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 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 services listed in the Plan's benefit chart; any service not listed is not covered. You can find this information on pages 21 to 33 of the Plan's 2021 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 only chiropractic service Medicare covers is manual manipulation of the spine to correct
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).
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 health
Plan contract says that the Plan covers manual manipulation of the spine to correct subluxation. The Plan
covers 12 supplemental routine chiropractic visits per year. You can find this information on page 66 of the
Plan's 2021 Evidence of Coverage
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that 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 Ostomy supplies are covered for use on a beneficiary with a surgically created opening
(stoma) to divert urine, or fecal contents outside the body. Ostomy supplies are appropriately used for
colostomies, ileostomies or urinary ostomies (see covered diagnosis codes below.) Use for other conditions will
be denied as noncovered. You can find this information in Local Coverage Article Ostomy Supplies, Policy
Article A52487.
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 the services listed in the Plan's benefit chart when provided in-network. You can find this information on pages 82 to 83 of the Plan's 2021 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 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
Medicare Program Integrity Manual Chapter 3, Section 3.3.2.1.
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, Section 424.5.
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 an inpatient admission is generally appropriate when the admitting physician expects the
patient to need hospital care that crosses at least two midnights. The expectation should be based on such
complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and
medical risk. The factors must be documented in the medical record.
If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be
considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as
"inpatient only" is generally appropriate, regardless of the length of stay. An inpatient admission may be
appropriate if the admitting physician expects a patient to require hospital care for only a limited period of
time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be
supported by the medical record. You can find this rule at 42 CFR Section 412.3.
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 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 $295 copayment for Medicare-covered surgery or other services
provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and
physician or surgical charges. You can find this information on pages 4-38 to 4-39 of the Plan's 2021 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 abdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the
abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally,
chronic pain, ulceration created by the abdominal skin fold, or intertrigo dermatitis, such surgery is considered
reconstructive. Preoperative photographs may be required to support justification and should be supplied upon
request.
Medicare considers panniculectomy medically necessary when the panniculus hangs below the level of the
pubis, and the medical records document that the panniculus causes chronic intertrigo (dermatitis occurring on
opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over 3 months while
receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of 3
months.
You can find more information at Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery
(L33428)
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 determination of the medical necessity for certain components/additions to the prosthesis
is based on the beneficiary's potential functional abilities. Potential functional ability is based on the reasonable
expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to:
The beneficiary's past history (including prior prosthetic use if applicable); and
The beneficiary's current condition including the status of the residual limb and the nature of other medical
problems; and
The beneficiary's desire to ambulate.
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.
The records must document the beneficiary's current functional capabilities and his/her expected functional
potential, including an explanation for the difference, if that is the case. It is recognized, within the functional
classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level
classifications.f a prosthesis is denied as not reasonable and necessary, related additions will also be denied as not reasonable
and necessary.
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 this information in the Local Coverage Determination (LCD): Lower Limb Prostheses (L33787)
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 effective for claims with dates of service on or after January 12, 2017, Medicare covers
therapeutic Continuous Glucose Monitor (CGM) devices under the Durable Medical Equipment (DME)
benefit. CGM devices covered by Medicare are defined in CMS Ruling 1682R as therapeutic CGM. CGM
devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied
as non-covered (no benefit). There is no Medicare benefit for supplies and accessories used with equipment
that is not classified as DME. Coverage of a CGM system supply allowance (K0553) is available for those
therapeutic CGM systems where the beneficiary uses a receiver classified as DME to display glucose data. You
can find this information in the Local Coverage Article: Glucose Monitor - Policy Article (A52464).
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 Appeal Number is:
1-10556263036
The Appeal Number is:
1-10556263036
The rules state that anesthesia time is defined as the period during which an anesthesia practitioner is present
with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in
the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing
anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care. You
can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual,
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 50.
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 pay for durable medical equipment that is mainly used to serve a medical
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are
clearly used for medical purposes. Medicare will not pay for:
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air
conditioners, humidifiers, dehumidifiers and electric air cleaners;
2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. 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.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The rules say that 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 rule at Local Coverage Article (LCA): Wheelchair Options/Accessories - Policy Article
(A52504).
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 codes A9276 (SENSOR; INVASIVE (E.G., SUBCUTANEOUS), DISPOSABLE, FOR USE
WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM, ONE UNIT = 1 DAY
SUPPLY) and A9277 (TRANSMITTER; EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS
GLUCOSE MONITORING SYSTEM) describe the supplies used with a non-therapeutic CGM. Codes A9276
and A9277 are not used to bill for supplies used with code K0554. You can find this rule in Local Coverage
Article: Glucose Monitor - Policy Article (A52464) - Effective June 7, 2018.
The rules say that code A9278 (RECEIVER (MONITOR); EXTERNAL, FOR USE WITH INTERSTITIAL
CONTINUOUS GLUCOSE MONITORING SYSTEM) describes any CGM system that fails to meet the DME
Benefit requirements as described in CMS Ruling 1682R. You can find this rule in Local Coverage Article:
Glucose Monitor - Policy Article (A52464) - Effective June 7, 2018.
The rules say that continuous glucose monitors that are covered by Medicare under the DME benefit are
defined by CMS ruling 1682R as therapeutic monitors. You can find this rule in Local Coverage Determination
(LCD): Glucose Monitors (L33822) - Effective January 1, 2020.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that 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 a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and
necessary. You can find this information on 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 to qualify for home health services, the patient must be:

1. Confined to the home;
2. Under the care of a physician or allowed practitioner;
3. Receiving services under a plan of care established and reviewed by a physician;
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d)
continuing occupational therapy.
You can find this rule at 42 CFR Section 409.42.

The rules say that eligibility for the home health benefit will be determined based on the certifying physician or
allowed practitioner's records. If the enrollee was directly admitted to home health from an acute or post-acute
care facility, the facility records may be used instead. The medical records for the enrollee must contain
information that justifies the referral for home health services.

The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the
enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face
encounter visit. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only
Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and
30.5.1.2.

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 say that health plans, physicians, hospitals, and other health care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding Guidelines. You can find this rule in the Medicare Claims Processing Manual, Chapter 23, Section 10. 

The rules also say that some 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 information in the ICD-10-CM Official Guidelines for Coding and Reporting, Section I, Conventions, general coding guidelines and chapter specific guidelines.

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.