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 ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure (BiPAP) device is 
made based upon the specifics of each persons medical condition. There must be enough detailed information 
in the medical record to justify the treatment selected. You can find this rule in the Local Coverage 
Determination (LCD): Respiratory Assist Devices (L33800). 
 
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 Functional blepharoplasty procedures and surgical procedures of the brow will be 
considered medically reasonable and necessary in the following situations: 
1. When the goal of the surgery is to restore function and normalcy to a structure that has been altered by 
trauma, infection, inflammation, degeneration, neoplasia, or developmental errors1 or; 
2. When there is interference with visual field, near or far visual impairment, or difficulty reading due to any 
of the following: 
a. Dermatochalasis 
b. Blepharochalasis 
c. Blepharoptosis 
d. Brow ptosis causing malposition of the upper eyelid1 and demonstrating a MRD1 (Margin reflex 
distance) of 2 mm or less 
e. Looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis 
f. Pseudoptosis 
g. When there is visual impairment secondary to redundant skin weighing down on upper lashes1 
resulting in eye strain, headache and loss of vision. 
h. When there is chronic, symptomatic dermatitis3 of pretarsal skin1 caused by redundant upper lid 
skin which has not been successfully treated by conservative measures such as education regarding 
hygiene, antibiotics, etc.; or 
3. Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual field 
impairment3; or 
4. When there is the presence of prosthesis difficulties in an anophthalmic socket3,6; or 
5. When there is laxity of the lower eyelid tissues causing lower eyelid ectropion resulting in eye irritation and 
inflammation and excessive tearing2; or 
6. When there is inward rotation of the eyelid margin causing entropion where the eyelashes are contacting 
the cornea resulting in discomfort, redness, tearing, and foreign body sensation2; or 
7. Lower eyelid edema, tumor or mass causing signs and symptoms of eyelid ectropion.1,2 
 
You can find this rule in the Local Coverage Determination (LCD) for Blepharoplasty, Blepharoptosis Repair 
and Surgical Procedures of the Brow, L34028. 
 
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 treatments for symptomatic varicose tributaries are either compressive sclerotherapy or 
microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are > than 4 mm in diameter and if the patient 
remains symptomatic after a six-week trial of conservative therapy.   
 
The components of the conservative therapy include, but are not limited to: 
 weight reduction, 
 a daily exercise plan, 
 periodic leg elevation, and 
 the use of graduated compression stockings. 
The conservative therapy must be documented in the medical record. Inability to tolerate compressive bandages 
or stockings and the reason for such intolerance must be documented in the medical record. You can find this 
rule at Local Coverage Determination (LCD) L33575: Varicose Veins of the Lower Extremity, Treatment of 
(eff. 11/21/19). 
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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
The rules say that contract suppliers are not required to furnish a specific brand name item or mode of delivery 
to a beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical outcome. 
You can find this information in the Medicare Claims Processing Manual, Chapter 36, Section 30.4 - 
Prescription for Particular Brand, Item, or Mode of Delivery 
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 Pneumatic Compression Device (PCD) that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a 
preventative service or function are excluded from coverage under the Medicare Durable Medical Equipment 
(DME) benefit. A PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
There is insufficient evidence to demonstrate that reimbursement is justified. Claims for E0675 will be denied 
as not reasonable and necessary. You can find this information in the Local Coverage Article: Pneumatic 
Compression Devices - Policy Article (A52488) and in the Local Coverage Determination (LCD): Pneumatic 
Compression Devices (L33829). 
 
The rules say lymphedema is the swelling of subcutaneous tissues due to the accumulation of excessive lymph 
fluid. The accumulation of lymph fluid results from impairment to the normal clearing function of the 
lymphatic system and/or from an excessive production of lymph. Lymphedema is divided into two broad 
classes according to etiology. Primary lymphedema is a relatively uncommon, chronic condition which may be 
due to such causes as Milroy's Disease or congenital anomalies. Secondary lymphedema, which is much more 
common, results from the destruction of or damage to formerly functioning lymphatic channels, such as 
surgical removal of lymph nodes or post radiation fibrosis, among other causes. 
 
Pneumatic compression devices are covered in the home setting for the treatment of lymphedema if the patient 
has undergone a four-week trial of conservative therapy and the treating physician determines that there has 
been no significant improvement or if significant symptoms remain after the trial. The trial of conservative 
therapy must include use of an appropriate compression bandage system or compression garment, exercise, and 
elevation of the limb. The garment may be prefabricated or custom-fabricated but must provide adequate 
graduated compression. You can find these rules in the National Coverage Determination (NCD) Pneumatic 
Compression Devices 280.6. 
 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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 10-11 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 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. You can find this information 
on pages 71 of the Plans 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 Field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative 
periods that apply to each surgical procedure. The payment rules for surgical procedures apply to codes with 
entries of 000, 010, 090, and, sometimes, YYY. Codes with 090 in Field 16 are major surgeries. Codes with 
000 or 010 are either minor surgical procedures or endoscopies. The Medicare approved amount for these 
procedures includes payment for supplies related to the surgery when furnished by the physician who performs 
the surgery. You can find this information in the Centers for Medicare and Medicaid Services (CMS), 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 Medicare covers medical nutrition therapy services (MNT) for certain enrollees who have 
diabetes or a renal disease. You can find this rule at 42 CFR Section 410.132(b)(4) and in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, National Coverage 
Determinations Manual, Chapter 1, Section 180.1. 
 
