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 a fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or 
more of the following criteria (1-4) are met: 
 
    1. The beneficiary has a medical condition which requires positioning of the body in ways not feasible with 
an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a 
hospital bed, or 
    2. The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to 
alleviate pain, or 
    3. The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration, or 
    4. The beneficiary requires traction equipment, which can only be attached to a hospital bed. 
 
A semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if the beneficiary meets one 
of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate 
need for a change in body position. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Hospital Beds And 
Accessories (L33820). 
 
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 these tests may be performed at rest and during exercise, or with pharmacologic 
intervention when exercise cannot be performed. The acquisition of the images may be planar (single plane) or 
by multiple planes with computer integration, SPECT (single-photon emission computer tomography). You can 
find this information in Local Coverage Determination (LCD): Cardiovascular Nuclear Medicine (L33560). 
 
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 whirlpool bathtub is covered if the patient is homebound and has a (standard) condition 
for which the whirlpool bath can be expected to provide substantial therapeutic benefit justifying its cost. 
Where patient is not homebound but has such a condition, payment is restricted to the cost of providing the 
services elsewhere; e.g., an outpatient department of a participating hospital, if that alternative is less costly. In 
all cases, refer claim to medical staff for a determination. You can find this rule in Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-03, National Coverage Determination (NCD) 
Durable Medical Equipment Reference List (280.1) 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 Group 2 Single Power Option Power Wheelchair (PWC) (K0835, K0836, K0837, K0838, 
K0839, K0840) is covered if all of the coverage criteria (a)-(e) for a PWC are met and if:  
Criterion 1 or 2 is met; 
1. The beneficiary requires a drive control interface other than a hand or chin-operated 
standard proportional joystick (examples include but are not limited to head control, sip 
and puff, switch control). 
2. The beneficiary meets coverage criteria for a power tilt or a power recline seating system 
(see next rule and the system is being used on the wheelchair. 
You can find more information in Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
The rules say that a power seating system  tilt only, recline only, or combination tilt and recline  with or 
without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: 
1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility 
Devices LCD; and 
2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a 
physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and 
experience in rehabilitation wheelchair evaluations of the beneficiarys seating and positioning needs. 
The PT, OT, or practitioner may have no financial relationship with the supplier; and 
3. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and Assistive 
Technology Society of North America certified Assistive Technology Professional (ATP) who 
specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the 
beneficiary. 
4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional 
weight shift; or 
5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to 
independently transfer from the wheelchair to bed; or 
6. The power seating system is needed to manage increased tone or spasticity. If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. 
You can find this rule in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). 
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 state that the single photon emission computed tomograph (SPECT) acquires information on the 
concentration of radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical 
conditions including: 
 stress fracture. 
 spondylosis. 
 infection (e.g., discitis). 
 tumor (e.g., osteoid osteoma). 
 analyze blood flow to an organ, as in the case of myocardial viability. 
 differentiate ischemic heart disease from dilated cardiomyopathy. 
You can find this information in National Coverage Determination (NCD): Single Photon Emission Computed 
Tomography (SPECT) (220.12). 
 
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 Viscosupplementation therapy for the knee via intra-articular injections of hyaluronic 
preparations will be considered medically reasonable and necessary when ALL of the following conditions are 
met: 
 The patient is symptomatic. Such symptoms may include pain which interferes with the activities of 
daily living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee 
stiffness  
 The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint 
space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts 
 If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, 
laboratory and imaging studies (i.e. the pain and functional disability is not considered likely to be due 
to a diagnosis other than osteoarthritis of the knee.) 
 The patient has failed at least three months of conservative therapy. Conservative therapy is defined as:  
o Nonpharmacologic therapy (such as but not limited to home exercise program, education, 
weight loss, physical therapy if indicated); and 
o If not contraindicated, simple analgesics and NSAIDS. 
 The patient has failed to respond to aspiration of the knee and intra-articular corticosteroid injection 
therapy when inflammation is a significant component of the patients symptoms and intra-articular 
corticosteroids are not contraindicated. 
You can find this rule in the Local Coverage Determination (LCD)- L33767, Viscosupplementation Therapy 
For Knee. 
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 whole gland high-intensity focused ultrasound (HIFU) is considered medically necessary as a 
local treatment for recurrent prostate cancer (PCa) following radiation therapy when ALL of the following 
criteria are met: 
 
1. Biochemical recurrence (BCR) according to the Phoenix definition (PSA nadir + 2 ng/mL) 
2. Positive post-RT transrectal ultrasound guided (TRUS) biopsy 
3. Candidate for local curative therapy as evidenced by favorable clinical and pathologic factors (BOTH OF 
THE FOLLOWING) 
 
a. Original (pre radiation therapy) clinical stage T1-T2, NX or N0 
b. Current (all are required) 
 
i. Prostate Specific Antigen (PSA) less than 10 ng/mL 
ii. absence of distant metastases per National Comprehensive Cancer Network (NCCN) imaging guidelines 
iii. no lymph node involvement 
iv. interval to biochemical failure more than 18 months 
v. International Society of Urological Pathology (ISUP) grade less than 4 
vi. local recurrence amenable to entire destruction 
 
4. Multi-disciplinary consensus (surgeon, oncologist, radiologist) 
5. Hi comorbidity (i.e., not a candidate for radical prostatectomy (RP)) 
 
You can find this rule in the Local Coverage Determination (LCD) -  Salvage High-intensity Focused 
Ultrasound (HIFU) Treatment in Prostate Cancer (PCa) (L38262) - Effective April 1, 2020. 
 
