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 a Medicare Advantage (MA) plan may offer coverage of a supplemental benefit only if it is 
medically necessary and additional to the benefit covered by original Medicare. A supplemental benefit is an 
item or service not covered by original Medicare, that is primarily health related and for which the MA plan 
must incur a non-zero direct medical cost. You can find this information in the Medicare Managed Care 
Manual, Chapter 4 - Benefits and Beneficiary Protections, 30.2  Supplemental Benefits Extending Original 
Medicare Benefits. 
 
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 if you request the Service Dog Support benefit, you must: 
- Provide supporting documentation identifying you (the member) as the owner and recipient who requires the 
use of a service dog and the services being rendered as defined under the Americans with Disabilities Act 
(ADA). The Plan can help you obtain this information. 
- Be in compliance with all local and state laws for dog ownership and be able to supply documentation, upon 
request. 
 
Note: The Plan is unable to initiate your benefit without speaking to you. By requesting this benefit, you are 
expressly authorizing the Plan to contact you by telephone. You can find this information on pages 84 and 85 
of the Plan's 2023 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 pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
The rules say that an option/accessory that is beneficial primarily in allowing the beneficiary to perform leisure 
or recreational activities is non-covered. A power seat elevation feature (E2300) and power standing feature 
(E2301) are non-covered because they are not primarily medical in nature. You can find this rule in the Local 
Coverage Article for 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 state that diagnostic lower extremity angiography performed at the time of an interventional 
procedure is separately reportable if at least one indication for medical necessity for a stand-alone lower 
extremity is met and one of the following is also met: 
- No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the 
decision to intervene is based on the diagnostic study, or 
- A prior study is available, but as documented in the medical record: 
~ the patients condition with respect to the clinical indication has changed since the prior study; 
or 
~ there is inadequate visualization of the anatomy or pathology; or 
~ there is a clinical change during the interventional procedure that requires new evaluation 
outside the target area of intervention. 
 
Indications for stand-alone iliac or lower extremity angiography must be documented by pre-procedure clinical 
assessment. This assessment should include the following: 
- Documentation that an invasive intervention is planned 
- Documentation that a prior non-invasive study was completed and indicates further study is needed by 
angiography for the planned intervention 
- Documentation of one of the following conditions: arterial embolism, acute or chronic ischemia, 
peripheral vascular disease (includes claudication), or aneurysm. 
 
You can find these rules in Local Coverage Determination (LCD) Aortography and Peripheral Angiography 
(L36767). 
 
The rules state that vascular stenting of lower extremity arteries performed for clinically significant occlusive 
vascular disease will be considered medically reasonable and necessary for a patient under any of the following 
circumstances: 
- Primary therapy for common iliac artery stenosis and occlusions. 
- Primary therapy for external iliac artery stenoses and occlusions. 
- Primary therapy for femoral/popliteal arterial stenosis and occlusions. - Salvage therapy for common and external iliac arteries for a suboptimal or failed result from balloon 
dilation (e.g., persistent translesional gradient, residual diameter stenosis greater than 50%, or flow-
limiting dissection). 
- Salvage therapy for femoral/popliteal arteries for a suboptimal or failed result from balloon dilation 
(e.g., persistent translesional gradient, residual diameter stenosis greater than 50%, or flow-limiting 
dissection). 
- Salvage therapy for tibial/peroneal arterial lesions for a suboptimal result from balloon dilation. 
 
You can find these rules in Local Coverage Determination (LCD) Vascular Stenting of Lower Extremity 
Arteries (L33763). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
  
  defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
glass crown if medical necessity is met. You can find this information in the 2023 Dental Benefits Chart pg.66.
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. 
 
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 that enrollees must pay a $50 copayment for each Medicare-covered eye exam to diagnose and 
treat diseases and conditions of the eye. You can find this information on pages 105 to 106 of the Plan's 2022 
Evidence of Coverage (EOC).  
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says they cover one non-Medicare covered routine vision exam per calendar year including refraction. 
Refraction is only covered when performed during a routine vision exam. You can find this information on 
pages 105 to 106 of the Plans 2022 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 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. 
 
