Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will 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 a power seating system  tilt only, recline only, or combination tilt and recline  with or 
without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: 
1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility 
Devices LCD; and 
2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical 
therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in 
rehabilitation wheelchair evaluations of the beneficiarys seating and positioning needs. The PT, OT, or 
practitioner may have no financial relationship with the supplier; and 
3. 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. 
4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional 
weight shift; or 
5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently 
transfer from the wheelchair to bed; or 
6. The power seating system is needed to manage increased tone or spasticity. 
 
You can find this rule in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). 
 
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). 
 
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 there is an $800 deductible which applies to certain items and services. The Plan 
deductible applies to the office visit. You can find this information on page 41 of the Plan's 2022 Evidence of 
Coverage (EOC).  
 
The contract also says that enrollees must pay 10% coinsurance after the deductible is met for doctor and other 
health care provider services. You can find this information on page 60 of the Plans 2022 EOC. 
 
The contract also says that enrollees may receive their free annual wellness visit only once every 12 months. 
You can find this information on page 52 of the Plans 2021 and 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 state that flow cytometry for cell surface, cytoplasmic, or nuclear marker will be considered 
medically reasonable and necessary when performed for the following indications: 
 
    -Cytopenias and Hypercellular Hematolymphoid Disorder 
    -Lymphomas 
    -Acute Leukemia 
    -Chronic Lymphocytic Leukemia (CLL) & Other Chronic Lymphoproliferative Diseases (CLPD) 
    -Plasma Cell Disorders 
    -Myelodysplastic Syndromes (MDS) 
    -Chronic Myeloproliferative Disorders (CMPD) 
    -Mast Cell Neoplasms 
    -Paroxysmal Nocturnal Hemoglobinuria (PNH) 
    -Minimal Residual Disease (MRD) 
    -HIV Infection 
    -Organ Transplants 
    -DNA Analysis 
    -Carcinoma, Non-hematolymphoid Tumors 
    -Molar Pregnancy 
    -Primary Immunodeficiencies (PDS) 
    -Primary Platelet Disorders, non-neoplastic 
    -Red Cell and White Cell Disorders, non-neoplastic 
 
You can find this information in Local Coverage Determination (LCD): Flow Cytometry (L35032) and Local 
Coverage Article (LCA): Billing and Coding: Flow Cytometry (A56676). 
 
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 core 
buildup and post and core but is limited to 3 of both every calendar year. The benefit also includes pontics and 
retainer crowns but is limited to 3 of both every calendar year. You can find this information on pages 105 to 
125 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 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. Core buildup and pontics are not covered by the Plan's dental benefits. You can find this 
information on pages 91 to 93 of the Plans 2022 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 state that Medicare has Medically Unlikely Edits (MUEs) for mileage for ambulance codes.  If a 
provider reports an ambulance code with units greater than the MUE value assigned, the line or the claim will 
deny. The MUE for code A0425 is 250 miles. You can find this rule at Centers for Medicare and Medicaid 
Services, Region JH Affiliated Contractor Novitas Solutions article entitled "Ambulance Mileage Claims May 
Require Supporting Documentation." 
 
The rules state that for codes with a MUE Adjudication Indicator (MAI) of 1, this means that the code has a 
line item edit, meaning that units of the code in excess of the MUE must be reported on a separate line with an 
appropriate modifier in order to be paid. You can find this rule at Centers for Medicare and Medicaid Services, 
Region JH Affiliated Contractor Novitas Solutions article entitled "Medically Unlikely Edits (MUE)". 
 
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 plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that services of other physicians and clearly distinct surgical procedures during the postoperative 
period which are not re-operations or treatment for complications, are not included in the global surgical 
package. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.1(B).  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 National Correct Coding Initiative (NCCI) was developed to prevent inappropriate 
payment of services that should not be reported together. NCCI edits are organized in a Column I/Column 2 
table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of an edit 
pair, only the Column 1 code is payable. For edits with a modifier indicator of 0, the Column 2 code cannot be 
paid regardless of whether a modifier is used. You can find this in the NCCI Manual, Chapter I. 
 
