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 a determination of the medical necessity for certain components/additions to the prosthesis 
is based on the beneficiarys potential functional abilities. A fluid, pneumatic, or electronic/microprocessor 
knee (L5610, L5613, L5614, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, 
L5830, L5840, L5848, L5856, L5857, L5858) is covered for beneficiaries whose functional level is 3 or above. 
Functional level 3 refers to a beneficiary who has the ability or potential for ambulation with variable cadence. 
Typical of the community ambulator who has the ability to traverse most environmental barriers and may have 
vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. The 
records must document the beneficiarys current functional capabilities and his/her expected functional 
potential, including an explanation for the difference, if that is the case. 
 
You can find this information in the Local Coverage Determination (LCD): Lower Limb Prostheses (L33787). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare does not pay for over-the-counter (OTC) items, including non-prescription drugs. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 40.2.  
 
The rules state that to receive payment for Medicare-covered items or services from either Medicare or a 
Medicare beneficiary, a provider or supplier must be enrolled in the Medicare program. You can find this rule 
in 42 Code of Federal Regulations (CFR) Section 424.505. 
 
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 over-the-counter (OTC) items must be included on the Plans allowed items list and the Plan 
unable to make exceptions. You can find this information on page 100 of the Plan's 2022 Evidence of 
Coverage. 
 
The Pick Your Perks benefit document includes a list of covered items/services. Nebulizer is not included on 
this list and is not a covered benefit. You can find this information in the Plan's 2023 Pick Your Perks guide.
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 reason for the encounter (for example, screening or counseling) should be sequenced first 
and the appropriate personal and/or family history code(s) should be assigned as additional diagnos(es). There 
are two types of history Z codes, personal and family. Personal history codes explain a patients past medical 
condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and 
therefore may require continued monitoring. Family history codes are for use when a patient has a family 
member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the 
disease. Personal history codes may be used in conjunction with follow-up codes and family history codes may 
be used in conjunction with screening codes to explain the need for a test or procedure. History codes are also 
acceptable on any medical record regardless of the reason for visit. A history of an illness, even if no longer 
present, is important information that may alter the type of treatment ordered. You can find this information in 
the International Classification of Diseases (ICD-10-CM) Official Guidelines for Coding and Reporting 
FY 2022 -- UPDATED April 1, 2022, Section I. Conventions, general coding guidelines and chapter specific 
guidelines, Chapter 21: Factors influencing health status and contact with health services (Z00-Z99), c. 
Categories of Z Codes, 4) History (of). 
 
 
The rules say that payment may be made for a one-time ultrasound screening for Abdominal Aortic Aneurysm 
(AAA) for beneficiaries who meet the following criteria: 
(i) receives a referral for such an ultrasound screening from the beneficiarys attending physician, physician 
assistant, nurse practitioner or clinical nurse specialist; 
(ii) receives such ultrasound screening from a provider or supplier who is authorized to provide covered  
ultrasound diagnostic services;  
(iii) has not been previously furnished such an ultrasound screening under the Medicare Program; and 
(vi) is included in at least one of the following risk categories-- 
(I) has a family history of abdominal aortic aneurysm; (II) is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or 
(III) is a beneficiary who manifests other risk factors in a beneficiary category recommended for  
screening by the United States Preventive Services Task Force regarding AAA, as specified by the  
Secretary of Health and Human Services, through the national coverage determination process 
 
You can find this information in the Medicare Claims Processing Manual Chapter 18 - Preventive and 
Screening Services, Section 110.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
requested item or service but is limited to only 1 of any (D5110-D5286, D5863-D5866) per arch every 60 
months. You can find this information on page 12 of the 2023 Dental Benefits Chart.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that screening services such as pre-symptomatic genetic tests and services used to detect an 
undiagnosed disease or disease predisposition are not a benefit and are not covered. Similarly, the costs of 
tests/examinations that assess the risk of a condition unless the risk assessment clearly and directly effects the 
management of the patient may not be reimbursed. You can find this rule in Local Coverage Determination 
(LCD) Molecular Pathology Procedures L34519. 
The rules say that the following types of tests are examples of services that are not relevant to a Medicare 
beneficiary, are not considered a Medicare benefit (statutorily excluded), and therefore will be denied as 
Medicare Excluded Tests: 
 Tests considered screening in the absence of clinical signs and symptoms of disease that are not 
specifically identified by the law 
 Tests performed to determine carrier screening 
 Tests performed for screening hereditary cancer syndromes 
 Prenatal diagnostic testing 
 Tests performed on patients without signs or symptoms to determine risk for developing a disease or 
condition  Tests performed to measure the quality of a process 
 Tests without diagnosis specific indications 
 Tests identified as investigational by available literature and/or the literature supplied by the developer 
and are not a part of a clinical trial 
Screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or 
disease predisposition are not a Medicare benefit and are not covered. You can find this information in Local 
Coverage Article Billing and Coding Billing and Coding: Molecular Pathology and Genetic Testing A58917. 
 
