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 the administration of continuous subcutaneous insulin for the treatment of diabetes mellitus 
is only covered if criterion A or B is met and if criterion C or D is met: 
A. C-peptide testing requirement  must meet criterion 1 or 2 and criterion 3: 
1. C-peptide level is less than or equal to 110 percent of the lower limit of normal of the 
laboratory's measurement method. 
2. For beneficiaries with renal insufficiency and a creatinine clearance (actual or calculated 
from age, weight, and serum creatinine) less than or equal to 50 ml/minute, a fasting C-
peptide level is less than or equal to 200 per cent of the lower limit of normal of the 
laboratorys measurement method. 
3. A fasting blood sugar obtained at the same time as the C-peptide level is less than or 
equal to 225 mg/dl. 
B. Beta cell autoantibody test is positive. 
C. The beneficiary has completed a comprehensive diabetes education program, has been on a 
program of multiple daily injections of insulin (i.e., at least 3 injections per day) with frequent 
self-adjustments of insulin dose for at least 6 months prior to initiation of the insulin pump, and 
has documented frequency of glucose self-testing an average of at least 4 times per day during 
the 2 months prior to initiation of the insulin pump, and meets one or more of the following 
criteria (1 - 5) while on the multiple injection regimen:  
1. Glycosylated hemoglobin level (HbA1C) greater than 7 percent 
2. History of recurring hypoglycemia 
3. Wide fluctuations in blood glucose before mealtime 
4. Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL 
5. History of severe glycemic excursions 
D. The beneficiary has been on an external insulin infusion pump prior to enrollment in Medicare 
and has documented frequency of glucose self-testing an average of at least 4 times per day 
during the month prior to Medicare enrollment. 
 
You can find this information in the Local Coverage Determination (LCD): External Infusion Pumps (L33794). 
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). 
 
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 $220 copayment per day, per admission for in-network hospital care for 
days 1 to 5, and a $0 copayment per day for days 6 to 90. for inpatient hospital care. You can find this 
information in Chapter 4 on page 78 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 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 $40 copayment for advanced imaging services at an independent 
diagnostic testing facility (IDTF). You can find this information on pages 86-87 of the Plan's 2022 Evidence of 
Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $225 copayment for ambulance services. You can find 
this information on page 65 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 an expandable controller can be covered when one or more of the following features are 
medically necessary: 
 
1. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head 
control, etc.) other than a standard proportional joystick. 
2. Non-proportional input devices (e.g., sip and puff, head array, etc.) 
3. The ability to operate 3 or more powered seating actuators through the drive control. 
4. A separate display (i.e., for alternate control devices) 
5. Other electronic devices (e.g., control of an augmentative speech device or computer through the chairs 
drive control) 
6. An attendant control 
 
Rules also state that a Column II is included in allowance for a corresponding Column I code when provided at 
the same time. These rules can be found 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.
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 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. You can find this rule in the Local Coverage Article (LCA) for Wheelchair 
Options/Accessories - Policy Article (A52504). 
 
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 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. 
 
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 clinical assessments of beneficiary rehabilitation potential must be based on the following 
classification levels: 
 
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a 
prosthesis does not enhance their quality of life or mobility. 
Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed 
cadence. Typical of the limited and unlimited household ambulator. 
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers 
such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator 
who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise 
activity that demands prosthetic utilization beyond simple locomotion. 
Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting 
high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. 
 
The records must document the beneficiarys current functional capabilities and his/her expected functional 
potential, including an explanation for the difference, if that is the case.  
 
A flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 or above. 
L5968 describes a product that is used as an addition to L-code foot systems for lower limb prosthesis 
construction. The product provides multiaxial motion in the coronal and sagittal plane from articulating 
components. At transition of stance phase to swing phase, the product will increase the ankles dorsiflexion 
angle and maintain it throughout swing phase. The product provides an accommodation of changing heel 
heights without the users input. Use of L5968 is based on the beneficiarys K-level modifier. You can find this 
rule in the Local Coverage Determination and Article for Lower Limb Prostheses, L33787 and A52496.  
 
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). 
 
