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 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 during the rental of a Transcutaneous Electrical Nerve Stimulator (TENS) unit, supplies for the unit are included in the rental allowance; there is no additional allowance for items such as electrodes, lead wires, and batteries. If a TENS unit (E0720 or E0730) is purchased, the allowance is all-inclusive of items such as lead wires and one month's supply of items such as electrodes, conductive paste or gel (if needed), and batteries. You can find this in the Medicare Local Coverage Article (LCA) Transcutaneous Electrical Nerve Stimulators (TENS) Policy Article (A52520)
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 state that Section 1862 of the Social Security Act requires that an item or service must be "reasonable and necessary" before payment may be made. A reasonable and necessary determination is largely based on a review of the published clinical literature that is relevant to the item under consideration. When there is no published policy for an item, contractors may still make individual determinations when reviewing claims. The contractor's medical directors have reviewed information about crutch substitutes billed using code E0118. The determination is that there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for these products. You can find this information in the Durable Medical Equipment contractor's website at https://cgsmedicare.com/jc/pubs/news/2010/0210/cope11657.html.

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 
extractions but is limited to 2 procedure codes per plan year and is also subject to 45% coinsurance when 
provided by an out-of-network provider. This benefit does not include bone replacement grafts. You can find 
this information on pages 92-93 and 98-10 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 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 and cover any medically necessary covered benefit of the plan provider network, but at in-network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii).

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 page 30 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 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 Plan contract says that supplemental coverage is provided for a wellness allowance benefit. The plan 
reimburses you up to $250 per calendar year towards your cost for membership in a qualified health club or 
fitness facility during the calendar year, covered instructional fitness classes, participation in wellness programs 
such as Matter of Balance, Chronic Disease self-management, diabetes workshop, Healthy Eating for 
Successful Living, Healthy IDEAS, Powerful Tools for Caregivers, Arthritis Foundation Exercise, Enhance 
Wellness, Fit For Your Life, AAA Senior Driving, memory fitness activities, acupuncture, and/or covered 
nutritional counseling sessions with a licensed nutritional counselor or registered dietician. You pay all charges 
over $250 per calendar year. Sales tax is not eligible for reimbursement. You can find this information on 
pages 79-80 of the Plans 2021 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 the Centers for Medicare and Medicaid Service (CMS) has established units of service edits referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most circumstances allowable by the same provider for the same enrollee on the same date of service. Claims submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are "per day edits based on policy." Codes with an MAI of "2" have been rigorously reviewed and vetted within CMS and obtain this MAI designation because units of service on the same date of service (DOS) in excess of the MUE value would be considered impossible because it was contrary to statute, regulation, or sub regulatory guidance. 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(V).
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 an ultrasonic osteogenesis stimulator (E0760) is covered only if all of the following criteria are met:

Nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days. Each radiograph set must include multiple views of the fracture site accompanied by a written interpretation by a treating practitioner stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs; and
The fracture is not of the skull or vertebrae; and
The fracture is not tumor related.
An ultrasonic osteogenesis stimulator will be denied as not medically necessary if any of the criteria above are not met.

Use of an ultrasonic osteogenesis stimulator for the treatment of a fresh fracture or delayed union will be denied as not medically necessary.

Ultrasound conductive coupling gel is covered and separately payable if an ultrasonic osteogenesis stimulator is covered.

An ultrasonic osteogenesis stimulator will be denied as not medically necessary if it is used with other noninvasive osteogenesis stimulators.

You can find these rules in the Local Coverage Determination (LCD) Osteogenesis Stimulators L33796.

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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment. You can find
this rule at 42 CFR 424.5.
The rules say for Medicare to consider coverage for any item or service, the information submitted by the
supplier or provider must corroborate the documentation in the beneficiary's medical documentation and
confirm that Medicare coverage criteria have been met. You can see this in the Centers for Medicare and
Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 3,
Section 3.3.2.1.
The rules say that despite the "dental services exclusion" in 1862(a)(12) of the Act (see the Medicare Benefit
Policy Manual, Chapter 16, "General Exclusions from Coverage," 140), an oral or dental examination
performed on an inpatient basis as part of a comprehensive workup prior to renal transplant surgery is a
covered service. This is because the purpose of the examination is not for the care of the teeth or structures
directly supporting the teeth. Rather, the examination is for the identification, prior to a complex surgical
procedure, of existing medical problems where the increased possibility of infection would not only reduce the
chances for successful surgery but would also expose the patient to additional risks in undergoing such surgery.
Such a dental or oral examination would be covered under Part A of the program if performed by a dentist on
the hospital's staff, or under Part B if performed by a physician. (When performing a dental or oral
examination, a dentist is not recognized as a physician under 1861(r) of the Act.) (See the Medicare General
Information, Eligibility, and Entitlement Manual , Chapter 5, "Definitions," 70.2, and the Medicare Benefit
and Entitlement Manual, Chapter 15, "Covered Medical and Other Health Services," 150. You can find this
rule in the National Coverage Determination (NCD) Dental Examination Prior to Kidney Transplantation
260.6.
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 state that a non-expandable controller has the following features: The ability to control up to 2 power seating actuators through the drive control (for example, seat elevator and single actuator power elevating leg rests). (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) Codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the beneficiary to select the motor that is being controlled and an indicator feature to visually show which function has been selected. This information is 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 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 does not include 
core buildup services. You can find this information on pages 72-75 and 80-82 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 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 Centers for Medicare and Medicaid Service (CMS) has established units of service edits referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most circumstances allowable by the same provider for the same enrollee on the same date of service. Claims submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied.
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are "per day edits based on policy." MUEs for codes with an MAI of 3 are "per day edits based on clinical benchmarks." Codes with an MAI of "3" are based on criteria combined with data such that it would be possible, but medically unlikely, that higher values would represent correctly reported medically necessary services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, were correctly coded, and were medically necessary. 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(V).
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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).   
 
The rules say subluxation may be shown by x-ray or physical exam. 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 240.1.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.   
The Plan contract says that the only covered chiropractic service is manual manipulation of the spine to correct 
a subluxation. You can find this information on page 63 of the Plans 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will 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 requested item or service but is limited to 1 per 24 floating months. You can find this information on page 284 of the Plan's 2023 Medicare quick reference guide.