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. 
 
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 they cover meals delivered to your home immediately following discharge from a network 
hospital as an inpatient due to congestive heart failure, up to two meals per day in a consecutive four-week 
period, once per calendar year. The Plan does not cover meals if you are discharged to another facility that 
provides meals (for example, inpatient rehabilitation). You can find this information on page 62 of the Plan's 
2023 Evidence of Coverage. 
 
The Plan contract says home delivered meals are services not covered by Medicare. Home delivered meals are 
covered only under specific conditions as described in the Medical Benefits Chart. You can find this 
information on pages 121 to 128 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. 
 
A manual wheelchair for use inside the home (K0001) is covered if: 
 
Criteria A, B, C, D, and E are met; and 
Criterion F or G is met. 
A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. A mobility limitation is one that: 
 
  1.  Prevents the beneficiary from accomplishing an MRADL entirely, or 
 
  2.  Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the 
attempts to perform an MRADL; or 
 
  3.  Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
 
B. The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted 
cane or walker. 
 
C. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for use 
of the manual wheelchair that is provided. 
 
D. Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in MRADLs 
and the beneficiary will use it on a regular basis in the home. 
 
D. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the 
home. 
 
F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to 
safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both 
upper extremities are relevant to the assessment of upper extremity function. 
 
G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair. 
 
You can find this information in the Local Coverage Determination (LCD) Manual Wheelchair Bases L33788. 
 
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 does not pay for over-the-counter (OTC) items, including non-prescription drugs. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 40.2.  
 
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 you get up to a $50 allowance each month for Medicare approved OTC items. You can find this 
information on page 92 of the Plan's 2022 Evidence of Coverage and on page 89 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 MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands 
and manufacturers, as long as the following conditions are met (42 CFR 422.100(l)): 
 
 The MA plan provides all categories of DME covered under original Medicare Part B; 
 The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
 The MA plans contracted suppliers provide access to all preferred DME brands; 
 During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 
90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year; 
 Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
 The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
 The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the Evidence of Coverage and Annual Notice of Change and on its website; and 
 The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by CMS to require full coverage. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS) Medicare Managed 
Care Manual Chapter 4, Section 10.12.2- Specifying Brands or Manufacturers of DME. 
 
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 non-preferred diabetic supplies are not covered. You can find this information on page 
38 of the Plans 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 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 20% coinsurance for in-network provider and professional services 
provided in a primary care provider (PCP) office. You can find this information on page 83 of the Plan's 2022 
Evidence of Coverage (EOC). The Plan contract also says that enrollees must pay a $5 copayment for in-
network provider and professional services provided in a primary care provider (PCP) office. You can find this 
information on pages 74 and 75 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that effective for services performed on and after October 24, 2006, the Centers for Medicare & 
Medicaid Services has determined that there is sufficient evidence to conclude the use of infrared therapy 
devices and any related accessories is not reasonable and necessary under section 1862(a)(1)(A) of the Social 
Security Act (the Act). The use of infrared and/or near-infrared light and/or heat, including monochromatic 
infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these 
conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin 
and/or subcutaneous tissues. You can find this information in the National Coverage Determination (NCD) 
270.6: Infrared Therapy Devices. 
 
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 invasive procedures for the treatment of varicose veins are considered medically reasonable 
and necessary when ALL of the following criteria have been met: 
- An evaluation of the patient has been performed including a history and physical examination, the Clinical-
Etiology-Anatomy-Pathophysiology (CEAP) clinical classification and the revised Venous Clinical Severity 
Score (VCSS), AND 
- A duplex scan of the deep and superficial venous systems supports the examination findings, AND 
- A duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers in the 
saphenous, or perforator veins is 500 milliseconds or greater and absence of deep venous obstruction, AND 
- The documentation supports signs and/or symptoms that interfere with activities of daily living and/or quality 
of life, AND  
- The CEAP clinical classification is C1 to C6 with the following criteria: 
- Treatment of C1 disease (telangiectasia and their feeding reticular veins) is considered medically reasonable 
and necessary for patients with spontaneous and/or traumatic venous hemorrhage. 
- For patients with C2 or C3 disease and VCSS less than 6, the plan of care shall include documentation of a 
period of conservative therapy (2 to 4 weeks) including graduated compression 20-30 mmHg or greater, 
ambulation, elevation, and avoiding prolonged sitting and standing. 
- For patients who meet any one of the following criteria, the mandatory conservative therapy prior to the 
invasive procedure may be waived. 
a. VCSS greater than or equal to 6 
b. C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, and active venous leg 
ulceration) 
c. Hemorrhage 
d. Recurrent superficial thrombophlebitis 
 
Surgery will be considered medically reasonable and necessary for treatment of incompetent saphenous veins 
for patients with symptomatic CEAP clinical classification C2 to C6 disease. 
 
