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 consider Total Knee Arthroplasty (TKA) medically reasonable and necessary 
when three or more of the following criteria are met: 
1. Advanced joint disease demonstrated by radiographic supported evidence or magnetic resonance 
imaging (MRI), e.g., fracture or deterioration, distortion of joint surfaces, subchondral cysts, 
subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular 
necrosis; 
2. History of unsuccessful appropriate conservative therapy that is clearly documented in the pre-
procedure medical record. Non-surgical medical management is usually implemented for 3 months or 
more to assess effectiveness. Conservative treatment as clinically appropriate for the patients current 
episode of care typically includes one or more of the following: anti-inflammatory medications; 
analgesics; flexibility and muscle strengthening exercises with supervised physical therapy. 
3. Pain with functional disability due to arthritis or trauma to the knee joint; activities of daily living 
(ADLs) are diminished despite compliance with plan of care including activity restrictions as is 
reasonable, assistive device use, weight reduction as appropriate or therapeutic injections into the knee 
as appropriate; 
4. Distinct structural abnormalities such as: 
 Distal femur fracture; 
 Proximal tibia fracture; 
 Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; 
 Avascular or other form of osteonecrosis of the knee; 
 Rheumatologic changes precluding or inconsistent with rehabilitation 
5. Failed previous joint replacement/arthroplasty necessitating revision as indicated by any of the 
following: 
 Loosening, fracture, or mechanical failure of one or more components; 
 Technical or functional failure of previous knee surgery, e.g., unicompartmental knee 
replacement; 
 Previous osteotomy or partial arthroplasty; 
 Infection; 
 Periprosthetic fracture or bone loss of distal femur, proximal tibia or patella; Implant or knee 
malalignment; 
 Bearing surface wear leading to symptomatic synovitis; 
 Tibiofemoral or extensor mechanism instability; or 
 Knee stiffness, arthrofibrosis or other destructive conditions that render the knee impaired to the 
extent to preclude employment or functional activities. You can find this rule in the Local Coverage Determination for Lower Extremity Major Joint Replacement 
(Hip and Knee), L36007. 
 
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 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 100 of the 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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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 page 3-4 of the Plan's 2021 
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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients 
with BOTH the following: 
1. Inclusion criteria (ALL are required):  
a. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5) by recent (within 30 
days) advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain 
score greater than or equal to 8) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) despite 
optimal non-surgical management (NSM) (ONE): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still greater than or equal to 5) (with greater 
than or equal to 2 of the following): 
A. Progression of vertebral body height loss 
B. Greater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) greater than 17) 
c. Continuum of care (BOTH): 
i. All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis 
education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment 
program. 
 
You can find this rule in the Local Coverage Determination for Percutaneous Vertebral Augmentation (PVA) 
for Vertebral Compression Fracture (VCF), L38737.  
 
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 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. 
 
For power wheelchairs which are capable of being upgraded to an expandable controller (K0835, K0836, 
K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, 
K0854, K0855, K0856 K0857, K0858, K0859, K0860, K0861 K0862, K0863, K0864, K0868, K0869, K0870, 
K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891), E2377 is used if an 
expandable controller is provided at the time of initial issue. Code E2376 is used with complete replacement of 
an expandable controller. 
 
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the 
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting 
hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and 
with complete replacement of the expandable controller. Code K0108 must not be used for any component or 
feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete 
expandable controller is included in the allowance for codes E2377/E2376 plus E2313. 
 
You can find these rules 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 state that special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The Plan must have written policies for determining enrollee eligibility and 
must document its determination that an enrollee is a chronically ill enrollee. You can find this information in 
42 CFR 422.102. 
 
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 if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. You can find this information on pages 101 to 
102 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 state that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic 
preparations will be considered medically reasonable and necessary when all of the following conditions are 
met: 
1. The patient is symptomatic. Such symptoms may include pain which interferes with the activities of 
daily living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee 
stiffness. 
2. The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint 
space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. 
3. If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, 
laboratory and imaging studies (i.e., the pain and functional disability is not considered likely to be due 
to a diagnosis other than osteoarthritis of the knee). 
4. The patient has failed at least three months of conservative therapy. Conservative therapy is defined as: 
 Nonpharmacologic therapy (such as but not limited to home exercise program, education, 
weight loss, physical therapy if indicated); and 
 If not contraindicated, simple analgesics and (e.g., acetaminophen) or NSAIDS per hyaluronan 
product prescribing information. 
5. The patient has failed to respond to aspiration of the knee when effusion is present and intra-articular 
corticosteroid injection therapy when inflammation is a significant component of the patients 
symptoms and intra-articular corticosteroids are not contraindicated. 
 
