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 Original Medicare pays for the routine costs of qualifying clinical trials. Medicare also pays 
for reasonable and necessary items and services used to diagnose and treat complications arising from 
participation in all clinical trials. The rules also say that Medicare plans must cover these services even if they 
are not available through in-network providers. Medicare plans may require reporting when enrollees 
participate in clinical trials but cannot require prior authorization or approval. You can find these rules in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National 
Coverage Determinations Manual, Chapter 1, Section 310.1.  
 
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 Plan 
contract also says that a clinical research study or clinical trial is a way that doctors and scientists test new 
types of medical care. They test new medical care procedures or drugs by asking for volunteers to help with the 
study. This kind of study is one of the final stages of a research process that helps doctors and scientists see if a 
new approach works and if it is safe. 
 
An enrollee who is in a clinical research study may stay enrolled in the Plan and continue to get the care that is 
not related to the study through the Plan. Enrollees must tell the plan before they start participating in a clinical 
research study. 
 
If an enrollee participates in a Medicare-approved study, Original Medicare pays most of the costs for the 
covered services received as part of the study. After Medicare has paid its share of the cost for these services, 
the Plan will also pay for part of the costs. The Plan will pay the difference between the cost-sharing in 
Original Medicare and the cost-sharing as a member of the Plan. This means the enrollee will pay the same 
amount for the services received as part of the study as he or she would if these services were received from the 
Plan. You can find this information on pages on page 40-41 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 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 only for the dental codes specifically laid out in the Dental 2023 Schedule of Benefits. You can find 
this information on pages 4 to 14 of the Plans 2023 Dental Benefit Details booklet.
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
 
2. The services require the skills or direct supervision of a therapist,  
 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. 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 220.2. 
 
The rules say that if at any point in the treatment it is determined that the treatment becomes repetitive and does 
not require the unique skills of a therapist, the services are non-covered. 
 
You can find this rule in the Local Coverage Determination (LCD): Outpatient Physical and Occupational 
Therapy Services (L33631). 
 
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 Facet Joint Interventions generally consist of four types of procedures: Intraarticular (IA) 
Facet Joint Injections, Medial Branch Blocks (MBB), Radiofrequency Ablations (RFA) and Facet cyst 
rupture/aspiration. Facet Joint Interventions are considered medically reasonable and necessary for the 
diagnosis and treatment of chronic pain in patients who meet ALL of the following criteria:  
   
  1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale; AND* 
  2. Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive 
conservative care management (as tolerated); AND 
  3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst); AND 
  4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L34892). 
 
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 Negative Pressure Wound Therapy (NPWT), utilizing either durable or disposable medical 
equipment, involves the application of controlled or intermittent negative pressure to a properly dressed wound 
cavity. Suction (negative pressure) is applied under airtight wound dressings to promote the healing of open 
wounds resistant to prior treatments. You can find this rule at Local Coverage Determination (LCD) 
L37228: Wound Care (eff. 4/27/23). 
 
The rules say that Negative Pressure Wound Therapy pump (E2402) and supplies (A6550, A7000) are covered 
when either criterion A or B is met: 
Ulcers and Wounds in the Home Setting: 
 
The beneficiary has a chronic Stage 3 or 4 pressure ulcer (see Appendices Section), neuropathic (for example, 
diabetic) ulcer, venous or arterial insufficiency ulcer, or a chronic (being present for at least 30 days) ulcer of 
mixed etiology. A complete wound therapy program described by criterion 1 and criteria 2, 3, or 4, as 
applicable depending on the type of wound, must have been tried or considered and ruled out prior to 
application of NPWT. 
1. For all ulcers or wounds, the following components of a wound therapy program must 
include a minimum of all of the following general measures, which should either be 
addressed, applied, or considered and ruled out prior to application of NPWT: 
a. Documentation in the beneficiary's medical record of evaluation, care, and 
wound measurements by a licensed medical professional, and 
b. Application of dressings to maintain a moist wound environment, and 
c. Debridement of necrotic tissue if present, and 
d. Evaluation of and provision for adequate nutritional status 
2. For Stage 3 or 4 pressure ulcers: a. The beneficiary has been appropriately turned and positioned, and 
b. The beneficiary has used a group 2 or 3 support surface for pressure ulcers on the 
posterior trunk or pelvis (see LCD on support surfaces), and 
c. The beneficiarys moisture and incontinence have been appropriately managed 
3. For neuropathic (for example, diabetic) ulcers: 
a. The beneficiary has been on a comprehensive diabetic management program, and 
b. Reduction in pressure on a foot ulcer has been accomplished with appropriate 
modalities 
4. For venous insufficiency ulcers: 
   
a. Compression bandages and/or garments have been consistently applied, and 
b. Leg elevation and ambulation have been encouraged 
You can find this rule at Local Coverage Determination (LCD) L33821: Negative Pressure Wound Therapy 
Pumps (eff. 5/1/21). 
 
