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 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 Medicare will pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relative's 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 and Medicaid Services, Internet 
Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D). 
 
The rules say that an add-on to convert a manual wheelchair to a joystick-controlled power mobility device 
(E0983) or to a tiller-controlled power mobility device (E0984) will be denied as not reasonable and necessary. 
You can find this rule in the Local Coverage Determination (LCD) Power Mobility Devices L33789. 
 
The rules say that a pneumatic tire (E2211, E2214) is a rubber tire which is used in conjunction with a separate 
tube (E2212, E2215) which is filled with air.  
 
Miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific HCPCS 
code and are not included in another code should be coded K0108. If multiple miscellaneous accessories are 
provided, each should be billed on a separate claim line using code K0108. When billing more than one line 
item with code K0108, ensure that the additional information can be matched to the appropriate line item on the 
claim. It is also helpful to reference the line item to the submitted charge. If a supplier chooses to bill separately 
for a component that is included in another code, code A9900 must be used. You can find this rule in the 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 elevators are not covered because they are considered convenience items that are not 
primarily medical in nature. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.1. 
 
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. 
 
Repeat ESI: The rules say that repeat epidural steroid injections (ESIs) when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
  
  necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using same scale for at least three months. If a patient fails to 
respond well to the initial ESI, a repeat ESI after 14 days can be performed, using a different approach, level 
and/or medication if appropriate, with the rationale and medical necessity for the second ESI documented in the 
medical record. You can find this information in 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. 
 
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says you have a $200 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses (1 per calendar year). You can find this information on page 87 of the Plan's 2022 Evidence of 
Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The Plan must have written policies for determining enrollee eligibility and 
must document its determination that an enrollee is a chronically ill enrollee. You can find this information in 
42 CFR 422.102. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. You can find this information on page 103 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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that the Plan covers certain routine vision care services. The eyewear protection plan is 
excluded from this benefit. You can find this information on pages 83 to 84 of the Plan's 2020 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 hospital outpatient psychiatric services must be for the purpose of diagnostic study or the 
services must reasonably be expected to improve the patient's condition. The treatment must be part of an 
individualized treatment plan. The treatment must, at a minimum, be designed to reduce or control the patient's 
psychiatric symptoms so as to prevent relapse or hospitalization and improve or maintain the patient's level of 
functioning. Screening procedures provided routinely to patients without regard to the signs and symptoms of 
the patients mental illness do not represent reasonable and necessary outpatient psychiatric services. You can 
find this rule in the Local Coverage Determination for Psychiatry and Psychology Services, L33632.  
 
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 state that Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing 
eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the 
course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered 
even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find 
these rules at 42 CFR Section 411.15(c). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules state that the Medicare approved amount for global surgery procedures includes payment for the 
following services related to the surgery when furnished by the physician who performs the surgery. 
 
- Preoperative Visits  
- Intra-operative Services  
- Complications Following Surgery  
- Postoperative Visits  
- Postsurgical Pain Management  
- Supplies  
- Miscellaneous Services 
 You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.1. 
 
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 testing methods that include (real-time) duplex scans and Doppler ultrasound waveform with 
spectral analysis are covered for the following indications: 
 
    Cervical bruits. 
    Amaurosis fugax (transient monocular blindness). 
    Focal cerebral or ocular transient ischemic attacks. 
    Drop attack or syncope is only covered with vertebrobasilar or bilateral carotid artery disease as suggested 
by the patients history. If an echocardiogram is negative for a cardiac or cardiac valvular cause, it may be 
medically appropriate to perform extracranial arteries studies for the drop attack or syncope. 
    Subclavian steal syndrome (symptoms usually associated with it are a bruit in the subclavian fossa, unequal 
radial pulses, arm claudication following minimal exercise, and a difference of 20 mm Hg or more between the 
systolic blood pressures in the arms). 
    Evaluation of blunt or penetrating neck trauma or injury to the carotid artery. 
    Follow-up after a carotid endarterectomy or carotid stenting. 
    Suspected aneurysm of the carotid artery. Patients with swelling of the neck particularly if occurring post 
carotid endarterectomy. 
    Re-evaluation of existing carotid stenosis. 
    Evaluation of pulsatile neck mass. 
    Preoperative evaluation of patient scheduled for major cardiovascular surgical procedure when there is 
evidence of systemic atherosclerosis. 
    Preoperatively validate the degree of carotid stenosis of patients whose previous duplex scan revealed a 
greater than 60% diameter reduction. The duplex is only covered when the surgeon questions the validity of the 
previous study and the repeat test is performed in lieu of a carotid arteriogram. 
    Ocular micro embolism (optic nerve/retinal arterial - Hollenhorst plaques/ocular). 
    Evaluation of suspected dissection. 
    Recent stroke (defined as less than six months) for determining the cause of the stroke. 
    Vasculitis involving the extracranial carotid arteries. 
    Diagnosis of carotid disease on medical management and cerebrovascular symptoms are reoccurring. 
    Pulsatile tinnitus with other symptoms involving the cardiovascular system.  
 
You can find this information in the Local Coverage Determination (LCD) for Non-Invasive Cerebrovascular 
Studies (L35753). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that wheelchair options and accessories must be billed with modifier GA, GY, GZ, or KX.  
Claim lines billed without one of these modifiers will be rejected as missing information. Items billed with 
modifier GY indicate that Medicare coverage criteria have not been met. If the GY modifier is not appropriate, 
the KX modifier must be added to the code. You can find this rule at Centers for Medicare and Medicaid 
Services Local Coverage Article A52504 entitled Wheelchair Options/Accessories- Policy Article. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that they have a link will take you to a list of Part B Drugs that may be subject to Step Therapy. 
You can find this information in Chapter 4 on page 63 of the Plan's 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 state that the scope of the covered portable x-ray benefit is defined as: 
 
- Skeletal films involving the extremities, pelvis, vertebral column, or skull; 
-  Chest films which do not involve the use of contrast media (except routine screening procedures and     
tests in connection with routine physical examinations); 
-  Abdominal films which do not involve the use of contrast media; and 
-  Diagnostic mammograms if the approved portable x-ray supplier 
 
You can find this information in the Medicare Benefit Policy Manual, Chapter 15, Section 80.4.3. 
 
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.
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 Denosumab (Prolia) is covered when the following are met:

Patient adequately supplemented with calcium and vitamin D (calcium 1000 mg daily and at least 400 IU vitamin D daily).

For postmenopausal osteoporosis at high risk for fracture, documentation should include but is not limited to:

1. Menopausal status (for female beneficiaries only)
2. Patients age and sex.
3. Documentation supporting the diagnosis of osteoporosis.
4. Previous treatment of osteoporosis, agents used, outcomes and adverse reactions if any.
5. History of previous fractures, including type of fracture, cause and time since occurrence.
6. Risk factors for future fracture including preventive measures.

For the treatment of cancer treatment-induced bone loss (CTIBL) due to hormone ablation such documentation should include, but is not limited to:

1. Documentation supporting the diagnosis of breast cancer or nonmetastatic prostate cancer.
2. Use of adjuvant aromatase inhibitor (AI) therapy or androgen deprivation therapy (ADT).
3. Additional diagnosed risk factors, if any.

You can find this rule in the Local Coverage Article Billing and Coding: Denosumab (Prolia TM, Xgeva TM), A52399.

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 the 
requested item or service but is limited to 1 set of complete or partial dentures every 5 calendar years. You can 
find this information in Chapter 4 on pages 54-55 of the Plan's 2023 Evidence of Coverage (EOC).