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 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 
 
Codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more 
of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional 
interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, 
power seat elevation, power standing. It includes a function selection switch which allows the beneficiary to 
select the motor that is being controlled and an indicator feature to visually show which function has been 
selected. When the wheelchair drive function has been selected, the indicator feature may also show the 
direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate 
display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for 
fixed mounting hardware for the control box and for the display box (if present). 
 
You can find this information in the Local Coverage Article (LCA): Wheelchair Options/Accessories 
(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 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 complete dentures (upper and lower) or partial dentures (upper and 
lower) (1 upper complete/partial and/or 1 lower complete/partial denture every 5 calendar years, including 
routine post-delivery care) includes necessary extractions to fit dentures (unlimited). You can find this 
information on page 79 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 in any circumstance in which a Medicare Advantage (MA) plan provides transplant services 
at a more distant location, the MA plan must provide reasonable transportation to the distant facility for the 
enrollee and a companion. The MA plan must also provide reasonable accommodations for the enrollee and a 
companion while in the distant location for medical care. You can find this information in the Centers for 
Medicare and Medicaid Service, Internet-Only Manual, Publication 100-16, Medicare Managed Care Manual, 
Chapter 4, Section 10.11. 
 
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 if the Plan provides transplant services at a location outside the pattern of care for transplants in your 
community and you choose to obtain transplants at this distant location, the Plan will arrange or pay for 
appropriate lodging and transportation costs for you and a companion. You can find this information on page 
59 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 say that Original Medicare pays for the routine costs of qualifying clinical trials. Medicare also pays 
for reasonable and necessary items and services used to diagnose and treat complications arising from 
participation in all clinical trials. The rules also say that Medicare plans must cover these services even if they 
are not available through in-network providers. Medicare plans may require reporting when enrollees 
participate in clinical trials but cannot require prior authorization or approval. You can find these rules in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National 
Coverage Determinations Manual, Chapter 1, Section 310.1.  
 
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. The Plan 
contract also says that a clinical research study or clinical trial is a way that doctors and scientists test new 
types of medical care. They test new medical care procedures or drugs by asking for volunteers to help with the 
study. This kind of study is one of the final stages of a research process that helps doctors and scientists see if a 
new approach works and if it is safe. 
 
An enrollee who is in a clinical research study may stay enrolled in the Plan and continue to get the care that is 
not related to the study through the Plan. Enrollees must tell the plan before they start participating in a clinical 
research study. 
 
If an enrollee participates in a Medicare-approved study, Original Medicare pays most of the costs for the 
covered services received as part of the study. After Medicare has paid its share of the cost for these services, 
the Plan will also pay for part of the costs. The Plan will pay the difference between the cost-sharing in 
Original Medicare and the cost-sharing as a member of the Plan. This means the enrollee will pay the same 
amount for the services received as part of the study as he or she would if these services were received from the Plan. You can find this information on pages on pages 49 to 51 of the Evidence of Coverage (EOC) of the 
Plan's 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 state that percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for the following indications: 
 
1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have not 
responded to non-surgical medical management with and without methods of immobility. 
 
Both percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA) will be considered 
reasonable and necessary when ALL of the following criteria are met: 
- Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1- 
L5), based on symptom onset, and documented by advanced imaging demonstrating bone marrow edema on 
magnetic resonance imaging (MRI) or bone-scan/Single-Photon Emission Computerized Tomography 
(SPECT)/computed tomography (CT) uptake and 
- The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or Visual 
Analog Scale [VAS] pain score greater than or equal to 8) or is non-hospitalized with moderate to severe pain 
(NRS or VAS greater than or equal to 5) despite optimal non-surgical management (NSM) with one of the 
following: 
Worsening Pain or 
Stable to improved pain (but NRS or VAS greater than or equal to 5) when 2 or more of the following are 
present: 
- Progression of vertebral body height loss 
- greater than 25% vertebral body height reduction 
- Kyphotic deformity 
- Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] greater than 17) 
 
Limitations 
 
Exclusion criteria 
Absolute contraindication 
- Current back pain is not primarily due to the identified acute or subacute VCF(s). 
- Osteomyelitis, discitis or active systemic infection 
- Pregnancy 
- Active surgical site infection 
 
Relative contraindication 
- Greater than three vertebral fractures per procedure 
- Allergy to bone cement or opacification agents 
- Uncorrected coagulopathy 
- Spinal instability 
- Myelopathy from the fracture 
- Neurologic deficit 
- Neural impingement 
- Fracture retropulsion/canal compromise 
 
You can find this information in the Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L34976). 
 
