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 microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), 
dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal 
(L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose 
functional level is 3 or above. 
 
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or 
design feature of a given type of foot. This information must be retained in the treating practitioner's or 
prosthetist's files. 
 
You can find this informaiton 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 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 70 to 71 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 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 enrollees must pay a $50 copayment for Medicare-covered visit. You can find this 
information on page(s) 94 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 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 a Medicare plan may restrict enrollees to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the plan must 
arrange for specialty care outside of the plan provider network when network providers are unavailable or 
inadequate to meet an enrollees medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community-based 
services. You can find this rule at 42 CFR Section 422.112. 
 
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, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 31-34 of the Plan's 2023 
EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 visits by the same physician on the same day as a minor surgery or endoscopy are included in 
the payment for the procedure, unless a significant, separately identifiable service is also performed. Modifier 
"-25" is used to facilitate billing of evaluation and management services on the day of a procedure for which 
separate payment may be made. It is used to report a significant, separately identifiable evaluation and 
management service by same physician on the day of a procedure. The physician may need to indicate that on 
the day a procedure or service that is identified with a CPT code was performed, the patient's condition 
required a significant, separately identifiable evaluation and management service above and beyond the usual 
preoperative and postoperative care associated with the procedure or service that was performed. This 
circumstance may be reported by adding the modifier "-25" to the appropriate level of evaluation and 
management service. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 10-04, Medicare Claims Processing Manual, Chapter 12, Section 40.1(C) and 40.2.A.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 invasive procedures will be considered medically reasonable and necessary if the patient 
meets the criteria as outlined in this LCD, and the intervention is addressed and supported in the plan of care, 
for a 90 day episode of care, that includes a specific treatment plan determined by the assessment and 
evaluation of the lower extremity venous incompetence. You can find this information in the Local Coverage 
Determination (LCD) for Treatment of Chronic Venous Insufficiency of the Lower Extremities (L34924). 
 
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 program reimbursement for HBO therapy will be limited to that which is administered in a 
chamber (including the one man unit) and is limited to the following conditions: 
1. Acute carbon monoxide intoxication, 
2. Decompression illness, 
3. Gas embolism, 
4. Gas gangrene, 
5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in 
combination with accepted standard therapeutic measures when loss of function, limb, or life is 
threatened. 
6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an 
adjunctive treatment when loss of function, limb, or life is threatened. 
7. Progressive necrotizing infections (necrotizing fasciitis), 
8. Acute peripheral arterial insufficiency, 
9. Preparation and preservation of compromised skin grafts (not for primary management of wounds), 
10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, 
11. Osteoradionecrosis as an adjunct to conventional treatment, 
12. Soft tissue radionecrosis as an adjunct to conventional treatment, 
13. Cyanide poisoning, 
14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to 
antibiotics and surgical treatment, 
15. Diabetic wounds of the lower extremities in patients who meet the following three criteria: 
a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; 
b. Patient has a wound classified as Wagner grade III or higher; and 
c. Patient has failed an adequate course of standard wound therapy. 
You can find this rule in the Center for Medicare Services (CMS) Publication 100-03, Medicare National 
Coverage Determination (NCD) Manual, Section 20.29. 
 
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 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 shoes are also covered if they are an integral part of a covered leg brace described by codes 
L1900, L1920, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2050, L2060, L2080, or L2090. Oxford 
shoes (L3224, L3225) are covered in these situations. Other shoes, e.g., high top, depth inlay or custom for 
non-diabetics, etc. (L3649), are also covered if they are an integral part of a covered brace and if they are 
medically necessary for the proper functioning of the brace. Heel replacements (L3455, L3460), sole 
replacements (L3530, L3540), and shoe transfers (L3600, L3610, L3620, L3630 and L3640) involving shoes 
on a covered brace are also covered. Inserts and other shoe modifications (L3000, L3001, L3002, L3003, 
L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, 
L3170, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, 
L3410, L3420, L3430, L3440, L3450, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3550, L3560, 
L3570, L3580, L3590 and L3595) are covered if they are on a shoe that is an integral part of a covered brace 
and if they are medically necessary for the proper functioning of the brace. Shoes and related modifications, 
inserts, heel/sole replacements or shoe transfers billed without a KX modifier will be denied as noncovered 
because coverage is statutorily excluded. You can find this rule in Local Coverage Article Orthopedic 
Footwear - Policy Article A52481. 
 
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 a group 2 support surface is covered if the beneficiary meets at least one of the following 
three Criteria (1, 2 or 3): 
 
    The beneficiary has multiple stage 2 pressure ulcers located on the trunk or pelvis (refer to the ICD-10 code 
list section in the LCD-related Policy Article for applicable diagnoses) which have failed to improve over the 
past month, during which time the beneficiary has been on a comprehensive ulcer treatment program including 
each of the following: 
        Use of an appropriate group 1 support surface, and 
        Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and 
        Appropriate turning and positioning, and 
        Appropriate wound care, and 
        Appropriate management of moisture/incontinence, and 
        Nutritional assessment and intervention consistent with the overall plan of care 
    The beneficiary has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis (refer to the ICD-10 
code list section in the LCD-related Policy Article for applicable diagnoses), 
    The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the 
past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses), 
and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing 
facility within the past 30 days 
 
You can find this information in the Local Coverage Determination (LCD) Pressure Reducing Support 
Surfaces - Group 2 L33642. 
 
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 research has shown supervised exercise therapy (SET) to be an effective, minimally invasive 
method to alleviate the most common symptom associated with peripheral artery disease (PAD)  intermittent 
claudication (IC). SET has been shown to be significantly more effective than unsupervised exercise and could 
prevent the progression of PAD and lower the risk of cardiovascular events that are prevalent in these patients. 
SET has also been shown to perform at least as well as more invasive revascularization treatments that are 
covered by Medicare. 
 
Effective for services performed on or after May 25, 2017, the Centers for Medicare & Medicaid Services has 
determined that the evidence is sufficient to cover SET for beneficiaries with IC for the treatment of 
symptomatic PAD. Up to 36 sessions over a 12-week period are covered if all of the following components of a 
SET program are met. The SET program must: 
 
    consist of sessions lasting 30-60 minutes comprising a therapeutic exercise-training program for PAD in 
patients with claudication; 
    be conducted in a hospital outpatient setting, or a physicians office; 
    be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained 
in exercise therapy for PAD; and 
    be under the direct supervision of a physician (as defined in 1861(r)(1)), physician assistant, or nurse 
practitioner/clinical nurse specialist (as identified in 1861(aa)(5)) who must be trained in both basic and 
advanced life support techniques. 
 
Beneficiaries must have a face-to-face visit with the physician responsible for PAD treatment to obtain the 
referral for SET. At this visit, the beneficiary must receive information regarding cardiovascular disease and 
PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome 
assessments. 
 
You can find this rule in the National Coverage Determination (NCD) Supervised Exercise Therapy (SET) for 
Symptomatic Peripheral Artery Disease (PAD) 20.35. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 66 of the 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 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 several Healthcare Common Procedural Coding System (HCPCS) modifiers are used to 
signify a specific line item is either not covered or not payable by Medicare, for many different 
reasons. Modifiers not payable on professional claims are also not payable on institutional claims and will be 
denied if submitted on such claims. Institutional standard systems will deny all line items on all type of bills 
using modifiers such as -HA through -HZ in all cases as part of processing claims. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Chapter 1, Section 40.6.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 38-44 of the Plan's 2023 
Evidence of Coverage (EOC).