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 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 
 
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. However, if individual 
components of the harness are replaced, code K0108 should be used. 
 
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 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. 
 
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 ambulance services billed with code A0425 have a Medically Unlikely Edit (MUE) of 250 
miles.  This is the maximum number of units billable on a single line of the claim.  If you report this code with 
units greater than the MUE, the claim will deny.  You can find this rule at Centers for Medicare and Medicaid 
Services, Novitas Solutions Policy Bulletin entitled "Ambulance Mileage Claims May Require Supporting 
Documentation." 
 
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 
 
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. However, if individual 
components of the harness are replaced, code K0108 should be used. 
 
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 that for any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit 
category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory 
requirements. Information provided in this policy article relates to determinations other than those based on 
Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary). 
 
The rules say that for claims for A9279 (monitoring feature/device, stand-alone or integrated, any type, 
includes all accessories, components and electronics, not otherwise classified) are denied as statutorily non-
covered (No Medicare benefit). 
 
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 Group 3 PWC with no power options (K0848, K0849, K0850, K0851, K0852, K0853, 
K0854, K0855) is covered if: 

A. All of the coverage criteria (a)-(e) for a PWC are met; and 
B. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital 
skeletal deformity; and 
C. The beneficiary has had a specialty evaluation that was performed by a licensed/certified 
medical professional, such as a PT or OT, or practitioner who has specific training and 
experience in rehabilitation wheelchair evaluations and that documents the medical necessity for 
the wheelchair and its special features (see Documentation Requirements section). The PT, OT, 
or practitioner may have no financial relationship with the supplier; and 
D. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology 
Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in 
the wheelchair selection for the beneficiary. 

If a Group 3 PWC is provided and if criteria (IV)(A) - (IV)(D) are not met, it will be denied as not reasonable 
and necessary. 

II. A Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with Multiple 
Power Options (K0861, K0862, K0863, K0864) is covered if: 
A. The Group 3 criteria IV(A) and IV(B) are met; and 
B. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria 
III[A] and III[B]) (respectively) are met. 

If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or (V)(B) 
is not met, it will be denied as not reasonable and necessary. You can find this rule at Local Coverage 
Determination (LCD) L33789: Power Mobility Devices (eff. 1/1/20). 

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 Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied.  You can 
find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative 
Policy Manual for Medicare Services, Chapter I(V). 
 
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 non-adjunctive CGM can be used to make treatment decisions without the need for a stand-
alone BGM to confirm testing results. An adjunctive CGM requires the user verify their glucose levels or 
trends displayed on a CGM with a BGM prior to making treatment decisions. On February 28, 2022, CMS 
determined that both non-adjunctive and adjunctive CGMs may be classified as DME. 
 
Refer to the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES and CODING 
GUIDELINES sections in the LCD-related Policy Article for additional information regarding classification of 
CGMs as DME. 
 
To be eligible for coverage of a CGM and related supplies, the beneficiary must meet all of the following initial 
coverage criteria (1)-(5): 
 
    1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses); and, 
    2. The beneficiarys treating practitioner has concluded that the beneficiary (or beneficiarys caregiver) has 
sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
    3. The CGM is prescribed in accordance with its FDA indications for use; and, 
    4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of 
the criteria below: 
       A. The beneficiary is insulin-treated; or, 
       B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the 
following (see the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section of the LCD-related 
Policy Article (A52464)): 
            Recurrent (more than one) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persist 
despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan; or, 
            A history of one level 3 hypoglycemic event (glucose less than 54mg/dL (3.0mmol/L)) characterized by 
altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia 
    5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-
approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1)-(4) above are met. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Glucose Monitors 
(L33822). 
 
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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that Modifiers are used to identify therapy services whether or not financial limitations are in 
effect. When limitations are in effect, the CWF tracks the financial limitation based on the presence of therapy 
modifiers. Providers/suppliers must continue to report one of these modifiers for any therapy code on the list of 
applicable therapy codes except as noted in 20 of this chapter. Consult 20 for the list of codes to which 
modifiers must be applied. These modifiers do not allow a provider to deliver services that they are not 
qualified and recognized by Medicare to perform.  
The claim must include one of the following modifiers to distinguish the discipline of the plan of care under 
which the service is delivered:  
GN Services delivered under an outpatient speech-language pathology plan of care;  
GO Services delivered under an outpatient occupational therapy plan of care; or,  
GP Services delivered under an outpatient physical therapy plan of care.  
 
This is applicable to all claims from physicians, nonphysician practitioners (NPPs), PTPPs, OTPPs, SLPPs, 
CORFs, OPTs, hospitals, SNFs, and any others billing for physical therapy, speech-language pathology or 
occupational therapy services as noted on the applicable code list in 20 of this chapter.  
 
Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, 
occupational therapy and speech-language pathology services. They should never be used with codes that are 
not on the list of applicable therapy services. For example, respiratory therapy services, or nutrition therapy 
services shall not be represented by therapy codes which require GN, GO, and GP modifiers. 
 
The rules also say that effective for claims with dates of service on and after January 1, 2020, the CQ and CO 
modifiers are required to be used, when applicable, for services furnished in whole or in part by PTAs and 
OTAs on the claim line of the service alongside the respective GP or GO therapy modifier, to identify those 
PTA and OTA services furnished under a PT or OT plan of care. 
 
You can find these rules in the Centers for Medicare & Medicaid Services, Medicare Claims Processing 
Manual Chapter 5, Section 20.1. 
 
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 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 65 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 92 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 say that covered indications for erythropoietin stimulating agents (ESAs): 
 
    - Treatment of significant anemia in patients with non-myeloid malignancies where anemia is specifically 
due to concomitantly administered chemotherapy; 
    - Treatment of symptomatic anemia related to end-stage renal disease (ESRD) and Stages IIIb, IV and V 
chronic kidney disease (CKD); 
    - Treatment of anemia induced by AZT (Zidovudine) used in Human Immunodeficiency Virus 
(HIV)/acquired immunodeficiency syndrome (AIDS) therapy 
    - Treatment of selected patients with anemia related to low prognostic risk myelodysplastic syndrome and 
some myeloproliferative neoplasms; 
    - Peri-surgical adjuvant therapy for purposes of allogenic RBC transfusion reduction 
 
ESA treatment is not reasonable and necessary for beneficiaries with certain clinical conditions, either because 
of a deleterious effect of the ESA on their underlying disease or because the underlying disease increases their 
risk of adverse effects related to ESA use. These conditions include: 
 
    - any anemia in cancer or cancer treatment patients due to folate deficiency, B-12 deficiency, iron deficiency, 
hemolysis, bleeding, or bone marrow fibrosis; 
    - the anemia associated with the treatment of acute and chronic myelogenous leukemias or erythroid cancers; 
    - the anemia of cancer not related to cancer treatment; 
    - any anemia associated only with radiotherapy; 
    - prophylactic use to prevent chemotherapy-induced anemia; 
    - prophylactic use to reduce tumor hypoxia; 
    - patients with Epoetin (EPO) type resistance due to neutralizing antibodies; and 
    - anemia due to cancer treatment if patients have uncontrolled hypertension. 
 
You can find this information in the Local Coverage Determination (LCD) for Erythropoiesis Stimulating 
Agents (L39237). 
 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.