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 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 Physician Fee Schedule Status Indicator I means that this code is not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment for, these services. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
  
The rules say that 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 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/m
2
; and 
3. A polysomnography (PSG) is performed within 24 months of first consultation for Hypoglossal Nerve 
Stimulation (HGNS) implant; and 
4. Beneficiary has predominantly obstructive events (defined as central and mixed apneas less than 25% 
of the total Apnea-Hypopnea Index [AHI]); and 
5. AHI is 15 to 65 events per hour; and 
6. Beneficiary has documentation that demonstrates CPAP (continuous positive airway pressure) 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 (e.g., tonsil size 3 or 4 per 
standardized tonsillar hypertrophy grading scale). 

You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD): Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (L38310). 
 
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 does not include 
alveoloplasty. You can find this information on pages 76-77 of the Plans 2023 Evidence of Coverage (EOC) 
and the dental benefits schedule.
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 both percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA) 
will be considered reasonable and necessary when ALL of the following criteria are met: 
- Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1- 
L5), based on symptom onset, and documented by advanced imaging demonstrating bone marrow edema on 
magnetic resonance imaging (MRI) or bone-scan/Single-Photon Emission Computerized Tomography 
(SPECT)/computed tomography (CT) uptake and 
- The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or Visual 
Analog Scale [VAS] pain score greater than or equal to 8) or is non-hospitalized with moderate to severe pain 
(NRS or VAS greater than or equal to 5) despite optimal non-surgical management (NSM) with one of the 
following: 
Worsening Pain or 
Stable to improved pain (but NRS or VAS greater than or equal to 5) when 2 or more of the following are 
present: 
- Progression of vertebral body height loss 
- greater than 25% vertebral body height reduction 
- Kyphotic deformity 
- Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] greater than 17) 
 
Limitations 
 
Exclusion criteria 
Absolute contraindication 
- Current back pain is not primarily due to the identified acute or subacute VCF(s). 
- Osteomyelitis, discitis or active systemic infection 
- Pregnancy 
- Active surgical site infection 
 
Relative contraindication 
- Greater than three vertebral fractures per procedure 
- Allergy to bone cement or opacification agents 
- Uncorrected coagulopathy 
- Spinal instability 
- Myelopathy from the fracture 
- Neurologic deficit 
- Neural impingement 
- Fracture retropulsion/canal compromise 
 
You can find this information in the Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L34976). 
 
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 when an initial below knee prosthesis (L5500) or a preparatory below knee prosthesis 
(L5510, L5520, L5530, L5540) is provided, prosthetic substitutions and/or additions of procedures and 
components are covered in accordance with the functional level assessment except for codes L5629, L5638, 
L5639, L5646, L5647, L5704, L5785, L5962, and L5980 which will be denied as not reasonable and 
necessary. When a below knee preparatory prefabricated prosthesis (L5535) is provided, prosthetic 
substitutions and/or additions of procedures are covered in accordance with the functional level assessment 
except for codes L5620, L5629, L5645, L5646, L5670, L5676, L5704, and L5962 which will be denied as not 
reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD) Lower Limb 
Prostheses L33787. 
 
The rules also say that lower limb prosthetic covers (L5704, L5705, L5706, and L5707) are complete products 
and afford shape, protection and waterproofing for normal daily usage of the prosthesis. They offer sufficient 
protection and weatherproofing for beneficiaries who require lower limb prosthetics. 
 
Protective outer surface covering systems (L5962, L5964, and L5966) are specialized covers intended to be 
worn over an existing prosthesis. They are used by a beneficiary who has special needs for protection against 
unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the 
level of protection that is afforded by L5704, L5705, L5706, and L5707. They are not for cosmetic or 
convenience reasons, or for everyday usage in a typical environment. Protective outer surface coverings are 
different from the covering that is already reimbursed as part of L5704, L5705, L5706, and L5707. You can 
find these rules in the Local Coverage Article Lower Limb Prostheses - Policy Article A52496. 
 
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 a group 2 support surface is covered if the beneficiary meets at least one of the following three criteria (1, 2, or 3):

1. The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program including each of the following:

a. Use of an appropriate group 1 support surface b. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and c. Appropriate turning and positioning, and d. Appropriate wound care e. Appropriate management of moisture/incontinence, and f. Nutritional assessment and intervention consistent with the overall plan of care

2. The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis

3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses), and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days

You can find this rule in Local Coverage Determination (LCD): Pressure Reducing Support Surfaces - Group 2 (L33642) - 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.