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 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.

The rules say that an expandable controller is capable of accommodating one or more of the following
additional functions: -Other types of proportional input devices (e.g., mini-proportional, or compact joysticks,
touchpads, chin control, head control, etc.) -Non-proportional input devices (e.g., sip and puff, head array, etc.)
-Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)
An expandable controller may also be able to operate one or more of the following: -A separate display (i.e.,
for alternate control devices) -Other electronic devices (e.g., control of an augmentative speech device or
computer through the chair's drive control) -An attendant control You can find this rule in Local Coverage
Article: Power Mobility Devices - Policy Article (A52498) - Effective January 1, 2020.

The rules say that code E2311 describes an electronic component that allows the patient to control two or more
of the following motors from a single interface; e.g. proportional joystick, touchpad or nonproportional
interface: -Power tilt -Power recline, with or without shear reduction -Combination power tilt and recline, with
or without shear reduction -Power leg elevation with or without articulation, power center mount elevating foot
platform with or without articulating properties You can find this rule in Local Coverage Article: Power
Mobility Devices - Policy Article (A52498) - Effective January 1, 2020.

The rules say that a harness (E2313) describes all the wires, fuse boxes, fuses, circuits, switches, etc. that are
required for the operation of an expandable controller (E2377). It also includes all the necessary fasteners,
connectors, and mounting hardware. You can find this rule in Local Coverage Article: Power Mobility Devices
- Policy Article (A52498) - Effective January 1, 2020.

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 Medicare covers pneumatic devices when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. You can find 
this in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-03, Medicare 
National Coverage Determinations Manual, Chapter 1, Section 280.6. 
 
The rules state that a pneumatic compression device (PCD) coded as E0652, is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen when all of the following are met: 
 
a. The beneficiary has lymphedema of an extremity as defined above 
b. The coverage criteria for an E0650 or E0651 are met 
c. The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits 
of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve 
with a four-week trial. (See below for trial guidelines.) 
 
A PCD coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen that does not 
meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable 
and necessary. You can find this rule 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 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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that evaluation and management services on the day before major surgery or on the day of major 
surgery that result in the initial decision to perform the surgery are not included in the global surgery payment 
for the major surgery and, therefore, may be billed and paid separately. If evaluation and management services 
occur on the day of surgery, the physician bills using modifier "-57," not "-25". You can find this rule in the 
Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 12, Sections 40.2.A(4). 
 
The rules say that visits by the same physician on the same day as a minor surgery or endoscopy are included in 
the payment for the procedure, unless a significant, separately identifiable service is also performed. Modifier 
"-25" is used to facilitate billing of evaluation and management services on the day of a procedure for which 
separate payment may be made. It is used to report a significant, separately identifiable evaluation and 
management service by same physician on the day of a procedure. You can find this rule in the Centers for 
Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 12, Sections 40.1(C) and 40.2.A(8). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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.  
 
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 Medicare-covered podiatry services.  
You can find this information on page 83 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 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. 
 
The rules say that chemotherapy agents may be covered if reasonable and medical necessity is met and the drug 
is: - approved by the Food and Drug Administration (FDA) and listed in the National Comprehensive Cancer 
Network (NCCN) Clinical Practice Guidelines in Oncology with the specific ICD-10 diagnosis (that is being 
treated) for the drug/agent. 
- the chemotherapy agent must be listed Category 1 or 2A in NCCN, 
- the chemotherapy agent must be utilized per the NCCN Recommended Use (order or combination). 
 
You can find this information in the Centers for Medicare & Medicaid Services, Local Coverage Determination 
(LCD): Chemotherapy Drugs and their Adjuncts (L37205). 
 
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 one 
partial/bridge every four years. You can find this information on pages 59-60 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 routine dental benefits such as exams, cleanings, filling, crowns, 
bridges, root canals, partial and complete dentures, and implants. Some covered services may consider prior 
tooth history and procedures in conjunction with frequency limitations. Detailed information about these 
benefits can be found in the Dental Medicare Quick Reference guide. You can find this information in Chapter 
4 on pages 126 to 129 of the Plan's 2023 Evidence of Coverage. 
 