You can find this information in the Local Coverage Determination (LCD): Treatment of Chronic Venous 
Insufficiency of the Lower Extremities (L38720).  
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 the Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. MUEs for codes with an MAI of 3 are per day edits based on clinical 
benchmarks. Codes with an MAI of 3 are based on criteria combined with data such that it would be 
possible, but medically unlikely, that higher values would represent correctly reported medically necessary 
services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, 
were correctly coded, and were medically necessary. 
 
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(V). 
 
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The rules say that a capsulotomy is covered when each of the following criteria are met and clearly 
documented: 
 The patient has decreased ability to carry out activities of daily living including (but not limited to) 
reading, watching television, driving, or meeting occupational or a vocational expectations; and 
 The patient has a best-corrected visual acuity of 20/50 or worse at distance or near; or additional testing 
shows one of the following: 
o Consensual light testing decreases visual acuity by two lines, or 
o Glare testing decreases visual acuity by two lines; and 
 The patient has determined that he/she is no longer able to function adequately with the current level of 
visual function; and 
 Other eye disease(s), including but not limited to macular degeneration or diabetic retinopathy, has 
(have) been excluded as the primary cause of visual functional disability, except for the instance in 
which significant visual debility, in the judgement of the treating physician, is deemed secondary to 
ACO or PCO and laser treatment would provide the patient with improved functionality; and 
 Physician concurrence with significant patient-defined improvement in visual function can be expected 
as a result of capsulotomy; and 
 The patient has been educated about the risks and benefits of capsulotomy and the alternative(s) to 
surgery (e.g., the avoidance of glare, use of optimal eyeglasses prescription, etc.); and  The patient has undergone an appropriate preoperative ophthalmologic evaluation. 
For patients with a best-corrected visual acuity of 20/40 or better, anterior and/or posterior capsulotomy will be 
considered if all other criteria have been met and documented to support the medical necessity of the procedure 
for that patient. 
Local Coverage Determination: Capsule Opacification Following Cataract Surgery: Discission 
and YAG Laser Capsulotomy (L33946). 
 
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 if an attendant control (E2331) is provided in addition to a beneficiary-operated drive 
control system, it will be denied as non-covered. You can find this rule in the Local Coverage Article for 
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 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 outpatient intravenous (IV) insulin therapy (OIVIT) refers to an outpatient regimen that 
integrates pulsatile or continuous intravenous infusion of insulin via any means, guided by the results of 
measurement of respiratory quotient, urine urea nitrogen, arterial venous or capillary glucose, and/or potassium 
concentration performed in scheduled recurring periodic intermittent episodes. In OIVIT, insulin is 
intravenously administered in the outpatient setting for a variety of indications. Most commonly, it is delivered 
in pulses, but it may be delivered as a more conventional drip solution. The insulin administration is adjunctive 
to the patient's routine diabetic management regimen (oral agent or insulin-based) or other disease management 
regimen, typically performed on an intermittent basis (often weekly), and frequently performed chronically 
without duration limits. Effective for claims with dates of service on and after December 23, 2009, the Centers 
for Medicare and Medicaid Services (CMS) determines that the evidence is adequate to conclude that OIVIT 
does not improve health outcomes in Medicare beneficiaries. Therefore, CMS determines that OIVIT is not 
reasonable and necessary for any indication under section 1862(a)(1)(A) of the Social Security Act. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, 
Medicare National Coverage Determination for Outpatient Intravenous Insulin Treatment, 40.7. 
 
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 ambulance services. You can find this information 
on page(s) 59-60 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 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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The rules say that no payment may be made for the implantation of dorsal column or depth brain stimulators or 
services and supplies related to such implantation, unless all of the conditions listed below have been met: 
 The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with 
chronic intractable pain; 
 With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or 
contraindicated for the given patient; 
 Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
 All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be 
available; and 
 Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
Local Determination Coverage (LCD): Spinal Cord Stimulators for Chronic Pain (L36204). 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.