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 for all adult manual wheelchairs (E1161, K0001, K0002, K0003, K0004, K0005, K0006, 
K0007, K0008, K0009), payment for seat widths and/or seat depths of 15-19 inches is included in the payment 
for the base code. These seat dimensions should not be billed separately. Codes E2201, E2202, E2203, E2204 
describe seat widths and/or depths of 20 inches or more for manual wheelchairs. 
 
For power wheelchairs, there is no separate billing for nonstandard seat frame dimensions (width, depth, or 
height) with the following exceptions: For Group 3 and 4 power wheelchairs, with a sling/solid seat/back, the 
following items may be billed separately using code K0108: 
 
    For Standard Duty, seat width and/or depth greater than 20 inches; 
 
    For Heavy Duty, seat width and/or depth greater than 22 inches; 
 
    For Very Heavy Duty, seat width and/or depth greater than 24 inches; 
 
    For Extra Heavy Duty, no separate billing 
 
For Group 3 and 4 PWCs with a sling/solid seat/back, the following items may be billed separately using code 
K0108: 
 
    For Standard Duty, back width greater than 20 inches; 
 
    For Heavy Duty, back width greater than 22 inches; 
 
    For Very Heavy Duty, back width greater than 24 inches; 
 
    For Extra Heavy Duty, no separate billing Code K0108 may not be billed for nonstandard dimensions of a power tilt and/or recline seating system 
(E1002, E1003, E1004, E1005, E1006, E1007, E1008). The definition of those codes includes any frame width 
and depth. You can find these rules in the 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 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 Freestyle Libre is the preferred meter. In order to get another device, you need to document that you have tried and failed the Freestyle Libre or why you cannot use it to avoid higher copayments for the device and its supplies. You can find this information in Chapter 4 on pages 54-55 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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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 38 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 repeat epidural steroid injection (ESI) when the first injection directly and significantly 
provided improvement of the condition being treated may be considered medically reasonable and necessary 
when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement 
in function measured from baseline using SAME scale for at least three months. If a patient fails to respond 
well to the initial ESI, a repeat ESI after 14 days can be performed using a different approach, level and/or 
medication, if appropriate, with the rationale and medical necessity for the second ESI documented in the 
medical record. You can find this information in the Local Coverage Determination (LCD): Epidural Steroid 
Injections for Pain Management (L36920). 
 
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 Plan 
contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This includes 
comprehensive dental services such as extractions. You can find this information in Chapter 4 on pages 63 to 
65 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 a flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 
or above. You can find this information in Local Coverage Determination (LCD): Lower Limb Prostheses 
(L33787). 
 
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Professional Component (PC)/Technical Component (TC) Indicator 0 identifies codes 
that describe physician services. The concept of PC/TC does not apply since physician services cannot be split 
into professional and technical components. Modifiers 26 & TC cannot be used with these codes. 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 50.6. 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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. The plan offers a Point-of-Service (POS) benefit that provides 
coverage for certain types of medical care when you see provider outside of the plan network. You can find this 
information to on pages 37 to 38 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 state that Percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or 
Kyphoplasty)  will be considered reasonable and necessary when ALL of the following criteria are met: 
            Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic Vertebral Compression Fracture 
(VCF)  (T1 L5), based on symptom onset, and documented by advanced imaging  
            The beneficiary is symptomatic and is hospitalized with severe pain or is non-hospitalized with 
moderate to severe pain  despite optimal non-surgical management: 
                Worsening Pain or 
                Stable to improved pain when 2 or more of the following are present: 
                    Progression of vertebral body height loss 
                    greater than 25% vertebral body height reduction 
                    Kyphotic deformity 
                    Severe impact of VCF on daily functioning  
 
Continuum of care: All patients presenting with vertebral compression fractures (VCF) should be referred for 
evaluation of bone mineral density and osteoporosis education for subsequent treatment as indicated and 
instructed to take part in an osteoporosis prevention/treatment program. 
 
You can find this information in the Local Coverage Determination (LCD) Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) L34976. 
 
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 before chronic care management services can start, an initiating visit is required. Initiating 
visits can occur during comprehensive face-to-face evaluation and management visit, annual wellness visit, or 
initial preventive physical exam. You can find this rule in the Centers for Medicare and Medicaid Services, 
Medicare Learning Network, for Chronic Care Management Services.  
 
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. Surgical extractions are not listed as a covered dental 
benefit. You can find this information on page 57 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 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 $3 copayment for Medicare-covered non-radiological diagnostic tests 
under the Outpatient diagnostic tests and therapeutic services and supplies benefit category. You can find this 
information pages 74 and 75 of the Plan's 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 does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 you have a $300 benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses 
(1 per calendar year). You can find this information on page 88 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 Percutaneous Vertebral Augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients with BOTH the following: 
 
1. Inclusion criteria (ALL are required):  
a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic Vertebral Compression Fracture (VCF) (T1  
L5) by recent (within 30 days) advanced imaging (bone marrow edema on advanced imaging) 
b. Symptomatic (ONE): 
   i. Hospitalized with severe pain 
   ii. Non-hospitalized with moderate to severe pain despite optimal non-surgical management (NSM) 
(ONE): 
      1. Worsening pain 
      2. Stable to improved pain (with equal to or greater than 2 of the following): 
         A. Progression of vertebral body height loss 
         B. Greater than 25% vertebral body height reduction 
         C. Kyphotic deformity 
         D. Severe impact of VCF on daily functioning 
 
c. Continuum of care (BOTH): 
   i. All patients presenting with VCF should be referred for evaluation of bone mineral density (BMD) and 
osteoporosis education for subsequent treatment as indicated. 
   ii. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment 
program. 
 
2. Exclusion criteria (Can have NONE of the following): 
a. Absolute contraindication 
   i. Current back pain is not primarily due to the identified acute or subacute VCF(s) 
   ii. Osteomyelitis, discitis or active systemic or surgical site infection 
   iii. Pregnancy 
b. Relative contraindication    i. Allergy to bone cement or opacification agents 
   ii. Uncorrected coagulopathy 
   iii. Spinal instability 
   iv. Myelopathy from the fracture 
   v. Neurologic deficit 
   vi. Neural impingement 
   vii. Fracture retropulsion/canal compromise 
   viii. Greater than three vertebral fractures 
 
Vertebral augmentation and kyphoplasty for vertebral compression fractures with intractable spinal pain not 
relieved with medical therapy will be covered for osteolytic vertebral metastatic disease or myeloma involving 
a vertebral body. You can find this information in the Local Coverage Determination (LCD): Percutaneous 
Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38737). 
 
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 77-78 in the Plan's 2023 Evidence of Coverage.