a companion to 
the distant facility. You can find this information in the Centers for Medicare and Medicaid Service, Internet-
Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 10.11. 
 
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 if the Plan provides transplant services at a location outside the pattern of care for transplants in your 
community and you choose to obtain transplants at this distant location, we will arrange or pay for appropriate 
lodging and transportation costs for you and a companion. You can find this information on page 69 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 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 modifiers XE, XS, XP, XU were developed to provide greater reporting specificity in 
situations where modifier 59 was previously reported and may be used in lieu of modifier -59 whenever 
possible. The modifier XU is defined as an unusual non-overlapping service. The use of a service that is 
distinct because it does not overlap usual components of the main service. 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(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 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 a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered. 

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.) 

A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the 
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting 
hardware. You can find this information in Local Coverage Article 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 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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, 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 39 in 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 codes E2310 and E2311 describe the electronic components that allow the beneficiary to 
control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or 
non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power 
leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the 
beneficiary to select the motor that is being controlled and an indicator feature to visually show which function 
has been selected. When the wheelchair drive function has been selected, the indicator feature may also show 
the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate 
display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for 
fixed mounting hardware for the control box and for the display box (if present).  
 
A non-expandable controller has the following features: 
 
May have the ability to control up to 2 power seating actuators through the drive control (for example, seat 
elevator and single actuator power elevating legrests). (Note: Control of the power seating actuators though the 
Control Input Device would require the use of an additional component, E2310 or E2311.) 
 
Can accommodate only an integral joystick or a standard proportional remote joystick 
May allow for the incorporation of an attendant control 
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 information in Medicare's Local Coverage Article: Wheelchair Options/Accessories - Policy 
Article (A52504). 
 
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 state that effective for claims with dates of service on and after December 23, 2009, the Centers for 
Medicare and Medicaid Services (CMS) determines that the evidence is adequate to conclude that OIVIT does 
not improve health outcomes in Medicare beneficiaries. Therefore, CMS determines that OIVIT is not 
reasonable and necessary for any indication under section 1862(a)(1)(A) of the Social Security Act. Services 
comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered under Medicare 
when furnished pursuant to an OIVIT regimen (see subsection A. above). 
 
You can find this information in the National Coverage Determination (NCD) Outpatient Intravenous Insulin 
Treatment 40.7. 
 
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 coverage for neuromuscular electrical stimulation/functional electrical stimulation (NMES/FES) for walking will be covered in spinal cord injury patients with all of the following characteristics:
1. Persons with intact lower motor units (L1 and below) (both muscle and peripheral nerve); 2. Persons with muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently; 3. Persons that demonstrate brisk muscle contraction to NMES and have sensory perception electrical stimulation sufficient for muscle contraction; 4. Persons that possess high motivation, commitment and cognitive ability to use such devices for walking; 5. Persons that can transfer independently and can demonstrate independent standing tolerance for at least 3 minutes; 6. Persons that can demonstrate hand and finger function to manipulate controls; 7. Persons with at least 6-month post recovery spinal cord injury and restorative surgery; 8. Persons without hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis; and 9. Persons who have demonstrated a willingness to use the device long-term.
You can find this rule in the National Coverage Determination (NCD) - Neuromuscular Electrical Stimulation (NMES) (160.12) - Effective October 1, 2006.
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 one to two levels, either unilateral or bilateral, are allowed per session per spine region. 
You can find this information in the Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management L38841. 
 
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 only 
those items and services specifically listed in your Plan contract. Cone beam CT capture and interpretation with 
limited field of view  less than one whole jaw (D0364) is not covered under the Plans dental benefits. You 
can find this information on pages 4-83 to 4-98 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 50% coinsurance for out-of-network advanced imaging services, 
including CT scans. You can find this information on pages 73-76 of the Plan's 2022 Evidence of Coverage 
(EOC).