The rules say that Medicare has determined for which surgical services an assistant surgeon is medically 
necessary. This information can be found in the Medicare Fee Schedule Database. If the database contains an 
assistant at surgery indicator of 1 for the surgical procedure in question, Medicare has determined that an 
assistant is not medically necessary. Assistant surgeons will not be paid for these procedures. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing 
Manual, Chapter 12, Section 40.8. 
 
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 
intraoral radiographic image but is limited to 1 procedure code per calendar year. You can find this information 
on pages 85 to 88 of the Plan's 2022 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 state that PVA (Percutaneous Vertebroplasty (PVP) or Kyphoplasty (PKP)) is covered in patients 
with BOTH the following: 
1. Inclusion criteria (ALL are required):  
a. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5), based on 
symptom onset, and documented by advanced imaging (bone marrow edema on MRI or bone-
scan/SPECT/CT uptake)  
b. Symptomatic (ONE):  
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score greater than or equal to 8)  
ii. Non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) 
despite optimal non-surgical management (NSM) (ONE):  
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still greater than or equal to 5) (with 
greater than or equal to 2 of the following):  
A. Progression of vertebral body height loss 
B. Greater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) greater than 17 
c. Continuum of care (Both)  
i. All patients presenting with VCF should be referred for evaluation of BMD and 
osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program. 
2. Exclusion criteria (Can have NONE of the following): 
a. Absolute contraindication  
i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
ii. Osteomyelitis, discitis or active systemic or surgical site infection 
iii. Pregnancy 
b. Relative contraindication  
i. Greater than three vertebral fractures per procedure 
ii. Allergy to bone cement or opacification agents iii. Uncorrected Coagulopathy 
iv. Spinal instability 
v. Myelopathy from the fracture 
vi. Neurologic deficit 
vii. Neural impingement 
viii. Fracture retropulsion/canal compromise 
You can find this rule in the Local Coverage Determination (LCD) for Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF), L34228. 
 
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 also says that refraction is only covered when billed as part of the routine eye exam. You can find this 
information on page 93 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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
states that each one-way trip for routine transportation must not exceed 50 miles of driving distance. You can 
find this information on page 88 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 state that A custom fabricated seat cushion is covered if criteria (1) and (3) are met. A custom 
fabricated back cushion is covered if criteria (2) and (3) are met: 
1. Beneficiary meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat 
cushion; 
A. A skin protection seat cushion is covered for a beneficiary who meets both of the following 
criteria: 
1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid 
seat/back and the beneficiary meets Medicare coverage criteria for it; and 
2. The beneficiary has either of the following (a or b): 
a. Current pressure ulcer or past history of a pressure ulcer on the area of contact 
with the seating surface as reflected in a diagnosis code listed in Group 1 of 
the ICD-10 code list in the LCD-related Policy Article; or 
b. Absent or impaired sensation in the area of contact with the seating surface or 
inability to carry out a functional weight shift as reflected in a diagnosis code 
listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article. 
2. Beneficiary meets all of the criteria for a prefabricated positioning back cushion; 
A. A positioning seat cushion, positioning back cushion, and positioning accessory are covered for 
a beneficiary who meets both of the following criteria: 
1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid 
seat/back and the beneficiary meets Medicare coverage criteria for it; and 
2. The beneficiary has any significant postural asymmetries that are due to one of the 
following (a or b): 
a. A diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related 
Policy Article; or 
b. A diagnosis code listed in Group 3 of the ICD-10 code list in the LCD-related 
Policy Article. 
3. There is a comprehensive written evaluation by a licensed/certified medical professional, such as a 
physical therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated seating system is not sufficient to meet the beneficiarys seating and positioning needs. The PT or OT 
may have no financial relationship with the supplier. 
 
If a custom fabricated cushion is provided for a beneficiary who does not meet the stated coverage criteria, it 
will be denied as not reasonable and necessary. You can find this information in Local Coverage Determination 
(LCD): Wheelchair Seating (L33312). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.