Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that when providing a seat lift mechanism that is incorporated into a chair as a complete unit at 
the time of purchase, suppliers must bill the item using the established HCPCS code for the seat-lift 
mechanism. In this situation, the supplier may bill the seat lift mechanism using E0627 or E0629, and bill 
A9270 for the chair. You can find this information in Local Coverage Article: Seat Lift Mechanisms - Policy 
Article (A52518). 
 
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 neuromuscular electrical stimulation to treat muscle atrophy is limited to the treatment of 
disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, 
and other non-neurological reasons for disuse atrophy. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determination for 
Neuromuscular Electrical Stimulation (NMES), 160.12. 
 
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 the limitations listed in sections 1-5 below refer to specific body areas and lesion 
characteristics. The use of Mohs Micrographic Surgery in these areas and for these conditions is not considered 
medically reasonable and necessary:  
1. Both recurrent and primary actinic keratosis (AK) with focal SCC in situ; Bowenoid AK; SCC in situ 
(AK type) of any size in all areas in healthy or immunocompromised   
2. Basal cell carcinoma located in Area L trunk and extremities (excluding pretibial surface, hands, feet, 
nail units, and ankles): 
o Recurrent superficial BCC (healthy or immunocompromised patients, or patients with genetic 
syndromes) of any size 
o Primary superficial BCC (healthy or immunocompromised patients) of any size 
o Primary nodular BCC (healthy patients)  2 cm 
o Primary nodular BCC (immunocompromised patients)  1 cm 
3. Squamous cell carcinoma located in Area L trunk and extremities (excluding pretibial surface, hands, 
feet, nail units, and ankles): 
o Primary SCC; without aggressive histologic features, <2 mm depth without other defining 
features, Clark level  III (healthy patients) 2 cm 
o Primary SCC keratoacanthoma (KA) type; not central facial (healthy patients)  1 cm 
o Primary in situ SCC/Bowen disease (healthy patients)  2 cm 
o Primary in situ SCC/Bowen disease (immunocompromised patients)  1 cm 4. Desmoplastic trichoepithelioma located in Area L trunk and extremities (excluding pretibial surface, 
hands, feet, nail units, and ankles)  
5. Bowenoid papulosis 
You can find this rule in Local Coverage Determination (LCD) Mohs Micrographic Surgery (MMS) L33689. 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. 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 29 of the Plan's 2022 
Member Handbook.
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 information on the Physician Fee Schedule Payment Policy Indicator file record layout is used for 
processing Method II CAH professional services with revenue codes 96X, 97X or 98X. 
4 = Global test only codes: This indicator identifies stand-alone codes for which there are associated codes that 
describe: a) the professional component of the test only and b) the technical component of the test only. 
modifiers 26 and TC cannot be used with these codes. The total RVUs for global procedure only codes include 
values for physician work, practice expense, and malpractice expense. The total RVUs for global procedure 
only codes equals the sum of the total RVUs for the professional and technical components only codes 
combined. 
5 = Incident to Codes: This indicator identifies codes that describe services covered incident to a physicians 
service when they are provided by auxiliary personnel employed by the physician and working under his or her 
direct supervision. 
You can find this rule at Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-
104, Medicare Claims Processing Manual, Chapter 23, Section 50.6. 
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 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 a Medicare plan may restrict enrollees 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 specialty care outside of the plan provider network when network providers are unavailable or 
inadequate to meet an enrollees medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community based 
services. You can find this rule at 42 CFR Section 422.112. 
 
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 39 of the plan's 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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules also say that glycated hemoglobin/protein testing is widely accepted as medically necessary for the 
management and control of diabetes. It is also valuable to assess hyperglycemia, a history of hyperglycemia or 
dangerous hypoglycemia. Glycated protein testing may be used in place of glycated hemoglobin in the 
management of diabetic patients, and is particularly useful in patients who have abnormalities of erythrocytes 
such as hemolytic anemia or hemoglobinopathies. These tests are not considered to be medically necessary for 
the diagnosis of diabetes. You can find this information in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-03, National Coverage Determinations (NCD) Manual: Glycated 
Hemoglobin/Glycated Protein (190.21). If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
 
 
  
  The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that except as specified in paragraph (b) of this section, Medicare does not pay for services 
furnished outside the United States. For purposes of this paragraph (a), the following rules apply: 
 
(1) The United States includes the 50 States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, 
American Samoa, The Northern Mariana Islands, and for purposes of services rendered on board ship, the 
territorial waters adjoining the land areas of the United States. 
(2) Services furnished on board ship are considered to have been furnished in United States territorial waters if 
they were furnished while the ship was in a port of one of the jurisdictions listed in paragraph (a)(1) of this 
section, or within 6 hours before arrival at, or 6 hours after departure from, such a port. 
 
You can find this rule at 42 CFR Section 411.9. 
 
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 cover worldwide emergency and urgently needed services under your plan. A 
medical emergency is when you believe, or any other prudent layperson with an average knowledge of health 
and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss 
of life, loss of limb, or loss of function of a limb. The medical symptoms may be an illness, injury, sever pain, 
or a medical condition that is quickly getting worse. You can find this information on page 50 of the Plans 
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 a pneumatic compression device (PCD) coded as E0650 or E0651 is covered for the 
treatment of chronic venous insufficiency (CVI) of the lower extremities only if the patient has all of the 
following: 
 
 Edema in the affected lower extremity 
 One or more venous stasis ulcer(s) 
 The ulcer(s) have failed to heal after a six-month trial of conservative therapy directed by the treating 
practitioner. 
 
A PCD coded as E0650 or E0651 used to treat CVI 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 these rules in 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 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 
coverage for pontic - porcelain fused to high noble metal (D6240), and retainer crown - porcelain fused to high 
noble metal (D6750) but each are limited to once per 60 month(s), per patient, per tooth. Pre-operative x-ray(s) 
is required documentation for review. You can find this information on page 107 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 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 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: 
 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  
 Post-laminectomy syndrome  
 Acute herpes zoster associated pain 
 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. 
 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 rule in Local Coverage Determination (LCD) Epidural Steroid Injections for Pain 
Management L39036. 
 
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 the treatments for symptomatic varicose tributaries are either compressive sclerotherapy or 
microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are > than 4 mm in diameter and if the patient 
remains symptomatic after a six-week trial of conservative therapy. You can find this rule in the Local 
Coverage Determination (LCD) for Varicose Veins of the Lower Extremity, Treatment of (L33575). 
 
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 the following indications are appropriately assessed by TTE: native and prosthetic valvular 
hearth disease, endocarditis, suspected cardiac thrombi and emboli, cardiac and pericardiac masses, aortic 
pathological conditions, critically ill patients, congenital heart disease, certain instances involving 
interventional and surgical cardiac interventions, and/or cardioversion. You can find this information in the 
Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD): Transesophageal 
Echocardiography (TEE) (L35016). 
 
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 sacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-
frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation 
to determine if an implantable stimulator would be effective and a permanent implantation in appropriate 
candidates. Both the test and the permanent implantation are covered. 
 
The following limitations for coverage apply to all three indications: 
 
 Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or 
surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can 
occur. 
 Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes 
with peripheral nerve involvement) which are associated with secondary manifestations of the above three 
indications are excluded. 
 Patient must have had a successful test stimulation in order to support subsequent implantation. Before 
a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement 
through test stimulation. Improvement is measured through voiding diaries. 
 Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical 
results of the implant procedure can be properly evaluated. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 230.18. 
 
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.