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. 
 
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 non-Medicare-covered routine eye exams and eyewear must be obtained from a provider in the Plan's 
vision vendor network. You can find this information on page 55 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 an expandable controller can accommodate 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).

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).

The rules say that the power seat elevation feature (E2300) and power standing feature (E2301) are noncovered
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).

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 Modifiers -LT or -RT apply to codes, which identify procedures, which can be performed on
paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries. Modifiers -LT and -RT should be used
whenever a procedure is performed on only one side. Hospitals use the appropriate -RT or -LT modifier to
identify which of the paired organs was operated upon. These modifiers are required whenever they are
appropriate. You can find this rule in the Medicare Claims Processing Manual Chapter 4, Sections 20.6.2 and
20.6.3.

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.
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 following tests may be billed in the post-biopsy setting (after a negative or non-malignant
biopsy, as defined in the policy) for individuals contemplating a repeat biopsy:
- Progensa PCA3 assay (CPT 81313), performed on post-digital rectal exam (DRE) urine specimens.
- ConfirmMDx assay (CPT 81551), performed on formalin-fixed, paraffin embedded (FFPE) tissue
specimens.

You can find this in the Medicare Local Coverage Article (LCA) Billing and Coding: MolDX: Molecular
Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (A58718).

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 when completing the 1500 claim form, providers must enter the correct Place of Service
(POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. You
can find this rule at Medicare Claims Processing Manual Ch. 26 Section 10.6.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that 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 certain dental services as a supplemental (extra) benefit. Limitations
and exclusions apply. Dental implants are not listed as a covered benefit. You can find this information starting
on page 61 of the Plans 2023 Evidence of Coverage and the Plans 2023 Dental Benefit literature.
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 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 following tests may be billed in the post-biopsy setting (after a negative 
or non-malignant biopsy, as defined in the policy) for individuals contemplating a repeat biopsy:
-    Progensa PCA3 assay (CPT 81313), performed on post-digital rectal exam (DRE) urine specimens.
-    ConfirmMDx assay (CPT 81551), performed on formalin-fixed, paraffin embedded (FFPE) tissue 
specimens.
You can find this in the Medicare Local Coverage Article (LCA) Billing and Coding: MolDX: Molecular
Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (A58718).

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 term PAP (positive airway pressure) device will refer to both a single-level continuous
positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470)
when it is used in the treatment of obstructive sleep apnea. An E0601 device is covered for the treatment of
obstructive sleep apnea (OSA) if criteria the beneficiary has an in-person clinical evaluation by the treating
practitioner prior to the sleep test to assess the beneficiary for obstructive sleep apnea AND the beneficiary has
a sleep test (as defined below) that meets either of the following criteria (1 or 2): 1. The apnea-hypopnea index
(AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of
30 events; or, 2. the AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour
with a minimum of 10 events and documentation of: Excessive daytime sleepiness, impaired cognition, mood
disorders, or insomnia; or, Hypertension, ischemic heart disease, or history of stroke. You can find these rules
in the Local Coverage Determination (LCD) Positive Airway Pressure (PAP) Devices for the Treatment of
Obstructive Sleep Apnea (L33718).

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).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says enrollees must use preferred brand diabetic products provided by Abbott brands
(Freestyle and Precision). You can see this on page 12 of the Plans Annual Notice of Coverage.

The Plan contract says that for diabetic supplies, prior authorization may be required. You can see this on page
59 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 that after the patient has had at least two (2) medically reasonable and necessary diagnostic 
medial branch blocks (MBB)s, with each one providing a consistent minimum of 80% sustained relief of 
primary (index) pain (with the duration of relief being consistent with the agent used) AND repeat thermal 
facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the 
patient had a minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% 
consistent improvement in the ability to perform previously painful movements and activities of daily living 
(ADL)s as compared to baseline measurement using the same scale. If there is an extended time, two years or 
more, since the last RFA and/or there is a question as to the source of the recurrent pain then diagnostic 
procedures must be repeated. You can find this information in the Local Coverage Determination (LCD): Facet 
Joint Interventions for Pain Management (38803). 
 
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 for a treatment to be considered medically reasonable and necessary per 1862(a)(1)(A) of 
The Act the treatment must be appropriate, including duration and frequency furnished in accordance with 
accepted standards of medical practice for the condition. The Medicare Administrative Contractor (MAC) 
determines that the existing evidence and lack of accepted standards of medical practice for platelet rich plasma 
(PRP) injections do not meet the requirement of medically reasonable and necessary. Thus, the MAC considers 
PRP injection and PRP combined with stem cells for musculoskeletal injuries and/or joint conditions, whether 
primary or adjunctive use, not medically reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Platelet Rich Plasma Injections for 
Non-Wound Injections (L39023). 
 
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 STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. You 
can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Chapter 4, Section 
10.4. 
 
The rules also state that an Outpatient Prospective Payment System (OPPS) payment status indicator is 
assigned to every HCPCS code. The status indicator identifies whether the service described by the HCPCS 
code is paid under the OPPS and if so, whether payment is made separately or packaged. The status indicator 
may also provide additional information about how the code is paid under the OPPS or under another payment 
system or fee schedule. For example, services with status indicator A are paid under a fee schedule or payment 
system other than the OPPS. Services with status indicator N are paid under the OPPS, but their payment is 
packaged into payment for a separately paid service. Services with status indicator T are paid separately under 
OPPS but a multiple procedure payment reduction applies when two or more services with a status indicator of 
T are billed on the same date of service. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Chapter 4, Section 10.1.1. 
 
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.
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 as of January 1, 2013, for most evaluation and management (E&M) visit 
families, practitioners will select visit level based on the level of medical decision making (MDM) or the 
amount of time spent by the physician or non-physician practitioner. For some types of visits (such as 
emergency department visits and critical care), in accordance with their CPT codes, practitioners do not have 
this choice and will use only MDM or only time to bill. It would not be medically necessary or appropriate to 
bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation 
should not be the primary influence upon which a specific level of service is billed. Documentation should 
support the level of service reported. You can find this rule in the Centers for Medicare and Medicaid Services 
(CMS), Internet Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1. 
 
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.
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 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 patient's 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.

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.