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 Power Mobility Device bases require a Standard Written Order (SWO) prior to delivery. The 
SWO may also list all associated options and accessories that are billed separately. 
 
The rules say that proof of delivery (POD) is a Supplier Standard and Durable Medical Equipment, Prosthetics, 
Orthotics and Supplies (DMEPOS) suppliers are required to maintain POD documentation in their files. Proof 
of delivery documentation must be made available to the Medicare contractor upon request. All services that do 
not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary. 
 
The rules say that a Standard Written Order (SWO) is required prior to claim submission for all options, 
accessories, and/or supplies that are separately billed in addition to the base. This SWO obtained prior to claim 
submission, may be prepared by someone other than a treating practitioner. If someone other than a treating 
practitioner prepares the SWO for separately billed options, accessories, and/or supplies, a treating practitioner 
must review and sign the order. 
 
The rules also say that prior to or at the time of delivery of a power operated vehicle (POV) or power 
wheelchair (PWC), the supplier or practitioner must perform an on-site evaluation of the beneficiarys home to 
verify that the beneficiary can adequately maneuver the device that is provided considering physical layout, 
doorway width, doorway thresholds, and surfaces. There must be a written report of this evaluation available 
on request. 
 
You can find these rules in the Local Coverage Determination (LCD) for Power Mobility Devices (L33789). 
 
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 and payment 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 & Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
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 417.414. 
 
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 pages 27-28 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 state that epidural steroid injection (ESI) will be considered medically reasonable and 
necessary when the following three (3) requirements are met: 
History, physical examination, and concordant radiological image-based diagnostic testing supporting 
one of the following: 
1. Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due 
to disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, 
producing foraminal or central spinal stenosis; OR 
Post-laminectomy syndrome; OR 
Acute herpes zoster associated pain 
2. Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly 
impact quality of life or function. An objective pain scale or functional assessment must be 
performed at baseline (prior to interventions). The same scale must be repeated at each 
follow-up for assessment of response. 
 
3. Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative 
care or medical documentation of failure to respond to four (4) weeks of noninvasive 
conservative care or acute herpes zoster refractory to conservative management where a four 
(4) week wait is not required. 
 
You can find these rules in Local Coverage Determination (LCD) Epidural Steroid Injections for Pain 
Management (L39242). 
 
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 to repair means to fix or mend and to put the equipment back in good condition after damage 
or wear. Repairs to equipment which a beneficiary owns are covered when necessary to make the equipment 
serviceable. However, do not pay for repair of previously denied equipment or equipment in the frequent and 
substantial servicing or oxygen equipment payment categories. If the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess. You can find this information in the Centers for Medicare 
and Medicaid Service, Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 
15, Section 110.2. 
 
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 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 & 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 
the retreatment of previous root canal therapy (D3347), post removal (D2955), the intraorifice barrier (D3911), 
the incomplete endodontic therapy (D3332), the prefabricated post and core (D2954), the abutment crown 
(D6740), and the porcelain/ceramic pontic (D6245). You can find this information on pages 84 to 91 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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) L36256 and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) A57527. 
 
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 treatment for lower urinary tract symptoms (LUTS)/benign prostatic hyperplasic (BPH) 
treatment will be considered reasonable and necessary when performed ONCE in patients with the following: 
  
1. Indications including ALL the following:  
 
1. Prostate volume of 30-150 cubic centimetre (cc) by transrectal ultrasound (TRUS) 
2. Persistent moderate to severe symptoms despite maximal medical management including ALL 
the following:  
1. International Prostate Symptom Score (IPSS) greater than or equal to 124 
2. Maximum urinary flow rate (Qmax) of less than or equal to 15 millilitre per second 
(mL/s4) (voided volume greater than 125 cc) 
3. Failure, contraindication or intolerance to at least 3 months of conventional medical 
therapy for LUTS/BPH  
     2. Only treatment using a Food and Drug Administration (FDA) approved/cleared device will be considered 
reasonable and necessary. 
  
You can find this information in the Local Coverage Determination (LCD): Transurethral Waterjet Ablation of 
the Prostate (L38549). 
 
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 epidural steroid injection (ESI) will be considered medical reasonable and necessary when 
the following requirements are met: 
 
1. History, physical examination, and concordant radiological image-based diagnostic testing that supports 
certain conditions; and 
2. Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality of 
life or function. An objective pain scale or functional assessment must be performed at baseline (prior to 
interventions). The same scale must be used at each follow-up for assessment of response; and 
3. Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or medical 
documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes zoster 
refractory to conservative management where a four (4) week wait is not required. 
 
You can find this information in the Local Coverage Determination (LCD) L39054: Epidural Steroid Injections 
for Pain Management. 
 
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 & 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 85-86 of the 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 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 & 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 crowns 
but is subject to certain clinical requirements. You can find this information on pages 75-76 and 78-82 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 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 & 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 one (1) panoramic radiography every three (3) years. You can find
this information on page 134 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare & 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. The contract also says that 
enrollees may be billed by the out-of-network provider for any charged amount greater than the payment made 
by the Plan. This benefit includes one panoramic or complete series imaging every 3 Plan years. You can find 
this information on pages 75-78 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). You can find these rules in the Centers for Medicare & Medicaid Services, Internet 
Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D). 
 
A PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. There is 
insufficient evidence to demonstrate that reimbursement is justified. Claims for E0675 will be denied as not 
reasonable and necessary. You can find this information in the Local Coverage Article: Pneumatic 
Compression Devices - Policy Article (A52488) and in the Local Coverage Determination (LCD): Pneumatic 
Compression Devices (L33829). 
 
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 diagnostic X-Ray tests, diagnostic laboratory tests, and other diagnostic tests must be 
ordered by the physician who is treating the beneficiary and tests not ordered by the physician who is treating 
the beneficiary are not reasonable and necessary. While a physician order is not required to be signed, the 
physician must clearly document, in the medical record, the intent that the test be performed. Contractors shall 
consider order requirements for diagnostic laboratory tests met if there is: 
 
1. A signed order or signed requisition listing the specific test; or 
2. An unsigned order or unsigned laboratory requisition listing the specific tests to be performed and an 
authenticated medical record that supports the physician/practitioners intent to order the tests; or 
3. An authenticated medical record that supports the physician/practitioners intent to order the specific tests. 
 
You can see this in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-08, 
Medicare Program Integrity Manual Chapter 6, Section 6.9.1. 
 
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.