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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 48 one-way trips, combined in and out-of-network, each year. The Plan contract also says each 
one-way trip must not exceed 50 miles of driving distance. You can find this information on pages 4-76 and 4-
77 of the Plans 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 and 
supporting one of the following: 
 Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic 
claudication due to central disc herniation, osteophyte or osteophyte complexes, severe 
degenerative disc disease, producing foraminal or central spinal stenosis; OR 
 Post-laminectomy syndrome 
 Acute herpes zoster associated pain 
AND 
 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. 
AND 
 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. 
 
Patients should be part of an active rehabilitation program, home exercise program or functional restoration 
program. You can find this rule in the Local Coverage Determination for Epidural Steroid Injections for Pain 
Management, L38994. 
 
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 a $350 copayment for each surgery or service at an ambulatory surgical 
center or outpatient hospital facility. You can find this information on page 93 of the Plan's 2021 Evidence of 
Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a standard walker and related accessories are covered if all of the following criteria (1-3) are 
met: 
1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADL) in the home. 
2. The beneficiary is able to safely use the walker; and 
3. The functional mobility deficit can be sufficiently resolved with use of a walker. 
  
If all of the criteria are not met, the walker will be denied as not reasonable and necessary. 
 
A heavy-duty walker (E0148, E0149) is covered for beneficiaries who meet coverage criteria for a standard 
walker and who weigh more than 300 pounds. If an E0148 or E0149 walker is provided and if the beneficiary 
weighs 300 pounds or less, it will be denied as not reasonable and necessary. You can find this rule in the Local 
Coverage Article for Walkers, L33791.  
 
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 epidural steroid injection (ESI) will be considered medically reasonable and necessary when 
the following requirements are met: 
o History, physical examination, and concordant radiological image-based diagnostic testing that 
supports 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
 
OR 
 Post-laminectomy syndrome, OR 
 Acute herpes zoster associated pain. 
AND 
o 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 
o 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. 
 
Repeat ESI 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. You can find this rule in the Local Coverage Determination for Epidural 
Steroid Injections for Pain Management, L33906. 
 
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 ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device is made 
based upon the specifics of each persons medical condition. There must be enough detailed information in the 
medical record to justify the treatment selected. You can find this rule in the Local Coverage Determination 
(LCD) for Respiratory Assist Devices, L33800. 
 
The rules say that oxygen reimbursement is a bundled payment. All options, supplies and accessories are 
considered included in the monthly rental payment for oxygen equipment. Oxygen rental is billed using the 
appropriate code for the provided oxygen equipment. Separately billed options, accessories or supply items will 
be denied as unbundling. You can find these rules in the Local Coverage Determination (LCD) for Oxygen and 
Oxygen Equipment, L33797. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a skin protection seat cushion (E2603, E2604, E2622, E2623) is covered for a beneficiary 
who meets both of the following criteria: 
 
1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the 
beneficiary meets Medicare coverage criteria for it; and 
2. The beneficiary has either of the following (a or b): 
   a. Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface as 
reflected in a diagnosis code listed in the rules; or 
   b. Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a 
functional weight shift as reflected in a diagnosis code listed in the rules. 
 
You can find this information in the Local Coverage Determination (LCD): Wheelchair Seating (L33312). 
 
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 an inversion/eversion correction device (A9285) is denied as noncovered (no Medicare 
benefit), because it does not act as a brace; that is, it does not support a weak or deformed body member or 
restrict or eliminate motion in a diseased or injured part of the body. You can find this rule in Local Coverage 
Article Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457). 
 
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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 48 one-way trips each year. You can find this information on page 4-76 of the Plans 2022 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 payment is not made under the physician fee schedule for Technical Component (TC) 
services furnished in institutional settings where the TC service is bundled into the facility payment, e.g., 
hospital inpatient and outpatient settings. Payment is made under the physician fee schedule for TC services 
furnished in institutional settings where the TC service is not bundled into the facility payment, e.g., an 
ambulatory surgery center (ASC). Payment may be made under the physician fee schedule for the TC of 
physician pathology services furnished by an independent laboratory, or a hospital if it is acting as an 
independent laboratory, to non-hospital patients. The physician fee schedule identifies physician laboratory or 
physician pathology services that have a TC service. 
 
