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 state that a patient lift is covered if transfer between bed and a chair, wheelchair, or commode is 
required and, without the use of a lift, the beneficiary would be bed confined. 
 
A patient lift described by codes E0630, E0635, E0639, or E0640 is covered if the basic coverage criteria are 
met. If the coverage criteria are not met, the lift will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Patient Lifts L33799. 
 
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 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 information in National Coverage Determination (NCD): Next Generation Sequencing (NGS) 
(90.2). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $250 copayment for outpatient hospital services/outpatient surgery.  
You can find this information on page(s) 88 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. 
 
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. 
 
A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot 
with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot 
system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. 
You can find these rules 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 state that a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and 
necessary. You can find this rule in Local Coverage Determination (LCD) Cold Therapy L33735. 
 
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 guidelines say that a skin substitute is reasonable and necessary when you have 
ONE of the following wounds and have failed to respond to standard wound care: 
 
  
  1. A diabetic (neuropathic) foot ulcer (DFU), and not responding to treatment for greater than four weeks; OR 
2. A leg ulcer (venous leg/stasis ulcer (VLU)) that has been present for at least three months, but not 
responding to treatment for at least 30 days; OR 
3. A skin ulcer that is a result of a swollen area filled with pus (abscess), injury, or trauma, and not responding 
to treatment for four weeks or longer 
AND ALL of the following criteria are met: 
Your medical records show that the wound has failed to respond to standard wound care and what treatments 
have been tried and failed 
Standard wound care includes the following, but is not limited to: 
- Control of swelling (edema), local high blood pressure in the veins (venous hypertension), or type of swelling 
from blood fluids (lymphedema) 
- Control of infection including infection of the bone (osteomyelitis) and skin (cellulitis) 
- Removal of foreign body or cancer if present - Surgery to clean foreign material and dead tissue out of the 
wound (debridement) 
- For diabetic foot ulcers: Appropriate non-weight bearing or off-loading of pressure 
- For venous stasis ulcers: Compression therapy and limb elevation 
- Wound environment that promotes healing 
 
You can find these rules in the Local Coverage Determination (LCD) Wound Application of Cellular and/or 
Tissue Based Products (CTPs), Lower Extremities L36690. 
 
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 breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genetic testing for susceptibility to 
breast or ovarian cancer is covered in adults as medically reasonable and necessary when there is a personal 
history of breast cancer (invasive breast cancer or ductal carcinoma in situ) and ANY of the following 
indications: 
1. Diagnosed at age 45 or younger. 
2. Diagnosed at age 50 or younger with at least one close blood relative with breast cancer at any age. 
3. Diagnosed with two breast primaries (includes bilateral disease or cases where there are two or more 
clearly separate ipsilateral primary tumors) when the first breast cancer diagnosis occurred prior to age 
50. 
4. Diagnosed at age 60 or younger with a triple negative breast cancer (estrogen receptor [ER] negative, 
progesterone receptor [PR] negative, and human epidermal growth factor receptor 2 [HER2] negative). 
5. Diagnosed at any age and there are at least two close blood relatives with pancreatic cancer or prostate 
cancer with Gleason score >7 at any age. 
6. Diagnosed at age 50 or younger with a limited family history (e.g., fewer than two first or second-
degree female relatives or female relatives surviving beyond 45 years in the relevant maternal and/or 
paternal lineage). 7. Diagnosed at any age and there are at least two close blood relatives with breast cancer at any age. 
8. Diagnosed at any age with at least one close blood relative with breast cancer at age 50 or younger. 
9. Diagnosed at any age with at least one close blood relative with epithelial ovarian cancer, fallopian 
tube, or primary peritoneal cancer. 
10. Close male blood relative with breast cancer. 
11. Individual of Ashkenazi Jewish descent (begin testing with Ashkenazi Jewish founder specific 
mutations). If negative, complete analysis may be considered if ancestry also includes non-Ashkenazi 
Jewish relatives or other criteria for BRCA1/BRCA2 genetic testing are met. 
You can find the rules in Local Coverage Determination (LCD) BRCA1 and BRCA2 Genetic Testing L36499. 
 
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 manual wheelchair for use inside the home (E1037, E1038, E1039, E1161, 
K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009) is covered if: 
 
Criteria A, B, C, D, and E are met; and 
Criterion F or G is met. 
The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more 
mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. A mobility limitation is one that: 
 
  1.  Prevents the beneficiary from accomplishing an MRADL entirely, or 
 
  2.  Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the 
attempts to perform an MRADL; or 
 
  3.  Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
 
The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane 
or walker. 
 
The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for use of 
the manual wheelchair that is provided. 
 
Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in MRADLs and 
the beneficiary will use it on a regular basis in the home. 
 
The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home. 
 
The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to 
safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both 
upper extremities are relevant to the assessment of upper extremity function. 
 
The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair. 
 
You can find this information in the Local Coverage Determination (LCD) Manual Wheelchair Bases L33788. 
 
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 to be eligible for coverage of a continuous glucose monitor (CGM) and related supplies, the 
beneficiary must meet all of the following initial coverage criteria (1)-(5): 
  
   
1. The beneficiary has diabetes mellitus; and, 
2. The beneficiarys treating practitioner has concluded that the beneficiary (or beneficiarys caregiver) has  
    sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
3. The CGM is prescribed in accordance with its Food and Drug Administration (FDA) indications for use; 
     and, 
4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the 
     criteria below: 
     A. The beneficiary is insulin-treated; or, 
     B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the 
          following: 
           -     Recurrent level 2 hypoglycemic events that persist despite multiple attempts to adjust  
                 medication(s) and/or modify the diabetes treatment plan; or, 
           -     A history of one level 3 hypoglycemic event characterized by altered mental and/or physical state  
                 requiring third-party assistance for treatment of hypoglycemia 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare- 
    approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria 
     (1)-(4) above are met.  
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
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 $150 copayment for outpatient surgery.  You can find this information 
on page(s) 78 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 state that if performed to facilitate the infusion or injection or hydration procedure, the following 
services and items are included and are not separately billable: 
1. Use of local anesthesia; 
2. Intravenous (IV) start; 
3. Access to indwelling IV, subcutaneous catheter or port; 
4. Flush at conclusion of infusion; and 
5. Standard tubing, syringes, and supplies. 
 
Payment for the above is included in the payment for the chemotherapy administration or nonchemotherapy 
injection and infusion service. You can find this rule in Medicare Claims Processing Manual Chapter 12, 
Section 30.5(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.
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 20% coinsurance for durable medical equipment (DME).  You can find 
this information on page(s) 72 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare & Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
requested item or service, but you have a $2,000 annual maximum, any remaining charges are your 
responsibility. You can find this information in Chapter 4 on page 99 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 & 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 pages 33-34 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 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 also says that enrollees must pay a $125 copayment for Medicare-covered radiological diagnostic 
services, including CT scans. You can find this information on pages 66-69 of the Plans 2023 Evidence of 
Coverage (EOC).