The rules say that the exclusion criteria for high-intensity focused ultrasound are: 
 
1. Life expectancy less than ten years 
2. PCa subtype other than adenocarcinoma 
3. Post radiation therapy androgen deprivation therapy (ADT) 
4. Post radiation therapy anal/rectal stenosis or rectal wall thickness more than 6 mm by transrectal ultrasound 
(TRUS) or magnetic resonance imaging (MRI) 
 
You can find this rule in the Local Coverage Determination (LCD) -  Salvage High-intensity Focused 
Ultrasound (HIFU) Treatment in Prostate Cancer (PCa) (L38262) - Effective April 1, 2020. 
 
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 epidural steroid injection (ESI) will be considered medically reasonable and necessary when 
the following three (3) requirements are met: 
  
   
1. History, physical examination, and concordant radiological image-based diagnostic testing supporting one of 
the following: 
 
-Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to disc 
herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis 
-Post-laminectomy syndrome 
-Acute herpes zoster associated pain 
 
2. Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality of 
life or function. An objective pain scale or functional assessment must be performed at baseline (prior to 
interventions). The same scale* must be repeated at each follow-up for assessment of response. 
3. Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or medical 
documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes zoster 
refractory to conservative management where a four (4) week wait is not required 
 
You can find this rule in the Local Coverage Determination (LCD) - Epidural Steroid Injections for Pain 
Management (L39036) - Effective December 5, 2021. 
 
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 state that coverage and payment for Medicare telehealth services includes consultation, office visits, 
individual psychotherapy, and pharmacologic management delivered via a telecommunications system. 
Eligible geographic areas include rural health professional shortage areas (HPSA) and counties not classified as 
a metropolitan statistical area (MSA). The originating site for telehealth services (location to which the enrollee 
presents) must be a practitioners office, hospital, rural health clinic (RHC), federally qualified health center 
(FQHC), skilled nursing facility or community mental health center. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 12, Sections 190.1 and 190.2. 
  
The rules say that for eligible telehealth services, telecommunications systems substitute for an in-person 
encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an originating 
site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional 
Shortage Area (HPSA) located in a rural census tract. You can find this in the CMS MLN document entitled 
Telehealth 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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
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 Plan 
offers a supplemental (extra) benefit to cover routine vision services that are not covered by Original Medicare. 
This benefit includes one routine (non-Medicare covered) eye exam every calendar year and one purchase of 
routine vision hardware (eyeglass lenses and frame and disposable or conventional contact lenses) every 2 
calendar years. There is a $250 allowance for routine vision hardware every 2 years. You must see an in-
network vision provider to receive routine vision benefits. You can find this information on page 92 of the 
Plan's 2021 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 definitive urine drug testing may be reasonable and necessary based on patient specific 
indications, including historical use, medication response, and clinical assessment, when accurate results are 
necessary to make clinical decisions. The clinicians rationale for the definitive urine drug testing and the tests 
ordered must be documented in the patients medical record. You can find this rule in the Local Coverage 
Determination (LCD) - Controlled Substance Monitoring and Drugs of Abuse Testing (L36393) - Effective 
October 1, 2019. 
 
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 $40 copayment for each Medicare-covered eye exam. You can find this 
information on pages 111-113 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. 
 
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 the following types of tests are examples of services that are not relevant to a Medicare 
beneficiary, are not considered a Medicare benefit (statutorily excluded), and therefore will be denied as 
Medicare Excluded Tests: 
 Tests considered screening in the absence of clinical signs and symptoms of disease that are not 
specifically identified by the law 
 Tests performed to determine carrier screening 
 Tests performed for screening hereditary cancer syndromes 
 Prenatal diagnostic testing 
 Tests performed on patients without signs or symptoms to determine risk for developing a disease or 
condition 
 Tests performed to measure the quality of a process 
 Tests without diagnosis specific indications 
 Tests identified as investigational by available literature and/or the literature supplied by the developer 
and are not a part of a clinical trial 
Screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or 
disease predisposition are not a Medicare benefit and are not covered. 
 In accordance with the Code of Federal Regulations, Title 42, Subchapter B, Part 410, Section 410.32, the 
referring/ordering practitioner must have an established relationship with the patient, and the test results must 
be used by the ordering/referring practitioner in the management of the patients specific medical problem. 
 
For ease of reading, the term gene in this document will be used to indicate a gene, region of a gene, and/or 
variant(s) of a gene. 
 
You can find these rules in the Local Coverage Article Billing and Coding: Molecular Pathology and Genetic 
Testing, A58917. 
 
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.