You can find this information in Local Coverage Determination (LCD): Hyaluronan Acid Therapies For 
Osteoarthritis Of The Knee (L35427). 
 
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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c).  
 
Medicare coverage and payment for cataract surgery is the same irrespective of whether the surgery is 
performed using conventional surgical techniques or a bladeless, computer-controlled laser. Under either 
method, Medicare will cover and pay for the cataract removal and insertion of a conventional intraocular lens." 
While traditional cataract surgery is fully covered by most private medical insurance and Medicare, blade-less 
cataract surgery requires patients to pay out-of-pocket for the portion of the procedure that insurance does not 
cover. You can find this rule in the Centers for Medicare and Medicaid Services: Laser-Assisted Cataract 
Surgery and CMS (Centers for Medicare and Medicaid Services) Rulings 05-01 and 1536-R. 
 
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 Eye exam and one pair of eyeglasses (or contact lenses) are covered for people after 
cataract surgery, but excludes scratch-resistant coatings, mirror coatings, polarized lenses, deluxe lens features, 
and progressive lenses. You can find this on page 121 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 state that a custom fabricated seat cushion (E2609) is covered if criteria (1) and (3) are met. A custom 
fabricated back cushion (E2617) is covered if criteria (2) and (3) are met: 
 
1. The Beneficiary meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat 
cushion; 
2. The Beneficiary meets all of the criteria for a prefabricated positioning back cushion; 
3. There is a comprehensive written evaluation by a licensed/certified medical professional, such as a physical 
therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated seating system is not 
sufficient to meet the beneficiarys seating and positioning needs. The PT or OT may have no financial 
relationship with the supplier. 
 
This rule is found in Local Coverage Determination (LCD): Wheelchair Seating (L33312). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that therapeutic continuous glucose monitors (CGMs) and related supplies are covered by 
Medicare when all of the following coverage criteria are met: 
  1. The beneficiary has diabetes mellitus, 
  2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a 
Medicare-covered continuous subcutaneous insulin infusion (CSII) pump, 
  3. The beneficiarys insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results, 
  4. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the 
beneficiary to evaluate their diabetes control and determined that criteria (1-3) above are met; and, 
  5. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that Abbott and Lifescan glucometers, diabetic test strips, lancets, control solutions and a 
continuous glucose monitoring device are available for dispense via a retail or mail order pharmacy. All other 
desired brands will need to be obtained from a Durable Medical Equipment (DME) supplier (or via an 
exception process). You can find this information on pages 67-69 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 state that repeat injections are covered when after the first diagnostic facet joint procedure, there is a 
consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief being 
consistent with the agent used). This rule is found in Local Coverage Determination (LCD): Facet Joint 
Interventions for Pain Management (L33930). 
 
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 spinal cord stimulators may be covered as therapy for relief of chronic intractable pain, 
provided that the following conditions are met: 
 
  
  a) The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic 
intractable pain;  
b) With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for 
the given patient;  
c) Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation);  
d) All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be available; and  
e) Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
National Coverage Determinations Manual, Section 160.7(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.
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 prior to sleep testing, the patient has a face-to-face clinical evaluation by the treating 
physician to assess the patient for OSA which must include, at a minimum, the following: 
1. Sleep history and symptoms including, but not limited to, snoring, daytime sleepiness, observed apneas, 
choking or gasping during sleep, morning headaches; and, 
2. Epworth Sleepiness Scale; and, 
3. Physical examination that documents body mass index, neck circumference and a focused 
cardiopulmonary and upper airway system evaluation. 
You can find this rule in the Medicare Local Coverage Determination (LCD)- L33405, Polysomnography and 
Sleep Testing. 
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.