For TC services furnished by independent laboratories to hospital inpatients and outpatients on or after July 1, 
2012, an independent laboratory may not bill the A/B Medicare Administrative Contractor (MAC) (B) (and the 
A/B MAC (B) may not pay) for the TC component of a physician pathology service furnished to a hospital 
inpatient or outpatient.  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 60. 
 
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 high frequency chest wall oscillation devices (HFCWODs) are covered when they are 
medically necessary for enrollees who have: 
 a. cystic fibrosis; or 
 b. bronchiectasis that has been confirmed by (computed tomography) CT scan; or  
 c. one of these neuromuscular diseases: post-polio, acid maltase deficiency, anterior horn cell diseases, 
multiple sclerosis, quadriplegia, hereditary muscular dystrophy, myotonic disorders, other myopathies, or 
paralysis of the diaphragm.  
 
Medical records must show failure of standard treatments to clear secretions. The rules also say that chronic 
bronchitis and chronic obstructive pulmonary disease (COPD) do not meet criteria for coverage when there is 
no diagnosis of bronchiectasis. You can find these rules in the Medicare Local Coverage Determination (LCD) 
L33785, High Frequency Chest Wall Oscillation Devices. This LCD is effective for services provided on or 
after July 1, 2016. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
The rules state that a spinal electrical osteogenesis stimulator (E0748) is covered only if any of the following 
criteria are met: 
1. Failed spinal fusion where a minimum of nine months has elapsed since the last surgery, or 
2. Following a multilevel spinal fusion surgery (see Appendices section), or 
3. Following spinal fusion surgery where there is a history of a previously failed spinal fusion at 
the same site. 
You can find more information in Local Coverage Determination (LCD): Osteogenesis Stimulators (L33796). 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
  
  
  The rules say that 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 
enhanced preventive and comprehensive services. Periodontal surgery/scaling and root planning  one per 
quadrant every three calendar years. You can find this information in Chapter 4 on pages 66 to 69 of the Plans 
2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the provider must notify the enrollee in writing before a Medicare plan ends coverage of 
skilled nursing facility services. A Notice of Medicare Non-Coverage (NOMNC) must be issued no later than 
  
  two days before the last covered day. The notice must state: 
1. The date that coverage of services ends, 
2. The date that the enrollee must begin to pay for the services, and 
3. A description of the enrollee's right to a fast-track appeal and other appeal procedures. 
The Medicare plan must continue to cover services until two days after valid notice is delivered. You can find 
this rule at 42 CFR Section 422.624. 
 
The rules say that notification of changes for an enrollee who is incapable of receiving or incompetent to 
receive the notice must be made to a representative of the enrollee. You can find these rules in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 30, Section 260.3.8. 
 
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 state that therapeutic facet joint procedures are considered medically reasonable and necessary for 
patients who meet ALL the following criteria: 
 
a. The patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with each 
one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of relief being 
consistent with the agent used); AND 
b. Subsequent therapeutic facet joint procedures at the same anatomic site results in at least consistent 50% 
pain relief for at least three (3) months from the prior therapeutic procedure or at least 50% consistent 
improvement in the ability to perform previously painful movements and ADLs as compared to baseline 
measurement using the same scale; AND 
c.  Documentation of why the patient is not a candidate for radiofrequency ablation (such as established spinal 
pseudarthrosis, implanted electrical device) 
 
Frequency Limitations: For each covered spinal region no more than four (4) therapeutic facet joint (IA) 
sessions will be reimbursed per rolling 12 months. You can find this rule in the Medicare Local Coverage 
Determination (LCD)- L38773, Facet Joint Interventions 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.