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 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 tThe 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. The Plan contract says that
you receive a $500 reimbursement allowance per year for preventive dental services. You can find this
information on page 70 of the 2022 Evidence of Coverage (EOC).his website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that 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.

The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance Manual, Section 50.12.1.

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 is limited to 1 set of bitewing x-rays per year. You can find this information on
page 69 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 claims or claim lines that have been determined to be exact duplicates of another claim or
claim line are denied. However, such denials may be appealed. An exact duplicate for physician and other
supplier claims is a claim that exactly matches another claim or claim line with respect to, among other items,
provider number, date of service, procedure code, place of services, and billed amount. You can find this rule
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare
Claims Processing Manual, Chapter 1, Section 120.2.

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 state that therapeutic continuous glucose monitors (CGMs) and related supplies are 
covered by
Medicare when all of the following coverage criteria are met:
1. The beneficiary has diabetes mellitus,
2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of 
insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump,
3. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on 
the basis of blood glucose monitor (BGM) or CGM testing results,
4. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person 
visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-3) 
above are met; and,
5. Every six (6) months following the initial prescription of the CGM, the treating practitioner 
has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment 
plan.

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 that physicians in the same group practice who are in the same specialty must bill and be paid as
though they were a single physician. If more than one evaluation and management (face-to-face) service is
provided on the same day to the same patient by the same physician or more than one physician in the same
specialty in the same group, only one evaluation and management service may be reported unless the
evaluation and management services are for unrelated problems. Instead of billing separately, the physicians
should select a level of service representative of the combined visits and submit the appropriate code for that
level. You can find this rule at Medicare Claims Processing Manual Chapter 12 - Section 30.6.5.

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).

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 for durable medical equipment (DME), contractors pay the fee schedule amounts on a
monthly rental basis not to exceed a period of continuous use of 15 months. In the tenth month of rental, the
beneficiary is given a purchase option (see 30.5.2). If the purchase option is exercised, contractors continue to
pay rental fees not to exceed a period of continuous use of 13 months and ownership of the equipment
passes to the beneficiary. If the purchase option is not exercised, contractors continue to pay rental fees
until the 15-month cap is reached and ownership of the equipment remains with the supplier (see
30.5.4). In the case of electric wheelchairs only, the beneficiary must be given a purchase option at the
time the equipment is first provided (see 30.5.3). You can find this rule in the Centers for Medicare
& Medicaid Services Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS) 30.5 - Capped Rental Items.

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 durable medical equipment (DME) includes items such as hospital beds ordered by a
provider for use in the home. In Original Medicare, people who rent certain types of DME own the equipment
after paying copayments for the item for 13 months. As a member of our plan, however, you usually will not
acquire ownership of rented DME items no matter how many copayments you make for the item while a
member of our plan, even if you made up to 12 consecutive payments for the DME item under Original
Medicare before you joined our plan. Under certain limited circumstances, we will transfer ownership of the
DME item to you. Call Customer Service for more information. You can see this on page 34 of the Plans 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 CGM devices that solely display results on a smartphone and do not have a stand-alone 
receiver or integration into an infusion pump do not meet the definition of DME and will be denied as non-
covered (no benefit). 
 
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. CGM 
devices that solely display results on a smartphone and do not have a stand-alone receiver or integration into an 
infusion pump do not meet the definition of DME and will be denied as non-covered (no benefit).
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 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 retainer 
crowns and a pontic when certain criteria is met. You can find this information in Chapter 4 on page 69 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 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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that to report home health visits, the home health agency reports a G-code to represent a visit by 
each home health care discipline. The location where services were provided must always be reported along 
with the first visit reported on the claim. In addition to reporting a visit line using the G codes, HHAs must 
report an additional line item with the same revenue code and date of service, reporting one of the three Q 
codes (Q5001, Q5002, and Q5009), one unit and a nominal covered charge (e.g., a penny). You can find this 
rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 10, Section 40.2. 
 
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 that a manual wheelchair for use inside the home (K0001) is covered if: 
 Criteria A, B, C, D, and E are met; and 
 Criterion F or G is met. 
A. 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. 
B. The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately 
fitted cane or walker. 
C. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for 
use of the manual wheelchair that is provided. 
D. 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. 
E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the 
home. 
F. 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. 
G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the 
wheelchair. 
 
You can find this rule in the Local Coverage Determination for Manual Wheelchair Bases, L33788.  
 
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 plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. Further, it is essential that each 
provider and supplier enroll with the appropriate Medicare fee-for-service contractor. You can find this rule in 
the Medicare Program Integrity Manual, Chapter 15, Section 15.1. 
 
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 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 crowns 
when certain criteria is met. You can find this information in Chapter 4 on page 88 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 that Medicare does not cover chiropractic maintenance care. When further clinical improvement 
cannot be reasonably expected from ongoing care, the care is considered maintenance. 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 240.1.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that the only covered chiropractic service is manual manipulation of the spine to correct 
subluxation. You can find this information on page 52 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 Sacroiliac joint injections (SIJI) will be considered medically reasonable and necessary 
when all the following requirements are met: 
1. Moderate to severe low back pain primarily experienced over the anatomical location of the SI joints 
between the upper level of the iliac crests and the gluteal fold, AND 
2. Low back pain duration of at least three (3) months, AND 
3. Low back pain below L5 without radiculopathy, AND 
4. Clinical findings and/or imaging studies do not suggest any other diagnosed or obvious cause of the 
lumbosacral pain (such as central spinal stenosis with neurogenic claudication/myelopathy, foraminal 
stenosis or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, 
pseudoarthrosis, or pain related to spinal instrumentation), AND 
5. At least three positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or 
Posterior Shear, SI Compression, SI Distraction and Yeoman Tests, AND 
6. Low back pain persists despite a minimum of four weeks of conservative therapies. 
You can find these rules in Local Coverage Determination (LCD) sacroiliac joint injections and procedures 
(L39475). 
 
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.