The Plan contract says that the Plan covers guided tissue regeneration, resorbable barrier, per site (dental code 
D4266) once per lifetime. The clinical documentation requirements are: 
1. Current dated radiographs of tooth/area of problem 
2. Complete 6-point periodontal charting 
3. Narrative of necessity 
 
You can find this rule in the Plan's 2023 Dental Medicare Quick Reference Guide (QRG).
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 page 89 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 Place of Service (POS) code 31 should be used with services for patients in a Part A 
covered skilled nursing facility (SNF) stay and POS code 32 should be used with services for beneficiaries in a 
non-covered stay. You can find this rule in Medicare Claims Processing Manual Chapter 6, 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 obstructive sleep apnea (OSA) is a disease characterized by recurrent episodes of upper 
airway obstruction during sleep. The disruption in airflow caused by OSA has been associated with multiple 
comorbidities, including hypertension, cardiovascular disease, cardiac arrhythmia, cerebrovascular disease, 
excessive daytime sleepiness, and mood disorders. Continuous positive airway pressure (CPAP) has long been 
the primary treatment modality of choice for OSA, showing improvements in many comorbidities. 
Unfortunately, despite attempts to improve compliance, many people are unable to tolerate treatment with 
CPAP. Because of the large percentage of patients not tolerating CPAP, alternative treatment strategies are 
necessary. 
 
The hypoglossal nerve is the twelfth cranial nerve and innervates all the extrinsic and intrinsic muscles of the 
tongue, except for the palatoglossus which is innervated by the vagus nerve. It is a nerve with a solely motor 
function. The nerve arises from the hypoglossal nucleus in the brain stem as a number of small rootlets, passes 
through the hypoglossal canal and down through the neck, and eventually passes up again over the tongue 
muscles it supplies into the tongue. There are two hypoglossal nerves in the body: one on the left, and one on 
the right. 
 
FDA-approved hypoglossal nerve neurostimulation is considered medically reasonable and necessary for the 
treatment of moderate to severe obstructive sleep apnea when all of the following criteria are met: 
 
1. Beneficiary is 22 years of age or older; and 
2. Body mass index (BMI) is less than 35 kg/m2; and 
3. A polysomnography (PSG) is performed within 24 months of first consultation for HGNS implant; and 
4. Beneficiary has predominantly obstructive events (defined as central and mixed apneas less than 25% of the 
total AHI); and 
5. AHI is 15 to 65 events per hour; and 
6. Beneficiary has documentation that demonstrates CPAP failure (defined as AHI greater than 15 despite 
CPAP usage) or CPAP intolerance (defined as less than 4 hours per night, 5 nights per week or the CPAP has 
been returned) including shared decision making that the patient was intolerant of CPAP despite consultation 
with a sleep expert: and 7. Absence of complete concentric collapse at the soft palate level as seen on a drug-induced sleep endoscopy 
(DISE) procedure; and 
8. No other anatomical findings that would compromise performance of device. 
 
You can find these rules in the Local Coverage Determination (LCD) Hypoglossal Nerve Stimulation for the 
Treatment of Obstructive Sleep Apnea L38307. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that 
meets Medicare coverage criteria and the option/accessory itself is medically necessary. If these criteria are not 
met, the item will be denied as not reasonable and necessary. You can find the rules in Local Coverage 
Determination (LCD) Wheelchair Options/Accessories L33792. 
 
The rules say that Wheelchair options and accessories are covered under the Durable Medical Equipment 
benefit (Social Security Act 1861(s)(6)). In order for a beneficiarys equipment to be eligible for 
reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage 
Determination must be met. In addition, there are specific statutory payment policy requirements, discussed 
below, that also must be met. You can find this rule in Local Coverage Article (LCA) 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 transportation furnished to inpatients  including transportation by ambulance to and from 
another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at 
the facility where the enrollee is an inpatient  is covered under Part A. Consequently, it is covered by the 
prospective payment rate or reimbursed as reasonable costs under Part A to hospitals excluded from the 
prospective payment system (PPS). You can find this rule in Medicare Claims Processing Manual Chapter 3, 
Section 10.4(A). 
 
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 20% coinsurance for Medicare Part B prescription drugs. You can find 
this information on pages 86 and 87 of the Plan's 2023 Evidence of Coverage (EOC).