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 the Plan covers items and services in accordance with Medicare rules. The rules say that 
starting January 15, most people with a health plan can go online, or to a pharmacy or store to purchase an at-
home over-the-counter COVID-19 diagnostic test authorized by the U.S. Food and Drug Administration (FDA) 
at no cost, either through reimbursement or free of charge through their insurance. The test will either be free 
directly at the point of sale, if the health plan provides for direct coverage, or by reimbursement if you are 
charged for your test. Medicare Advantage plans may cover this as a supplemental benefit starting January 15, 
2022, or prior depending on the specific benefits offered by the Plan. Insurance companies are required to 
reimburse you at a rate of up to $12 per individual test (or the cost of the test, if less than $12). You can find 
this information on the Centers for Medicare and Medicaid Services website at https://www.cms.gov/how-to-
get-your-at-home-OTC-COVID-19-test-for-free.
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 high frequency chest wall oscillation devices (HFCWO) (E0483) are covered for 
beneficiaries who meet: 
A. Criterion 1, 2, or 3, and 
B. Criterion 4 
1. There is a diagnosis of cystic fibrosis. 
2. There is a diagnosis of bronchiectasis which has been confirmed by a high resolution, spiral, or 
standard CT scan and which is characterized by: 
a. Daily productive cough for at least 6 continuous months; or 
b. Frequent (i.e., more than 2/year) exacerbations requiring antibiotic therapy. 
c. Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence 
of a confirmed diagnosis of bronchiectasis do not meet this criterion. 
3. The beneficiary has one of the following neuromuscular disease diagnoses: 
- Post-polio, Acid maltase deficiency, Anterior horn cell diseases, Multiple sclerosis, 
Quadriplegia, Hereditary muscular dystrophy, Myotonic disorders, Other myopathies, 
Paralysis of the diaphragm 
4. There must be well-documented failure of standard treatments to adequately mobilize retained 
secretions. 
 
If all of the criteria are not met, the claim will be denied as not reasonable and necessary. 
You can find these rules in Local Coverage Determination (LCD) High Frequency Chest Wall Oscillation 
Devices (L33785). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes bone 
replacement graft  if medical necessity is met. You can find this information in the 2023 Medical 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 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. 
  
   
The rules say that the plan must pay for emergency and urgently needed services. This rule applies whether the 
services are obtained in or out of the plans network. This rule applies whether or not there is prior 
authorization for the services. The rules say that an emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules 
say that urgently needed services are those needed because of an unforeseen illness or condition and it is not 
reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside 
of the service area. You can find this rule at 42 CFR Section 422.113. 
 
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 worldwide coverage for emergent or urgent services, up to $100,000 per year. The enrollee 
must pay up front and then submit a request for reimbursement. This information is found on page 67 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 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 pages 57 to 58 of the Plan's 2023 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 Leadless pacemakers are non-covered when furnished outside of a CMS approved 
Coverage with Evidence Development study. This rule is found in National Coverage Determination (NCD): 
Leadless Pacemakers (20.8.4). 
 
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 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 the Ottobock Genium X3 Waterproof prosthesis has not been assigned the Healthcare 
Common Procedure Coding System (HCPCS) codes L5856, L5828, L5845, L5848, and L5999, effective 
currently. This means the Ottobock Genium X3 Waterproof prosthesis has not been classified by Medicare 
coverage as L5856, L5828, L5845, L5848, and L5999 at this time. You can find this rule in the Pricing, Data 
Analysis and Coding Contractor (PDAC) Durable Medical Equipment, Prosthetics, Orthotics and Supplies 
(DMEPOS) Product Classification List. 
 
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 power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered. 
 
Expandable Controller - An electronic system that is capable of accommodating one or more of the following 
additional functions: 
a. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head 
control, etc.) other than a standard proportional joystick. 
b. Non-proportional input devices (e.g., sip and puff, head array, etc.) 
c. 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: 
d. A separate display (i.e., for alternate control devices) 
e. Other electronic devices (e.g., control of an augmentative speech device or computer through the chairs 
drive control) 
f. An attendant control 
 
A power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a solid back; any 
frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway 
detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable 
speed programmability; a switch control which is independent of the power wheelchair drive control interface; 
A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or 
without variable speed programmability which allows the legrest to be raised and lowered independently of the 
recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with 
the power tilt and/or recline control(s). You can find this information 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.