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 the durable medical equipment (DME) list that follows is designed to facilitate the Medicare 
Administrative Contractors (MAC's) processing of DME claims. This section is designed as a quick reference 
tool for determining the coverage status of certain pieces of DME and especially for those items commonly 
referred to by both brand and generic names. The information contained herein is applicable (where 
appropriate) to all DME national coverage determinations (NCDs) discussed in the DME portion of this 
manual. The list is organized into two columns. The first column lists alphabetically various generic categories 
of equipment on which NCDs have been made by the Centers for Medicare & Medicaid Services (CMS); the 
second column notes the coverage status. 
 
In the case of equipment categories that have been determined by CMS to be covered under the DME benefit, 
the list outlines the conditions of coverage that must be met if payment is to be allowed for the rental or 
purchase of the DME by a particular patient, or cross-refers to another section of the manual where the 
applicable coverage criteria are described in more detail. With respect to equipment categories that cannot be 
covered as DME, the list includes a brief explanation of why the equipment is not covered. This DME list will 
be updated periodically to reflect any additional NCDs that CMS may make with regard to other categories of 
equipment. 
 
When the MAC receives a claim for an item of equipment which does not appear to fall logically into any of 
the generic categories listed, the MAC has the authority and responsibility for deciding whether those items are 
covered under the DME benefit. 
 
 The term DME is defined as equipment which: 
 
    Can withstand repeated use; i.e., could normally be rented and used by successive patients; 
    Is primarily and customarily used to serve a medical purpose; 
    Generally is not useful to a person in the absence of illness or injury; and, 
    Is appropriate for use in a patients home. 
 
You can find these rules in the 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 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 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 Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a 50% coinsurance for crowns - porcelain/ceramic, and core buildup, 
including any pins when required.  You can find this information in Chapter 4 on pages 4-83 to 4-84 of the 
Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that the Plan covers certain dental services as a supplemental (extra) benefit. For 
services obtained out-of-network (OON) the plan only pays up to a certain amount. If you choose to see an 
OON dentist, you might be billed for any amount greater than what the plan pays, even for services listed as $0 
copayment. You can find this information in Chapter 4 on page 80 of the Plan's 2022 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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that providers or suppliers shall use anatomic modifiers (e.g., RT, LT, FA, F1-F9, TA, T1-T9, 
E1-E4) and report procedures with differing modifiers on individual claim lines when appropriate. Many 
medically unlikely edits (MUEs) are based on the assumption that correct modifiers are used. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 23, Section 20.9.3.2. 
 
The rules say that some international classification of diseases, 10
th
 revision, clinical modification (ICD-10-
CM) codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no 
bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If 
the side is not identified in the medical record, assign the code for the unspecified side. You can find this rule 
in the ICD-10-CM Official Guidelines for Coding and Reporting, Section 1.B.13. 
 
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 $95 copayment for other diagnostic procedures and tests, including a 
nerve study. You can find this information on pages 53-54 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 state that a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control, are covered if the beneficiary has had recent injury to or a surgical procedure on the 
knee(s). 
 
Addition codes will be denied as not reasonable and necessary if the base orthosis is not reasonable and 
necessary or the addition is not reasonable and necessary. 
 
You can find this information in Local Coverage Determination (LCD): Knee Orthoses (L33318). 
 
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 the plan of care must be signed and dated by a physician or allowed practitioner as 
described who meets certification and recertification requirements before the claim for each 30-day period for 
services is submitted for the final percentage payment. Any changes in the plan of care must be signed and 
dated by a physician or allowed practitioner. You can find this rule in Medicare Benefit Policy Manual Chapter 
7, Section 30.2.5. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for the requested items or services, but only when they are received from an in-network provider. You 
can find this information on page 30 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 says that enrollees must pay a 20% coinsurance for outpatient dialysis services received in 2021. You 
can find this information 105 of the Plan's 2021 Evidence of Coverage (EOC). 
 
The Plan contract says that enrollees must pay a 20% coinsurance for outpatient dialysis services received in 
2022. You can find this information 105 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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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. Members 
with chronic conditions may benefit from the services provided by trained service dog as described under the 
Americans with Disabilities Act (ADA). The Plan uses the ADA definition of a service dog that is individually 
trained to do work or perform tasks for people with disabilities. The work or task a service dog has been trained 
to provide must be directly related to the persons disability. Dogs whose sole function is to provide comfort or 
emotional support do not qualify as service animals under the ADA. You can find this information in Chapter 4 
on pages 93 to 95 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 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 180 to 183 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). You can find these rules in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D). 
 
Medicare rules also say that if an option or accessory that is included in another code is billed separately, the 
claim line will be denied as not separately payable. This rule is found in 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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) (L36256) and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) (A57527). 
 
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 specify brands and manufacturers as preferred and charge lower cost-sharing for 
the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the 
following conditions are met (42 CFR 422.100(l)): 
1. The MA plan provides all categories of DME covered under original Medicare Part B; 
2. The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) 
DME products or brands; 
3. The MA plans contracted suppliers provide access to all preferred DME brands; 
4. During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will 
provide a 90-day transition period (commencing with the initial time of enrollment) during which the plan 
provides (and repairs, as applicable) non-preferred DME brands furnished in the previous year; 
5. Although the MA plan may add brands to its preferred formulary during the year, it may not remove 
any brands mid-year; 
6. The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
7. The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-
preferred DME product or brand with the EOC and ANOC and on its website; and 
8. The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories 
or subcategories annually determined by CMS to require full coverage. 
 
You can find this rule in the Center for Medicare Services (CMS) Internet-Only Manual, Publication 100-16, 
Medicare Managed Care Manual, Chapter 4, Section 10.12.2. 
 
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 for test strips and blood glucose monitors, the preferred manufacturer is Roche Diagnostics. 
ACCU-CHEK (made by Roche Diagnostics). You can find this information on page 60 of the 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 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 page 97 of the Plans 2023 Evidence of Coverage.