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 when nutritional support other than the oral route is necessary, enteral nutrition (EN) is 
usually initially preferable to parenteral nutrition for the following reasons: (1) In a fluid restricted beneficiary, 
EN permits delivery of all necessary nutrients in a more concentrated volume than parenteral nutrition; (2) EN 
allows for safer home delivery of nutrients; and (3) EN lowers the risk of Central Line-Associated Bloodstream 
Infections (CLABSI). 
 
For parenteral nutrition to be considered reasonable and necessary, the treating practitioner must document that 
enteral nutrition has been considered and ruled out, tried and been found ineffective, or that EN exacerbates 
gastrointestinal tract dysfunction. The beneficiary must have (a) a condition involving the small intestine and/or 
its exocrine glands which significantly impairs the absorption of nutrients or (b) disease of the stomach and/or 
intestine which is a motility disorder and impairs the ability of nutrients to be transported through and absorbed 
by the gastrointestinal (GI) system. The beneficiary must have a permanent impairment. 
 
The treating practitioner is required to evaluate the beneficiary within 30 days prior to initiation of parenteral 
nutrition. If the treating practitioner does not see the beneficiary within this timeframe, they must document the 
reason why and describe what other monitoring methods were used to evaluate the beneficiary's parenteral 
nutrition needs. There must be documentation in the medical record supporting the clinical diagnosis. 
 
You can find these rules in the Local Coverage Determination (LCD) Parenteral Nutrition L38953. 
 
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 for qualifying wounds and ulcers, once placed on a negative pressure wound therapy 
(NPWT) pump and supplies, in order for coverage to continue, a licensed medical professional must do the 
following: 
1. On a regular basis, 
a. Directly assess the wound(s) being treated with the NPWT pump, and 
b. Supervise or directly perform the NPWT dressing changes, and 
2. On at least a monthly basis, document changes in the ulcers dimensions and characteristics. 
 
If criteria 1 and 2 are not fulfilled, continued coverage of the NPWT pump and supplies will be denied as not 
reasonable and necessary. For qualifying wounds and ulcers, a NPWT pump and supplies will be denied as not 
reasonable and necessary with any of the following, whichever occurs earliest: 
3. Criteria 1 and 2 (above) cease to occur, 
4. In the judgment of the treating practitioner, adequate wound healing has occurred to the degree that 
NPWT may be discontinued, 
5. Any measurable degree of wound healing has failed to occur over the prior month. Wound healing is 
defined as improvement occurring in either surface area (length times width) or depth of the wound 
6. 4 months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) 
have elapsed using a NPWT pump in the treatment of the most recent wound 
7. Once equipment or supplies are no longer being used for the beneficiary, whether or not by the treating 
practitioners order 
 
You can find these rules in Local Coverage Determination (LCD) Negative Pressure Wound Therapy Pumps 
(L33821). 
 
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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
 
The rules say that all of the basic criteria must be met for a power mobility device (K0856) or a push-rim 
activated power assist device (E0986) to be covered.  
 
You can find this information in Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
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 a list of 
covered preventive and comprehensive dental benefits. A prefabricated post and core in addition to crown 
(D2954) is not listed and therefore not covered by the Plan's dental benefit. The contract also says out-of-
network dentists have not agreed to provide services at contracted fees, and you may be billed by the out-of-
network provider for any amount greater than the payment made by the Plan to the provider. You can find this 
information in Chapter 4 on pages 81 to 85 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 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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 37-40 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 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 Breast Cancer Index (BCI) test is covered for postmenopausal women with invasive 
breast cancer when the following criteria are met: 
 Pathology reveals invasive carcinoma of the breast that is ER+ and/or PR+ and HER2 -; and 
 Patient has early-stage disease (T1-3, pN0-N1, M0); and 
 Patient has no evidence of distant breast cancer metastasis (i.e., non-relapsed); and 
 Test results will be used in determining treatment management of the patient for chemotherapy and/or 
endocrine therapy. 
 
To report a BCI service, please submit the following claim information: 
 Select CPT

 code 81518 
 Enter unit of service (UOS) 
 Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT

 code in the comment/narrative 
field for the Part B claim field/type 
 Select the appropriate ICD-10 CM code 
 
You can find this rule in the Local Coverage Article for the Billing and Coding of Molecular Diagnostic 
(MolDX): Breast Cancer Index (BCI) Gene Expression Test, A57773. 
 
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 if Field 21 contains an indicator of 3, and multiple endoscopies are billed, the special rules 
for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the 
difference between the next highest and the base endoscopy. You can find this rule in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, 
Chapter 12, Section 40. 
 
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 one-time ultrasound screening for AAA is covered for beneficiaries who meet the following 
criteria: 
 
1.     has a family history of abdominal aortic aneurysm. 
2. is a man aged 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or 
3. is a beneficiary who manifests other risk factors in a beneficiary category recommended for 
screening by the United States Preventive Services Task Force regarding AAA, as specified by 
the Secretary of Health and Human Services, through the national coverage determination 
process.  
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 18, Section 110.2. 
 
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.