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 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 an expandable controller is capable of accommodating one or more of the following additional 
functions: 
- Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, 
chin control, head control, etc.) 
- Non-proportional input devices (e.g., sip and puff, head array, etc.) 
- Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power 
seating actuators though the Control Input Device would require the use of an additional component, 
E2310 or E2311.) 
 An expandable controller may also be able to operate one or more of the following: 
- A separate display (i.e., for alternate control devices) 
- Other electronic devices (e.g., control of an augmentative speech device or computer through the 
chair's drive control) 
- An attendant control 
 
You can find this information in the Local Coverage Article (LCA): Wheelchair Options/Accessories 
(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 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 $350 copayment for in-network outpatient surgery, including services provided at ambulatory surgical centers. You can find this information on page(s) 83 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 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 specific dental items/services stated in the Plans contract. Bone replacement grafts for ridge 
preservation-per site (D7953) are not covered. You can find this information on pages 88-100 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 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 1010 of the Plan's 2023 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 the Medicare approved amount for surgical procedures includes payment for certain 
services related to the surgery when furnished by the physician who performs the surgery. Major surgical 
procedures have a global period of 90 days. The initial consultation or evaluation of the problem by the surgeon 
to determine the need for surgery is not included in the global package. Please note that this policy only applies 
to major surgical procedures. 
 
Evaluation and management services on the day before major surgery or on the day of major surgery that result 
in the initial decision to perform the surgery are not included in the global surgery payment for the major 
surgery and, therefore, may be billed and paid separately. Modifier -57 can be used to report this situation. You 
can find this in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 12, Section 40.1. 
 
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 the medical necessity for the additional features of a custom fabricated prosthesis (L8035) 
compared to a prefabricated silicone breast prosthesis has not been established, and therefore, if an L8035 
breast prosthesis is billed, it will be denied as not reasonable and necessary. You can find this information in 
the Local Coverage Determination (LCD) for External Breast Prostheses (L33317). 
 
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 a fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, 
L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is 
covered for beneficiaries whose functional level is 3 or above.  
 
You can find this information in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787). 
 
When submitting a prosthetic claim, the billed code for knee, foot, ankle and hip (HCPCS codes L5610, L5611, 
L5613, L5614, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, 
L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, 
L5857, L5858, L5859, L5930, L5961, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, 
L5980, L5981, L5982, L5984, L5985, L5986, L5987) components must be submitted with modifiers K0 - K4, 
indicating the expected beneficiary functional level. This expectation of functional ability information must be 
clearly documented and retained in the prosthetist's records. The simple entry of a K modifier in those records 
is not sufficient. There must be information about the beneficiary's history and current condition which 
supports the designation of the functional level by the prosthetist. 
 
You can find this information in Local Policy Article (LCA) Lower Limb Prostheses (A52496). 

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 percutaneous laminotomy/laminectomy is a procedure proposed as a treatment for 
symptomatic Lumbar Spinal Stenosis (LSS) unresponsive to conservative therapy. This procedure is generally 
described as a non-invasive procedure using specially designed instruments to percutaneously remove a portion 
of the lamina and debulk the ligamentum flavum. The procedure is performed under x-ray guidance (e.g., 
fluoroscopic, CT) with the assistance of contrast media to identify and monitor the compressed area via 
epiduragram. Effective for claims with dates of service on or after January 9, 2014, Percutaneous Image-
Guided Lumbar Decompression (PILD) is covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E) through Coverage with Evidence Development (CED) for beneficiaries with LSS who are 
enrolled in an approved clinical study and meets the criteria listed in NCD-150.13, Transmittal 167. Effective 
for claims with dates of service on or after December 7, 2016, Medicare will cover PILD under CED for 
beneficiaries with LSS who are enrolled in a CMS-approved prospective longitudinal study PILD procedure 
using and FDA-approved/cleared device that completed a CMS-approved RCT (randomized controlled trial) 
that met the criteria listed in the January 2014 National Coverage Determination (NCD) (see CR 8757, 
transmittal #2959, dated May 16, 2014). You can find this information in Local Coverage Determination 
(LCD): Category III Codes (L35490). 
 
