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 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 health 
plan contract says up to 24 one-way trips are covered each year (limited to ground transportation only). You 
can find this information in Chapter 4 on pages 4-52 to 4-53 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 May 5, 2005, CMS finds that the evidence is adequate to determine that MAE is 
reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their 
participation in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, 
  
  grooming, and bathing in customary locations within the home. Determination of the presence of a mobility 
deficit will be made by an algorithmic process, Clinical Criteria for MAE Coverage, to provide the appropriate 
MAE to correct the mobility deficit. 
 
Clinical Criteria for MAE Coverage 
 
The beneficiary, the beneficiarys family or other caregiver, or a clinician, will usually initiate the discussion 
and consideration of MAE use. Sequential consideration of the questions below provides clinical guidance for 
the coverage of equipment of appropriate type and complexity to restore the beneficiarys ability to participate 
in MRADLs such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. 
These questions correspond to the numbered decision points on the accompanying flow chart. In individual 
cases where the beneficiarys condition clearly and unambiguously precludes the reasonable use of a device, it 
is not necessary to undertake a trial of that device for that beneficiary. 
 
You can find this information in the National Coverage Determination (NCD) Mobility Assistive Equipment 
(MAE) 280.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Medicare guidance says this test is cover for member with advance cancers. You can find this guidance in the 
National Coverage Determination (NCD) for Next Generation Sequencing (NGS) (90.2). 
 
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. 
 
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 health 
plan contract says that a $350 allowance is provided once every calendar year. if the eyewear purchased costs 
more than $350, you pay the difference. You can find this information on page 72 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 repeat Epidural Steroid Injections (ESI) when the first injection directly and significantly 
provided improvement of the condition being treated may be considered medically reasonable and necessary 
when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement 
in function measured from baseline using the same scale for at least three months. If a patient fails to respond 
well to the initial ESI, a repeat ESI after 14 days can be performed, using a different approach, level and/or 
medication if appropriate, with the rationale and medical necessity for the second ESI documented in the 
medical record. You can find this information in Medicare's Local Coverage Determination (LCD): Epidural 
Steroid Injections for Pain Management (L39036). 
 
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 state that an OPPS payment status indicator is assigned to every HCPCS code. The status indicator 
identifies whether the service described by the HCPCS code is paid under the OPPS and if so, whether payment 
is made separately or packaged. The status indicator may also provide additional information about how the 
code is paid under the OPPS or under another payment system or fee schedule. For example, services with 
status indicator A are paid under a fee schedule or payment system other than the OPPS. Services with status 
indicator N are paid under the OPPS, but their payment is packaged into payment for a separately paid service. 
Services with status indicator T are paid separately under OPPS but a multiple procedure payment reduction 
applies when two or more services with a status indicator of T are billed on the same date of service. You can 
find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Section 10.1.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 an add-on to convert a manual wheelchair to a joystick-controlled power mobility device 
(E0983) or to a tiller-controlled power mobility device (E0984) will be denied as not reasonable and necessary. 
Payment is made for only one wheelchair at a time. Backup chairs are denied as not reasonable and necessary. 
You can find this rule in Local Coverage Determination: Power Mobility Devices L33789. 
 
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 gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. 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 health 
plan contract says a cash card is provided to make fitness membership payments. Swipe your card at any 
licensed fitness facility that provides membership programs. Any fitness center services that usually have an 
extra fee are not included in this benefit. There is a reimbursement of up to $25 per month for monthly 
membership dues at a licensed facility. If for some reasons, you are unable to use your card, you can submit a 
reimbursement request via the card portal on your MyChart account. You can find this information on page 68 
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 27-28 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 pneumatic devices are covered for the treatment of lymphedema or for the treatment of 
chronic venous insufficiency with venous stasis ulcers.  Pneumatic compression devices are covered in the 
home setting for the treatment of lymphedema if the patient has undergone a four-week trial of conservative 
therapy and the treating physician determines that there has been no significant improvement or if significant 
symptoms remain after the trial. The trial of conservative therapy must include use of an appropriate 
compression bandage system or compression garment, exercise, and elevation of the limb. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare 
National Coverage Determination for Pneumatic Compression Devices, 280.6. 
 
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 a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1852), are covered if the beneficiary has had recent injury to or a surgical 
procedure on the knee(s).  Knee orthoses are also covered for a beneficiary who is ambulatory and has knee 
instability. For code L1852, knee instability must be documented by examination of the beneficiary and 
objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). Claims for 
L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for 
coverage. You can find this rule in the Local Coverage Determination for Knee Orthoses, L33318.  
 
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 special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The Plan must have written policies for determining enrollee eligibility and 
must document its determination that an enrollee is a chronically ill enrollee. You can find this information in 
42 CFR 422.102. 
 
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 if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. You can find this information on pages 105 
and 106 of the Plans 2022 Evidence of Coverage (EOC).  
 
You can find further information on the specific chronic conditions that qualify for additional benefits in 
Chapter 4 Section 2.1 on pages 60 through 62 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 state that testing of individuals with no personal history of breast, ovarian, fallopian tube, primary 
peritoneal, pancreatic, or prostate cancer. Such testing is considered screening and is excluded by Medicare 
statute. 
 
You can find these rules in the Local Coverage Determination (LCD): MolDX: BRCA1 and BRCA2 for 
Genetic Testing, L36813. 
 
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 all of the following criteria must apply in order for Medicare to provide coverage for MRA 
of the head and neck: 
 MRA is used to evaluate the carotid arteries, the circle of Willis, the anterior, middle or posterior 
cerebral arteries, the vertebral or basilar arteries or the venous sinuses;  
 MRA is performed on patients with conditions of the head and neck for which surgery is anticipated 
and may be found to be appropriate based on the MRA. These conditions include, but are not limited to, 
tumor, aneurysms, vascular malformations, vascular occlusion or thrombosis. Within this broad 
category of disorders, medical necessity is the underlying determinant of the need for an MRA in 
specific diseases. The medical records should clearly justify and demonstrate the existence of medical 
necessity; and,  
 MRA and CA are not expected to be performed on the same patient for diagnostic purposes prior to the 
application of anticipated therapy. Only one of these tests will be covered routinely unless the physician 
can demonstrate the medical need to perform both tests. 
You can find this information in Local Coverage Determination (LCD): Magnetic Resonance Angiography 
(MRA) (L33633). 
 
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 one to two levels, either unilateral or bilateral, are allowed per session per region. The need 
for a three or four-level procedure bilaterally may be considered under unique circumstances and with 
sufficient documentation of medical necessity on appeal. You can find this rule in Local Coverage 
Determination (LCD) - Facet Joint Interventions for Pain Management (L34892) - Effective April 25, 2021. 
 
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 53-54 of the Plan's 2022 Evidence of Coverage.