Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that each one-way trip must not exceed 50 miles of driving distance. A trip is one-way 
transportation; a round trip is 2 trips. You can find this information in Chapter 4 on page 92 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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 14 of the 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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 35-38 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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 30-34 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 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. 
 
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 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 also say that a fluid, pneumatic, or electronic/microprocessor knee is covered for beneficiaries whose 
functional level is 3 or above. You can find this information in Local Coverage Determination (LCD): Lower 
Limb Prosthesis (L33787). 
 
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 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. 
 
A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot 
with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot 
system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. 
You can find these rules in Local Coverage Determination (LCD) Lower Limb Prostheses (L33787). 
 
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 $465 copayment per day for days 1-4 of each in-network inpatient 
hospital stay. You then pay a $0 copayment after day four. Inpatient hospital care starts the day you are 
formally admitted to the hospital with a doctors order. The day before you are discharged is your last inpatient 
day. You can find this information on pages 80-84 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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 72 one-way trips per year. You can find this information on pages 92-93 of the Plans 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 an implantable loop recorder (ILR) is another type of pre-symptom memory loop recorder 
(MLR). It is implanted subcutaneously in a patients upper left chest and may remain implanted for many 
months. An ILR is used when syncope is thought to be cardiac-related but is too infrequent to be detected by 
either a HolterTM monitor or a traditional pre-symptom MLR. 
 
The following indications are covered nationally unless otherwise indicated: 
1. Computer analysis of electrocardiograms (EKGs) when furnished in a setting and under the 
circumstances required for coverage of other EKG services. 
2. EKG services rendered by an independent diagnostic testing facility (IDTF), including physician review 
and interpretation. Separate physician services are not covered unless he/she is the patients attending or 
consulting physician. 
3. Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed 
as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance 
at the time the service is performed or immediately thereafter. 
4. Home EKG services with documentation of medical necessity. 
5. Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications 
described below, when performed with equipment meeting the standards described below, subject to the 
limitations and conditions specified below. Coverage is further limited to the amounts payable with 
respect to the physicians service in interpreting the results of such transmissions, including charges for 
rental of the equipment. The device used by the beneficiary is part of a total diagnostic system and is 
not considered durable medical equipment (DME) separately. Covered uses are to: 
a. Detect, characterize, and document symptomatic transient arrhythmias; 
b. Initiate, revise, or discontinue arrhythmic drug therapy; or, 
c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); 
(only if 24-hour coverage is provided, see C.5. below). 
 
Certain uses other than those specified above may be covered if, in the judgment of the local Medicare 
Administrative Contractor (MAC), such use is medically necessary. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determination for Electrocardiographic Services, 20.15. 
 
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 durable medical equipment (DME) MACs may not allow separate delivery and service 
charges for oxygen or DME except in rare and unusual circumstances when the delivery is not typical of the 
particular supplier's operation. You can find this rule in the Medicare Claim Processing Manual, Chapter 20, 
Section 60. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that A manual wheelchair for use inside the home (E1037, E1038, E1039, E1161, K0001, K0002, 
K0003, K0004, K0005, K0006, K0007, K0008, K0009) 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 beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately 
fitted cane or walker. 

C. The beneficiary's 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 beneficiary's ability to participate in 
MRADLs and the beneficiary will use it on a regular basis in the home. 

E. 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 rule at Local Coverage Determination (LCD) L33788: Manual Wheelchair Bases (eff. 
1/1/20). 
 
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 procedures that exceed the medical need are not reasonable and necessary (not a Medicare 
covered service), therefore, documentation (pre-procedure E/M note and/or post-procedure operative notes) 
must address (a) why the lesion will not be (was not) managed by standard excision or destruction technique 
and (when applicable) (b) why (when utilized or referred to a plastic surgeon) procedures for complex repair, 
adjacent tissue transfer or rearrangement, flap, or graft codes are employed. Also, the options for care (both the 
primary procedure options and repair options) must be discussed with the patient and clearly noted in the pre-
procedure (or post procedure as appropriate) documentation.  
 
The limitations listed in sections 1-5 below refer to specific body areas and lesion characteristics. The use of 
Mohs Micrographic Surgery in these areas and for these conditions is not considered medically reasonable and 
necessary:  
 
    Both recurrent and primary actinic keratosis (AK) with focal SCC in situ; Bowenoid AK; SCC in situ (AK 
type) of any size in all areas in healthy or immunocompromised   
    Basal cell carcinoma located in Area L trunk and extremities (excluding pretibial surface, hands, feet, nail 
units, and ankles): 
        Recurrent superficial BCC (healthy or immunocompromised patients, or patients with genetic syndromes) 
of any size 
        Primary superficial BCC (healthy or immunocompromised patients) of any size 
        Primary nodular BCC (healthy patients) = 2 cm 
        Primary nodular BCC (immunocompromised patients) = 1 cm 
    Squamous cell carcinoma located in Area L trunk and extremities (excluding pretibial surface, hands, feet, 
nail units, and ankles): 
        Primary SCC; without aggressive histologic features, <2 mm depth without other defining features, Clark 
level = III (healthy patients) =2 cm 
        Primary SCC keratoacanthoma (KA) type; not central facial (healthy patients) = 1 cm 
        Primary in situ SCC/Bowen disease (healthy patients) = 2 cm 
        Primary in situ SCC/Bowen disease (immunocompromised patients) = 1 cm 
    Desmoplastic trichoepithelioma located in Area L trunk and extremities (excluding pretibial surface, hands, feet, nail units, and ankles)  
    Bowenoid papulosis 
 
You can find this information in the Local Coverage Determination (LCD) Mohs Micrographic Surgery 
(MMS) L33689. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.