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 $65 copayment for lab services at an out-of-network primary care 
physicians office or specialists office. You can find this information in Chapter 4 on page 77 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 Per CMS-Ruling 1536-R, effective for services on and after January 22, 2007, Medicare 
will allow beneficiaries to pay additional charges (which are non-covered by Medicare as these additional 
charges are not part of a Medicare benefit category) for insertion of an astigmatism correcting intraocular lens 
(AC-IOL). Medicare coverage and payment for cataract surgery is the same irrespective of whether the surgery 
is performed using conventional surgical techniques or a bladeless, computer-controlled laser.  Under either 
method, Medicare will cover and pay for the cataract removal and insertion of a conventional intraocular lens.  
If the bladeless, computer-controlled laser cataract surgery includes implantation of a PC-IOL or AC-IOL, only 
charges for those non-covered services specified above may be charged to the beneficiary. You can find this 
information the CMS Rulings 05-01 and 1536R. 
 
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 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(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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 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 $200 copayment for a CT scan provided in-network. You can find this 
information in Chapter 4 on pages 85 to 86 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 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 for all beneficiaries receiving HH services in 2021 whose services will continue in 2022, the 
HHA shall submit an NOA with a one-time, artificial 'admission' date corresponding to the "From" date of the 
first period of continuing care in 2022. For example, if a period of care begins in 2021 and ends on January 10, 
2022, the HHA submits and NOA with an admission date of January 11, 2022, and then submits a claim when 
the 30-day period of care is over. The HHA should submit the January 11, 2022, admission date on all 
subsequent claims until the beneficiary is discharged and another NOA is required. This is to ensure the claim 
is matched to the correct NOA and the correct receipt date is used for payment. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 10, Section 10.1.10.3. 
 
The rules say that home health services under a plan of care are paid based on a 30-day period of care. Home 
health agencies (HHAs) submit a notice of admission (NOA) at the beginning of an admission and then submit 
one claim for each 30-day period of care. The HHA enters a date of admission matching the From date on the 
first period of care in an admission. On subsequent periods of care, the HHA continues to submit the admission 
date reported on the first period of care. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, 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.
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 L5968, L5982, L5984, L5985, L5986, L5988, L5990 are additional features and/or 
functions that do not describe a complete prosthetic foot and may be used in combination with L5970, L5971, 
L5972, L5974, L5975, L5976, L5978, L5979, L5980, L5981, and L5987. The use of additional feature L-codes 
may also depend on the assigned K-Level modifier (K0-K4) as referenced in the LCD. 
 
When submitting a prosthetic claim, the billed code for knee, foot, ankle and hip (HCPCS codes L5610, L5611, 
L5613, L5614, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, 
L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, 
L5857, L5858, L5859, L5930, L5961, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, 
L5980, L5981, L5982, L5984, L5985, L5986, L5987) components must be submitted with modifiers K0 - K4, 
indicating the expected beneficiary functional level. This expectation of functional ability information must be 
clearly documented and retained in the prosthetist's records. The simple entry of a K modifier in those records 
is not sufficient. There must be information about the beneficiary's history and current condition which 
supports the designation of the functional level by the prosthetist." L5986 does not represent a complete foot. It 
is part of a foot that must be paired with a complete foot based on member's functional classification. The 
vendor indicates that the member's "expected beneficiary functional level" is K3, which, as noted above, is not 
supported by the medical record. If this part is needed, this need must be corroborated by provider without 
financial interest in the claim outcome, as noted above. There must be clear documentation why this part is 
needed, which has not been provided. 
 
You can find these rules in the Local Coverage Article for Lower Limb Prostheses - Policy Article, A52496. 
 
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 when services or supplies are rendered by a non-contracting, original Medicare, participating 
provider, there is no balance billing paid by either the Plan or the enrollee. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 4, Section 170.2. 
 
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 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 $0 copayment for an annual physical. The Plan contract also says if you 
receive services that address a medical condition during the same office visit, additional cost-share may apply. 
You can find this information in Chapter 4 on pages71 to 72. of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $10 copayment for each covered visit or consultation in 
an outpatient location with your PCP or other primary care provider. You can find this information in Chapter 4 
on page 107 of the Plans 2022 EOC,