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 Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
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 also says that covered drugs include drugs that usually aren't self-administered by the patient and are 
injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. 
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 Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 hearing aid fitting/evaluations are limited to 1 exam every calendar year. You can find this 
information on page 71 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 a SWO must be communicated to the supplier prior to claim submission. For certain items of 
DMEPOS, a written order is required prior to delivery (WOPD) of the item(s) to the beneficiary (see below). 
 
A SWO must contain all of the following elements: 
 
Beneficiary's name or Medicare Beneficiary Identifier (MBI) 
Order Date 
General description of the item 
The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS 
code narrative, or a brand name/model number 
For equipment - In addition to the description of the base item, the SWO may include all concurrently ordered 
options, accessories or additional features that are separately billed or require an upgraded code (List each 
separately). 
For supplies  In addition to the description of the base item, the DMEPOS order/prescription may include all 
concurrently ordered supplies that are separately billed (List each separately) 
Quantity to be dispensed, if applicable 
Treating Practitioner Name or NPI Treating practitioner's signature 
Signatures must comply with the CMS signature requirements outlined in the Medicare Program Integrity 
Manual (CMS Pub.100-08), Chapter 3, Section 3.3.2.4. Signature and date stamps are not allowed. 
 
Upon request by a contractor, DMEPOS suppliers must provide documentation of the completed SWO. 
 
In those limited instances in which the treating practitioner is also the supplier and is permitted to furnish 
specific items of DMEPOS and fulfill the role of the supplier in accordance with any applicable laws and 
policies, a SWO is not required. However, the medical record must still contain all of the required SWO 
elements. You can find this information in Medicare's Local Coverage Article Standard Documentation 
Requirements for All Claims Submitted to DME MACs (A55426). 
 
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. 
 
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). 
 
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 
offers a supplemental (extra) benefit to cover routine vision services that are not covered by Original Medicare. 
This benefit includes one routine eye exam including contact lens fitting per year and up to $200 every 
calendar year for eyeglasses, frames, lenses or contact lenses from participating network providers. Any costs 
you pay above this allowance will not count toward your maximum out-of-pocket amount. You can find this 
information on page 100 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 Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 you must use the Plan's approved hearing aid brand to receive hearing aid benefits. You can 
find this information on page 72 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 state that MDCT angiography of the chest for non-cardiac assessment will be considered medically 
reasonable and necessary for the following signs or symptoms of disease: Assessment of a symptomatic patient 
when presentation is suspicious for pulmonary emboli; Abnormalities of the thoracic vasculature such as aortic 
dissection, aortic aneurysm, pulmonary arterio-venous malformation (AVM) and other abnormalities of the 
systemic circulation, excluding the heart; Assessment of suspected congenital anomalies of the heart or great 
vessels; and Assessment of cardiac, mediastinal or lung parenchymal lesions, the vascularity of which is 
unknown or ill defined, but is critical to the diagnosis. 
 
MDCT angiography of the chest for cardiac assessment will be considered medically reasonable and necessary 
for the following signs or symptoms of disease: Cardiac evaluation of a patient with chest pain syndrome (e.g. 
anginal equivalent, angina), who is at a low to moderate risk for coronary artery disease (CAD), if use of 
MDCT is expected to avoid performing diagnostic cardiac catheterization. MDCT and coronary angiography 
are not expected to be performed on the same patient for diagnostic purposes prior to the application of 
anticipated therapy. (If a high pre-test probability of disease exists, as if the patient has known CAD, it is 
assumed the patient would go to coronary angiography as the definitive test, where possible angioplasty and/or 
stenting could be performed at the same time). Assessment of suspected congenital anomalies of coronary 
circulation. Assessment of symptomatic patients with equivocal stress test results, with or without cardiac 
imaging, if MDCT is expected to avoid performing diagnostic coronary angiography. (Again, if a high pre-test 
probability of disease exists, as if the patient has known CAD, it is not expected that CT coronary angiography 
would be done in addition to a subsequent coronary catheterization and angiogram). Evaluation of pulmonary 
veins prior to arrhythmia ablation procedures. Evaluation of cardiac veins prior to insertion of biventricular 
pacemaker. You can find this rule in the Local Coverage Determination (LCD), L33282-Computed 
Tomographic Angiography of the Chest, Heart and Coronary Arteries. 
 