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 Plan 
contract also says that medical nutrition therapy is for people with diabetes or kidney disease without 
dialysis. It is also for after a kidney transplant when referred by your doctor. You can find this information on 
page 62 of the Plan's 2022 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 417.414. 
 
The rules state that percutaneous image-guided lumbar decompression (PILD) for lumbar spinal stenosis (LSS) 
may only be covered under the context of a clinical trial as described in section B above according to section 
1862(a)(1)(E) of the Social Security Act. CMS has determined that PILD for LSS is not reasonable and 
necessary under section 1862(a)(1)(A) of the Act. You can find this information in National Coverage 
Determination (NCD): Percutaneous Image-Guided Lumbar Decompression for Lumbar Spinal Stenosis 
(150.13). 
 
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 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 
preventive and comprehensive dental services. The deep gum and root cleaning is covered by the Plan's dental 
benefits. You can find this information on pages 73 to 77 of the Plans 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 the surgical management for the treatment of morbid obesity is considered reasonable and 
necessary for all nationally covered bariatric surgical procedures and Laproscopic sleeve gastrectomy when 
ALL of the following conditions are met and recorded in the medical record: 
 
   - The patient meets the definition of morbid obesity which is defined as a body mass index (BMI) > 35 and 
comorbid conditions exist (e.g., hypertensive cardiovascular disease, pulmonary/respiratory disease, diabetes, 
sleep apnea or degenerative arthritis of weight-bearing joints). Documentation of the level of severity of the 
comorbid existing condition must be included in the patients medical record; AND 
   - The patient has been previously unsuccessful with medical treatment for obesity; AND 
   - Treatable metabolic causes for obesity (e.g., adrenal or thyroid disorders) have been ruled out or have been 
clinically treated if present. 
 
You can find this rule in the Local Coverage Determination (LCD) for Surgical Management of Morbid 
Obesity (L33411). 
 
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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) 
procedures will be considered medically reasonable and necessary for the following indications: 
1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have 
not responded to non-surgical medical management (e.g., narcotic and/or non- narcotic medication, 
physical therapy modalities) with and without methods of immobility (e.g., rest, bracing). 
- Both percutaneous vertebroplasty (PVP) and PVA will be considered reasonable and necessary 
when ALL of the following criteria are met: 
o Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression 
fracture (VCF) (T1- L5), based on symptom onset, and documented by advanced 
imaging demonstrating bone marrow edema on MRI or bone-scan uptake and 
o The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating 
Scale [NRS] or Visual Analog Scale [VAS] pain score greater than or equal to 8) or is 
non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) 
despite optimal non-surgical management (NSM) with one of the following: 
 Worsening Pain or 
 Stable to improved pain (but NRS or VAS greater than or equal to 5) when 2 or 
more of the following are present: 
o Progression of vertebral body height loss 
o Less than 25% vertebral body height reduction 
o Kyphotic deformity 
o Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire [RDQ] less than 17) 
 
Exclusion criteria  
- Absolute contraindication 
o Current back pain is not primarily due to the identified acute or subacute VCF(s). 
o Osteomyelitis, discitis or active systemic infection 
o Pregnancy 
o Active surgical site infection 
- Relative contraindication 
o Greater than three vertebral fractures per procedure 
o Allergy to bone cement or opacification agents 
o Uncorrected coagulopathy o Spinal instability 
o Myelopathy from the fracture 
o Neurologic deficit 
o Neural impingement 
o Fracture retropulsion/canal compromise 
 
You can find this rule in the Local Coverage Determination for Percutaneous Vertebral Augmentation (PVA) 
for Vertebral Compression Fracture (VCF), L35130.  
 
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 ambulance services are only covered when the patient's clinical condition is such that other 
methods of transport are contraindicated. You can find this rule at 42 CFR Section 410.40(e). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that non-emergency transportation by ambulance is appropriate if it is documented that the member's condition is such that other means of transportation could endanger the person's health and that transportation by ambulance is medically required. You can find this information on page 64 of the Plan's 2022 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 for a combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625), a KX modifier must be added to the code only if criterion (a) or (b) or (c) is met and criterion (d) is met:

a. There is a past history of, or current, pressure ulcer in the area of contact with the seating 
surface (refer
to the Group 1 codes in the ICD-10 code list section); or
b. There is absent or impaired sensation in the area of contact with the seating surface due to one 
of the diagnoses listed as a covered diagnosis for skin protection cushions (refer to the Group 2 
codes in the ICD-10 code list section); or
c.  There is an inability to carry out a functional weight shift due one of the diagnoses listed as 
a covered diagnosis for skin protection cushions (refer to the Group 2 codes in the ICD-10 code 
list section); and
d. The beneficiary has significant postural asymmetries due to one of the diagnoses listed as a 
covered diagnosis for positioning cushions (refer to the Group 2 and Group 3 codes in the ICD-10 
code list section).
 
You can find this rule in Local Coverage Article Wheelchair Seating - Policy Article A52505.

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.