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 Plan 
contract says your routine eye exam charge will not exceed $0 at a network optical provider. Please inform the 
network provider that you are a part of the network. You can find this information on pages 89 to 90 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 effective for services performed on and after February 21, 2006, Open and laparoscopic 
Roux-en-Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch 
(BPD/DS) or Gastric Reduction Duodenal Switch (BPD/GRDS), and laparoscopic adjustable gastric banding 
  
  (LAGB) are covered for Medicare beneficiaries who have a body-mass index = 35, have at least one co-
morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. 
 
Effective for dates of service on and after February 21, 2006, these procedures are only covered when 
performed at facilities that are: (1) certified by the American College of Surgeons as a Level 1 Bariatric 
Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the 
American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and 
requirements in effect on February 15, 2006). Effective for dates of service on and after September 24, 2013, 
facilities are no longer required to be certified. 
 
Effective for services performed on and after February 12, 2009, the Centers for Medicare & Medicaid 
Services (CMS) determines that Type 2 diabetes mellitus is a co-morbidity for purposes of this NCD. 
 
A list of approved facilities and their approval dates are listed and maintained on the CMS Coverage Web site 
at http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/Bariatric-
Surgery.html, and published in the Federal Register for services provided up to and including date of service 
September 23, 2013. 
 
You can find this information in the National Coverage Determination (NCD) Bariatric Surgery for Treatment 
of Co-Morbid Conditions Related to Morbid Obesity 100.1. 
 
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 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 does not include 
non-autogenous connective tissue graft. You can find this information in Chapter 4 on pages 141 through 152 
of the Plans 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 covers services in an emergency department only if the emergency clinic is 
affiliated with a hospital. You can find this rule at SSA 1861, 42 CFR 489.24, and 42 CFR 413.65. 
 
The rules state that CMS is creating additional flexibilities to allow licensed independent freestanding 
emergency departments (EDs) to participate in Medicare and Medicaid to help address the urgent need to 
increase hospital capacity to provide care to patients. The following ways to participate include: 
Becoming affiliated with a Medicare/Medicaid-certified hospital under the temporary expansion 1135 
emergency waiver. Participating in Medicaid under the clinic benefit if permitted by the State, or 
Enrolling temporarily as a Medicare/Medicaid-certified hospital to provide hospital services. You can find this 
information in The Centers for Medicare and Medicaid Services (CMS) Guidance for Licensed Independent 
Freestanding Emergency Departments (EDs) to Participate in Medicare and Medicaid during the COVID-19 
Public Health Emergency. 
 
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 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 provides supplemental (extra) coverage for hearing aids/services. This benefit includes 
coverage for up to 2 hearing aids purchased through the Plans select hearing aid provider. You must contact 
the Plans select hearing aid provider to use this benefit. Ear molds are not covered. You can find this 
information on pages 79-80 of the Plans 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 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 only 
those items and services specifically listed in your Plan contract. Surgical placement of implant body: endosteal 
implant (D6010) and bone replacement graft for ridge preservation - per site (D7953) are not covered under the 
Plans dental benefits. You can find this information on pages 103-109 of the Plans 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 Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. You can find this rule at 42 CFR Section 422.111(a) and (b). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that Accu-Chek and OneTouch are preferred vendors. You can find this information on page 
62 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 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 
abutment supported crown (D6059), custom fabricated abutment (D6057), dental implant (D6010) and interim 
abutment teeth (D6051) but is limited to 2 per year. You can find this information in the 2023 Dental Benefits 
Chart. 
 
The Plan contract also says that surgical placement implant (D7994), treatment simulation (D0393), 
modification of removable prosthesis (D5875) and cone beam (D0367) are not covered services. You can find 
this information in the Dental Benefits Chart
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 does not include 
upper denture and lower partial. You can find this information in the 2023 Dental Benefits Chart.