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 the power seat elevation feature (E2300) and power standing feature (E2301) are non-
covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device 
described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or 
power standing feature, it will be denied as non-covered. You can find this rule in Local Coverage Article: 
Wheelchair Options/Accessories - Policy Article (A52504) - Effective January 1, 2020. 
 
The rules say that 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  
You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective 
January 1, 2020. 
 
The rules say that code E2311 describes an electronic component that allows the patient to control two or more 
of the following motors from a single interface; e.g. proportional joystick, touchpad or nonproportional 
interface: 
 
-Power tilt 
-Power recline, with or without shear reduction 
-Combination power tilt and recline, with or without shear reduction 
-Power leg elevation with or without articulation, power center mount elevating foot platform with or without 
articulating properties 
 
You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective 
January 1, 2020. 
 
The rules say that a harness (E2313) describes all the wires, fuse boxes, fuses, circuits, switches, etc. that are 
required for the operation of an expandable controller (E2377). It also includes all the necessary fasteners, 
connectors, and mounting hardware. You can find this rule in Local Coverage Article: Power Mobility Devices 
- Policy Article (A52498) - 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.
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 only 
those items and services specifically listed in your Plan contract. Core buildup, including any pins when 
required is not covered under the Plans dental benefits. You can find this information on pages 66-67 of the 
Plans 2022 Evidence of Coverage (EOC). This benefit also includes coverage for crowns - porcelain/ceramic 
(D2740), one per 60 month(s) per patient per tooth. Pre-operative x-ray(s) are required documentation for 
review. You can find this information on page 53 of the Plans 2022 Office Reference Manual.
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 pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
The rules say that miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a 
specific Healthcare Common Procedure Coding System (HCPCS) code and are not included in another code 
should be coded K0108.  
 
The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered. 
 
The rules say 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 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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says there are limitations and exclusions that apply to the additional hearing aid benefit. Hearing aids 
ordered through providers other than the Plan are not covered. You can find this information on pages 4-91 to 
4-92 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that an ultra-lightweight manual wheelchair ((K0005) is covered for a beneficiary if criteria (1) 
or (2) is met and (3) and (4) are met: 
 
    The beneficiary must be a full-time manual wheelchair user. 
 
    The beneficiary must require individualized fitting and adjustments for one or more features such as, but not 
limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a 
K0001 through K0004 manual wheelchair. 
 
    The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical 
professional (LCMP), such as a physical therapist (PT) or occupational therapist (OT), or physician who has 
specific training and experience in rehabilitation wheelchair evaluations and that documents the medical 
necessity for the wheelchair and its special features. The LCMP may have no financial relationship with the 
supplier. 
 
    The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified 
Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person 
involvement in the wheelchair selection for the patient. 
 
    If the manual wheelchair base is not covered, then related accessories will be denied as not reasonable and 
necessary. 
 
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 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 20% coinsurance for Medicare Part B prescription drugs. You can find 
this information on page 97 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 say that clinical assessments of beneficiary rehabilitation potential must be based on the following 
classification levels: 
 
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a 
prosthesis does not enhance their quality of life or mobility. 
Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed 
cadence. Typical of the limited and unlimited household ambulator. 
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers 
such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator 
who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise 
activity that demands prosthetic utilization beyond simple locomotion. 
Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting 
high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. 
 
The records must document the beneficiarys current functional capabilities and his/her expected functional 
potential, including an explanation for the difference, if that is the case. It is recognized, within the functional 
classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level 
classifications. 
 
A flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 or above. 
Code L5986 describes separate products which provide either a single motion or a combination of motions 
generally attributed to functional movement of the lower limb during ambulation. The use of these codes can 
be used to fully describe additional features or functions not found in the prosthetic foot system (L5981) 
L5986 describes a product that is used as an addition to L-code foot systems for lower limb prosthesis 
construction. The product provides multiaxial motion in all three planes of motion, sagittal, coronal, and 
transverse.  
 
You can find this rule in the Local Coverage Determination and Article for Lower Limb Prostheses, L33787 
and 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 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 only 
those items and services specifically listed in your Plan contract. Cone beam CT capture and interpretation with 
field of view of both jaws, with or without cranium (D0367) is not covered under the Plans dental benefits. 
You can find this information on pages 86-87 and 97-102 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 Medicare does not pay for gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. 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 Plan 
contract says the plan reimburses you up to $150 per calendar year towards your cost for membership in a 
qualified health club or fitness facility during the calendar year. To obtain this reimbursement please submit a 
Wellness Allowance reimbursement form along with proof of payment and any additional information outlined 
on the form. You can find this information on pages 82 to 85 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says supplemental benefits include one routine vision exam per year (including eye refraction for 
eyeglasses/contact lenses). You can find this information on pages 131 to 132 of the Plan's 2022 Evidence of 
Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that indications for wireless capsule endoscopy are: 
 For investigating suspected small intestinal bleeding in persons with objective evidence of recurrent, 
obscure GI bleeding (e.g., persistent or recurrent iron-deficiency anemia and/or persistent or recurrent positive 
fecal occult blood test (FOBT), or visible bleeding) who have had upper and lower GI endoscopies within the 
past 12 months (esophagogastroduodenoscopy (EGD) and colonoscopy) that have failed to identify a bleeding 
source; 
 For evaluation of regional non-metastatic carcinoid tumors of the small bowel in persons with carcinoid 
syndrome; 
 For evaluation of persons with celiac disease with a positive serology and negative biopsy; 
 For re-evaluation of persons with celiac disease who remain symptomatic despite treatment and there is no 
suspected or confirmed GI obstruction, stricture, or fistulae; 
 For initial diagnosis in persons with suspected Crohn's disease (abdominal pain or diarrhea plus 1 or more 
signs of inflammation (e.g., fever, elevated white blood cell (WBC) count, elevated erythrocyte sedimentation 
rate, or bleeding) without evidence of disease on conventional diagnostic tests, including small-bowel follow-
through or abdominal computed tomography (CT) scan/CT enterography and upper and lower endoscopy 
(EGD and colonoscopy); 
 For re-evaluation of persons with Crohn's disease who remain symptomatic despite treatment and there is no 
suspected or confirmed GI obstruction, stricture, or fistulae; 
 For surveillance of small intestinal tumors in persons with Lynch syndrome, Peutz-Jeghers syndrome and 
other polyposis syndromes affecting the small bowel; or 
 For screening or surveillance of esophageal varices. 
 
You can find this rule in the Local Coverage Determination for Wireless Capsule Endscopy, L36427.  
 
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 supply allowance (code K0553 or A4238) is billed as one (1) unit of service (UOS) per thirty (30) days. Only one (1) UOS of code K0553 or A4238 may be billed to the DME MACs at a time. Billing more than one (1) UOS per thirty (30) days of code K0553 or A4238 will be denied as not reasonable and necessary. You can find this in the Local Coverage Determination (LCD): Glucose Monitors (L33822).
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 specific dental procedure codes listed. Non-listed procedures are not covered. You can find this 
information in Chapter 4 on pages 4-81 to 4-92 of the Plans 2022 Evidence of Coverage (EOC).