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 thyroid function testing may be medically necessary in patients with disease or neoplasm of 
the thyroid and other endocrine glands. Thyroid function testing may also be medically necessary in patients 
with metabolic disorders; malnutrition; hyperlipidemia; certain types of anemia; psychosis and non-psychotic 
personality disorders; unexplained depression; ophthalmologic disorders; various cardiac arrhythmias; 
disorders of menstruation; skin conditions; myalgias; and a wide array of signs and symptoms, including alterations in consciousness; malaise; hypothermia; symptoms of the nervous and musculoskeletal system; skin 
and integumentary system; nutrition and metabolism; cardiovascular; and gastrointestinal system. You can find 
this rule in National Coverage Determination (NCD) Thyroid Testing 190.22. 
 
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 continued coverage of a positive airway pressure (PAP) device (E0470 or E0601) beyond the 
first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after 
initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document that the 
beneficiary is benefiting from PAP therapy. For PAP devices with initial dates of service on or after November 
1, 2008, documentation of clinical benefit is demonstrated by: 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved; and, 
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. 
 
Adherence to therapy is defined as use of PAP greater than or equal to 4 hours per night on 70% of nights 
during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. If the 
above criteria are not met, continued coverage of a PAP device and related accessories will be denied as not 
reasonable and necessary. 
 
Accessories used with a PAP device are covered when the coverage criteria for the device are met. If the 
coverage criteria are not met, the accessories will be denied as not reasonable and necessary. Quantities of 
supplies greater than those described in the policy as the usual maximum amounts will be denied as not 
reasonable and necessary. 
 
You can find this rule in the Local Coverage Determination for Positive Airway Pressure (PAP) Devices for the 
Treatment of Obstructive Sleep Apnea, L33718. 
 
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 Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 in Chapter 3 on page 24 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 for parenteral nutrition to be considered reasonable and necessary, the treating practitioner 
must document that enteral nutrition has been considered and ruled out, tried and been found ineffective, or that 
enteral nutrition (EN) exacerbates gastrointestinal tract dysfunction. The beneficiary must have (a) a condition 
involving the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients 
or (b) disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to 
be transported through and absorbed by the gastrointestinal (GI) system. The beneficiary must have a 
permanent impairment. Please refer to the LCD-related Policy Article for further guidance regarding the test of 
permanence.   
 
The treating practitioner is required to evaluate the beneficiary within 30 days prior to initiation of parenteral 
nutrition. If the treating practitioner does not see the beneficiary within this timeframe, they must document the 
reason why and describe what other monitoring methods were used to evaluate the beneficiary's parenteral 
nutrition needs. There must be documentation in the medical record supporting the clinical diagnosis. You can 
find this information in Medicare's Local Coverage Determination (LCD): Parenteral Nutrition (L38953). 
 
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 a fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, 
L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is 
covered for beneficiaries whose functional level is 3 or above. 
 
You can find this information in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787). 
 
The rules say when submitting a prosthetic claim, the billed code for knee, foot, ankle and hip (HCPCS codes 
L5610, L5611, L5613, L5614, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, 
L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, 
L5848, L5856, L5857, L5858, L5859, L5930, L5961, L5970, L5971, L5972, L5973, L5974, L5975, L5976, 
L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987) components must be submitted with 
modifiers K0 - K4, indicating the expected beneficiary functional level. This expectation of functional ability 
information must be clearly documented and retained in the prosthetist's records. The simple entry of a K 
modifier in those records is not sufficient. There must be information about the beneficiary's history and 
current condition which supports the designation of the functional level by the prosthetist. 
You can find this information in Local Policy Article (LCA) Lower Limb Prostheses (A52496). 

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. 
You can find this information on page 120 of the Plans 2023 Evidence of Coverage (EOC).