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 an ultra-lightweight manual wheelchair (K0005) is covered for a beneficiary if criteria (1) or 
(2) is met and (3) and (4) are met: 
1. The beneficiary must be a full-time manual wheelchair user. 
2. The beneficiary must require individualized fitting and adjustments for one or more features such as, 
but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be 
accommodated by a K0001 through K0004 manual wheelchair. 
3. The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical 
professional (LCMP), such as a PT or OT, or physician 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 LCMP may have no financial 
relationship with the supplier. 
4. The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) 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 patient. 
You can find this information in Local Coverage Determination (LCD) Manual Wheelchair Bases L33788. 
 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). 
 
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 pays up to $160 for eyeglasses every 12 months. You can find this information on pages 4-76 
and 4-77 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 the CxBladder test is now covered utilizing the reasonable and necessary guidelines as 
outlined in Title XVIII of the Social Security Act, Section 1862(a)(1)(A) which states that no Medicare 
payment shall be made for items or services which are not reasonable and necessary for the diagnosis or 
treatment of illness or injury. Therefore, CxBladder is not addressed in the LCD or billing and coding article. 
You can find this in the Local Coverage Article for Response to Comments: Biomarkers for Oncology, A58529 
(eff 12/13/20). 
 
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). 
 
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 Section 2005 of the SUPPORT Act amended section 1861 of the Act by adding a new 
subsection (jjj)(2) to define an Opioid Treatment Program (OTP) as an entity meeting the definition of OTP in 
42 CFR 8.2 or any successor regulation (that is, a program or practitioner engaged in opioid treatment of 
individuals with an opioid agonist treatment medication registered under 21 U.S.C. 823(g)(1)), that meets the 
additional requirements set forth in subparagraphs (A) through (D) of section 1861(jjj)(2) of the Act. 
Specifically that the OTP: is enrolled under section 1866(j) of the Act; has in effect a certification by the 
Substance Abuse and Mental Health Services Administration (SAMHSA) for such a program; is accredited by 
an accrediting body approved by SAMHSA; and meets such additional conditions as the Secretary may find 
necessary to ensure the health and safety of individuals being furnished services under such program and the 
effective and efficient furnishing of such services. 
 
We defined "opioid treatment program" at  410.67(b) as an entity that is an OTP as defined in  8.2 (or any 
successor regulation) that meets the applicable requirements for an OTP. For an OTP to participate and receive 
payment under the Medicare program, the OTP must be enrolled under section 1866(j) of the Act, have in 
effect a certification by SAMHSA for such a program, and be accredited by an accrediting body approved by 
SAMHSA. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 39, Section 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 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.
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 you are covered by both Medicare and Medicaid. Medicare covers health care and 
prescription drugs. Medicaid covers your cost-sharing for Medicare services, including plan medical 
deductibles and cost shares as well as premiums for anyone who receives cost-share assistance from the state. 
Medicaid also covers services Medicare does not cover. You can find this information on page 54 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 payment for inpatient psychiatric hospital services is to be made only for active treatment. 
For services to be designated as active treatment they must: 
 
  
  1. be provided under an individualized treatment or diagnostic plan; 
 
2. reasonably be expected to improve the patients condition, or for the purpose of diagnosis; and 
 
3. be supervised and evaluated by a physician.   
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 2, Sections 30.2.2 and 30.2.2.1. 
 
The rules say that Medicare will not pay any expenses for items or services which are not medically necessary 
and reasonable for the diagnosis or treatment of illness or injury. This exclusion extends to claims for services 
which are provided in inappropriate settings. You can find this rule in the Social Security Act, Section 
1862(a)(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 state that physicians report the appropriate anesthesia modifier to denote whether the service was 
personally performed, medically directed, or medically supervised. Among these modifiers are -QX, denoting a 
certified registered nurse anesthetist (CRNA) service with medical direction by a physician, and -QZ, denoting 
a CRNA service without medical direction by a physician. 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.