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 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 specific 
dental items/services stated in the Plans contract. The guided tissue regeneration-resorbable barrier, per site 
(D4266), bone replacement graft for ridge preservation-per site (D7953), and the therapeutic parenteral drugs, 
two or more administrations, of different medications (D9612) are not covered. You can find this information 
on pages 4-85 to 4-99 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 will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit does not include 
gingival irrigation (D4921) and drugs or medicaments dispensed in the office for home use (D9630). You can 
find this information on pages 129 to 138 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 covers a lung cancer screening counseling and shared decision-making visit, and 
for appropriate beneficiaries, annual screening for lung cancer with LDCT, as an additional preventive service 
benefit under the Medicare program when certain criteria are met. For purposes of Medicare coverage of lung 
cancer screening with LDCT, beneficiaries must meet all of the following eligibility criteria: 
 
1. Age of 50-77 years, 
2. Absence of signs/symptoms of lung cancer, 
3. Tobacco smoking history of at least 20 pack-years (one pack-year equates to smoking one pack/day for 
one year, 
4. Current smoker or former smoker who quit within the last 15 years. 
5.         Receive an order for lung cancer screening with LDCT 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Lung Cancer Screening with 
Low Dose Computed Tomography (LDCT) (210.14). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
radiographic image but is limited to 1 procedure code every 5 calendar years. The risk assessment and 
documentation are not covered by the Plan's dental benefits. You can find this information on pages 85 to 87 of 
the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a standard walker (E0130, E0135, E0141, E0143) and related accessories are covered if all 
of the following criteria (1-3) are met: 
 
    The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADL) in the home. 
 
    A mobility limitation is one that: 
 
        Prevents the beneficiary from accomplishing the MRADL entirely, or 
 
        Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the 
attempts to perform the MRADL, or 
 
        Prevents the beneficiary from completing the MRADL within a reasonable time frame; and 
 
    The beneficiary is able to safely use the walker; and 
    The functional mobility deficit can be sufficiently resolved with use of a walker. 
 
If all of the criteria are not met, the walker will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Walkers L33791. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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. Bone replacement graft for ridge preservation 
(D7953) is not covered under the Plans dental benefits under any circumstance. This benefit includes coverage 
for the requested resin-based composite (D2393), but only when they are received from an in-network provider. 
You can find this information on pages 4-58 to 4-63 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 will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
requested item or service but is limited to 1 procedure code per calendar year. You can find this information on 
pages 86 to 89 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 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 no payment is recognized for code 85060 furnished to hospital outpatients or non-hospital 
patients. The physician interpretation is paid through the clinical laboratory fee schedule payment for the 
clinical laboratory test. You can find this information in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 50.6. 
 
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 state that the physician who treats a patient must order all diagnostic laboratory tests for a specific 
medical problem. Tests not ordered by the physician arent considered reasonable and necessary. The physician 
should clearly indicate all tests to be performed (for example, run labs or check blood by itself doesnt 
support intent to order) when completing progress notes. Medical review contractors will consider diagnostic 
test order requirements met if theres: 
 
1.  A signed order or requisition listing the specific test 
2. An unsigned order or requisition listing the specific test(s) and an authenticated medical record supporting 
the physicians intent to order the tests (for example, order labs, check blood, repeat urine) 
3. An authenticated medical record supporting the physician intent to order specific tests. 
 
You can find this rule at Centers for Medicare and Medicaid Services, MedLearn Matters Booklet entitled 
Complying with Laboratory Services Documentation Requirements, ICD MLN 909221. 
 
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information in the Chapter 4 of the Plans 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 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 30-day period of care is the unit of payment for the home health prospective payment 
system (HH PPS). The period of care payment is specific to one individual homebound beneficiary. It pays all 
Medicare covered home care that is reasonable and necessary for the patient's care, including routine and 
nonroutine supplies used by that beneficiary during the period of care. It is the only Medicare form of payment 
for such services. Home health agencies (HHAs) shall no longer submit Requests for Anticipated Payment 
(RAPS -Type of Bill 0322) for any HH period of care with a From date on or after January 1, 2022. Instead, for 
each admission to home health, the HHA notifies Medicare systems via submission of a Notice of Admission 
(NOA). 
 
For all beneficiaries receiving HH services in 2021 whose services will continue in 2022, the HHA shall submit 
an NOA with a one-time, artificial 'admission' date corresponding to the "From" date of the first period of 
continuing care in 2022. Only one NOA is required for any series of HH periods of care beginning with 
admission to home care and ending with discharge. After a discharge has been reported to Medicare, a new 
NOA is required before the HHA submits any additional claims. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.1.4 and 10.1.10.3. 
 
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 state that effective for dates of service on or after January 1, 2018, the KX modifier continues to be 
used. It no longer represents an exception request but serves as a confirmation that services are medically 
necessary after the beneficiary has exceeded the KX modifier threshold of incurred expenses. When exceptions 
are in effect and the beneficiary qualifies for a therapy cap exception, the provider shall add a KX modifier to 
the therapy code subject to the cap limits. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 5, 
Section 10.3.3. 
 
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 state that a group 3 power wheelchair with multiple power options is covered if the beneficiary's 
mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and the 
beneficiary either uses a ventilator which is mounted on the wheelchair or meets coverage criteria for a power 
tilt and recline seating system and the system is being used on the wheelchair. You can find this rule in Local 
Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
The rules also say that a power seating system  tilt only, recline only, or combination tilt and recline  with or 
without power elevating legrests will be covered if the beneficiary is at high risk for development of a pressure 
ulcer and is unable to perform a functional weight shift; or the beneficiary utilizes intermittent catheterization 
for bladder management and is unable to independently transfer from the wheelchair to bed; or the power 
seating system is needed to manage increased tone or spasticity. Local Coverage Determination (LCD): 
Wheelchair Options/Accessories (L33792). 
 
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. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes a 
complete maxillary denture (D5110), but is limited to one every five years. An unspecified adjunctive 
procedure (D9999) is excluded from this benefit. You can find this information on page 74 of the Plan's 2022 
Evidence of Coverage (EOC). You can also find this information on page 6 of the Plan's Schedule A 
Description of Benefits and Copayments.