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 Polyethylene-glycol (PEG) hydrogel is covered once in patients with clinically localized 
prostate cancer who meet specific coverage criteria and do not meet any of the following exclusion criteria: 
1. Less than 5-year life-expectancy and asymptomatic  
2. Prior prostate cancer treatment (surgery or radiation therapy)  
3. Active bleeding disorder or clinically significant coagulopathy  
4. Active inflammatory or infectious disease in the perineum or injection area (e.g., prostatitis, anorectal 
irritable bowel disease)  
5. Prostate volume > 80 cc  
 
You can find this information in the Centers for Medicare & Medicaid Services, Local Coverage Determination 
(LCD): Prostate Rectal Spacers (L37485). 
 
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 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). 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.

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 the 
blood glucose level test (D0412) but is limited to one per 36 floating months. You can find this information on 
pages 114 to 117 of the Plan's 2023 Evidence of Coverage (EOC) and on page 181 of the Plan's Medicare 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 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 portable oxygen system is covered if the beneficiary is mobile within the home for Groups 
I and II, and the qualifying blood gas study was performed while at rest (awake) or during exercise. If the only 
qualifying blood gas study was performed during sleep, portable oxygen will be denied as not reasonable and 
necessary. You can find this information in Local Coverage Determination (LCD): Oxygen and Oxygen 
Equipment (L33797). 
 
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 a lower limb prosthesis is covered when the beneficiary:
-Will reach or maintain a defined functional state within a reasonable period of time; and
-Is motivated to ambulate.

FUNCTIONAL LEVELS:

A determination of the medical necessity for certain components/additions to the prosthesis is based on the
beneficiary's potential functional abilities. Potential functional ability is based on the reasonable expectations
of the prosthetist, and treating practitioner, considering factors including, but not limited to:
-The beneficiary's past history (including prior prosthetic use if applicable); and
-The beneficiary's current condition including the status of the residual limb and the nature of other medical
problems; and
-The beneficiary's desire to ambulate.

Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels:

Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a
prosthesis does not enhance their quality of life or mobility.

Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed
cadence. Typical of the limited and unlimited household ambulator.

Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers
such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator.

Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator
who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise
activity that demands prosthetic utilization beyond simple locomotion.

Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting.
high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.

The records must document the beneficiary's current functional capabilities and his/her expected functional
potential, including an explanation for the difference, if that is the case. It is recognized, within the functional
classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level
classifications.

You can find these rules in the Local Coverage Determination (LCD) for Lower Limb Prostheses, L33787.

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 Peripheral nerve stimulators may also be employed to assess a patients suitability for 
continued treatment with an electric nerve stimulator. As explained in 160.7.1, such use of the stimulator is 
covered as part of the total diagnostic service furnished to the beneficiary rather than as a prosthesis. 
 
You can find this information in National Coverage Determination (NCD): Electrical Nerve Stimulators 
(160.7). 
 
The rules also 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). 
 
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 PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in 
beneficiaries with chronic and severe lymphedema when all of the following three requirements are met: 
1. The beneficiary has a diagnosis of lymphedema as defined above, and 
2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented 
presence of at least one of the following clinical findings:  
a. Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
b. Papillomatosis cutis lymphostatica, 
c. Deformity of elephantiasis, 
d. Skin breakdown with persisting lymphorrhea, 
e. Detailed measurements over time confirming the persistence of the lymphedema with a history 
evidencing a likely etiology, and 
3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to 
other clinical treatment over the course of a required four-week trial. 
A PCD coded as E0652, is covered for the treatment of lymphedema extending onto the chest, trunk and/or 
abdomen when all of the following are met: 
a. The beneficiary has lymphedema of an extremity as defined above 
b. The coverage criteria for an E0650 or E0651 are met 
c. The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the 
limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed 
to improve with a four-week trial. 
A PCD coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen that does not 
meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable 
and necessary. You can find this rule at Local Coverage Determination (LCD) L33829: Pneumatic 
Compression Devices (eff. 10/22/23). 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services,
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The Plan
contract says that we cover a comprehensive exam (D0150) once every three plan years. You can find this
information on page 4-84 of the 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. 
 
Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise 
reasonable and necessary for the patient. Food and Drug Administration (FDA) approved drugs used for 
indications other than what is indicated on the official label may be covered if the use is determined to be 
medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or 
accepted standards of medical practice. 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, Sections 
50.4.1 and 50.4.2. 
 
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.
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). 
 
Short-latency somatosensory evoked potentials (SEPs) represent early electrophysiologic responses of the 
somatosensory pathways to stimulation. Somatosensory testing involves the application of multiple brief 
electrical stimuli over peripheral nerves (e.g., the median, peroneal, and tibial nerves) and recording the evoked 
potentials over proximal portions of the nerves stimulated, the plexus, spine and/or scalp. These readings are 
then averaged by a computer and can be traced and recorded in the form of waveforms. A physician trained in 
interpreting clinical evoked potential studies then interprets these waveforms. The waveforms obtained should 
be described and the peak latencies, interpeak intervals (when appropriate), and amplitudes of the significant 
components detailed. The nerves most commonly stimulated are the median nerve at the wrist for testing in the 
upper extremity, and the common peroneal nerve (CPN) at the knee and the posterior tibial nerve at the ankle 
for the lower extremity. The use of short-latency somatosensory evoked potentials will be considered to be 
medically reasonable and necessary to assist in the diagnosis of certain neuropathologic states (as described 
below) in order to provide information for treatment and for intraoperative testing during spinal surgeries in 
which there is risk of additional nerve or spinal cord injury. There is a list of diagnosis codes that support 
medical necessity. You can find this information in the Local Coverage Determination for Billing and Coding: 
Somatosensory Testing (L33958) and the Local Coverage Article (A57540). 
 
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 
coverage for the requested items or services, but only when they are received from an in-network provider. You 
can find this information on pages 72 to 73 and 78 to 79 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 D6010 but is 
limited to two per calendar year. This benefit does not include D7953, D9120, D9222 or D9223. You can find 
this information on pages 85-97 of the Plan's 2023 Evidence of Coverage (EOC).