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 Citation(s): Social Security Act, Section 1862(a)1(A). 
 
Summary of Citation(s): CMS has not issued specific coverage criteria in the form of an LCD (Local Coverage 
Determination) or NCD (National Coverage Determination) for this particular item or service. However, per 
Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), 
 
The rules say that Medicare does not pay for any items or services that are not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The 
determination of medical necessity must be tailored to the individual patient and their unique clinical scenario. 
CMS considers services to be medically reasonable and necessary if they are:  
  
 Safe and effective; 
 Not mainly for the convenience of the patient or the physician; 
 Not experimental or investigational; and 
 Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of 
whether it is: 
   - Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the 
patient's condition or to improve the function of a malformed body member; 
   - Furnished in a setting appropriate to the patient's medical needs and condition; 
   - Ordered and furnished by qualified personnel; 
   - One that meets, but does not exceed, the patient's medical need; and 
   - At least as beneficial as an existing and available medically appropriate alternative. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Program Integrity Manual, Chapter 13, Section 13.5.4. 
 
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 one to two levels, either unilateral or bilateral, are allowed per session per spine region. The 
need for a three or four level procedure bilaterally may be considered under unique circumstances and with 
sufficient documentation of medical necessity on appeal. A session is a time period, which includes all 
procedures (i.e., medial branch block (MBB), intraarticular injections (IA), facet cyst ruptures, and RFA 
ablations that are performed during the same day. You can find this rule in the Local Coverage Determination 
(LCD): Facet Joint Interventions for Pain Management (L35936). 
 
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 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.  
 
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 
 
 A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the 
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting 
hardware. 
 
You can find this rule in the Local Coverage Article for 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 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. You can find this information 
on pages 63-70 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 state that a total electric hospital bed is not covered. The height adjustment feature is a convenience 
feature. Total electric hospital beds will be denied as not reasonable and necessary. You can find this rule in 
Local Coverage Determination (LCD) Hospital Beds and Accessories (L33820). 
 
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 Initial Hospital Care (CPT codes 99221 - 99223) and Subsequent Hospital Care (CPT codes 
99231 - 99233) codes are per diem services and may be reported only once per day by the same physician or 
physicians of the same specialty from the same group practice. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 12, 
Section 30.6.9. 
 
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 seat lift mechanism is covered if all of the following are met: 
 
1. The enrollee must have severe arthritis of the hip or knee or have a severe neuromuscular disease.  
 
2. The seat lift mechanism must be a part of the treating practitioner's course of treatment and be prescribed to 
improve, or stop deterioration of, the enrollee's condition. 
 
3. The enrollee must be completely unable to stand up from a regular armchair or any chair in the home.  
 
4. Once standing, the enrollee must have the ability to walk. 
You can find this rule in the Medicare Local Coverage Determination (LCD) L33801, Seat Lift Mechanisms. 
This LCD is effective for services provided on or after July 1, 2016. 
 
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 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 an expandable controller is capable of accommodating one or more of the following 
additional functions: 
 
- Other types of proportional input devices (such as, mini-proportional or compact joysticks, touchpads, chin 
control, head control, and so on) 
- Non-proportional input devices (such as, sip and puff, head array, and so on) 
- 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 (for example, for alternate control devices) 
- Other electronic devices (such as, 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 procedure code E2311 describes 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. 
 
You can find this information in the Local Coverage Article for 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 Medicare pays for outpatient rehabilitation therapy services only when they are provided by 
those trained specifically in physical therapy, occupational therapy or speech-language pathology. This means 
that the services of massage therapists may not be billed as covered therapy services. 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 230.5. 
 
The rules say that Medicare plans may not offer a massage therapy benefit. 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 30.4. 
 
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 participation in instructional fitness classes, online instructional fitness classes, 
memberships in a qualified health club or fitness facility, visits to a licensed acupuncturist, and visits to a 
licensed nutritional counselor or registered dietician for nutritional counseling services are covered under the 
wellness allowance. Massages are excluded from this benefit. You can find this information on page 82 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 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. 
 
The rules say that composite dressings (A6203) are covered for moderately to highly exudative wounds. 
Composite dressing change is up to 3 times per week, one wound cover per dressing change. The frequency of 
recommended dressing changes depends on the type and use of the surgical dressing. Suppliers must not 
dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to 
changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the treating 
practitioner that any changed or atypical utilization is warranted. Regardless of utilization, no more than a 
months supply of dressings may be provided at one time, unless there is documentation to support the 
necessity of greater quantities in the home setting in an individual case. You can find this rule in the Local 
Coverage Determination for Surgical Dressings, L33831. 
 
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 effective for services performed on or after May 16, 2023, power seat elevation equipment is reasonable and necessary for individuals using complex rehabilitative power-driven wheelchairs, when the following conditions are met:
1. The individual has undergone a specialty evaluation that confirms the individual's ability to safely operate the seat elevation equipment in the home. This evaluation must be performed by a licensed/certified medical professional such as a physical therapist (PT), occupational therapist (OT), or other practitioner, who has specific training and experience in rehabilitation wheelchair evaluations; and,
2. At least one of the following apply:
a. The individual performs weight bearing transfers to/from the power wheelchair while in the home, using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a sit to stand transfer. Transfers may be accomplished with or without caregiver assistance and/or the use of assistive equipment (e.g. sliding board, cane, crutch, walker, etc.); or,
b. The individual requires a non-weight bearing transfer (e.g. a dependent transfer) to/from the power wheelchair while in the home. Transfers may be accomplished with or without a floor or mounted lift; or,
c. The individual performs reaching from the power wheelchair to complete one or more mobility related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in customary locations within the home. MRADLs may be accomplished with or without caregiver assistance and/or the use of assistive equipment.
You can find this information in National Coverage Determination (NCD): Seat Elevation Equipment (Power Operated) on Power Wheelchairs (280.16).

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 when coverage criteria 
for a group 3 power wheelchair is met, and the beneficiary meets coverage criteria for a power tilt and recline 
seating system and the system is being used on the wheelchair, or the beneficiary uses a ventilator which is 
mounted on the wheelchair. This rule is found 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 in the absence of professional guidelines based on proven scientific literature, standing 
orders from clinicians for such tests as Ki-67 and EGFR on every breast cancer are not reasonable and 
necessary, and are not a covered Medicine service.  
 
In addition, basal phenotype markers (eg, IHC for CK5) are not routinely necessary. Neither are IHC stains 
such as E-cadherin, p27, or high molecular weight cytokeratin to distinguish ductal from lobular differentiation 
necessary on every breast case, nor are myoepithelial cell markers such as p63 or smooth muscle myosin heavy 
chain necessary on every case. You can find this rule at Local Coverage Determination (LCD) L36351: Lab: 
Special Histochemical Stains and Immunohistochemical Stains (eff. 12/24/20). 
 
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 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. 
 
The rules also say that the rate, facility or nonfacility, that a physician service is paid under the Medicare 
Physician Fee Schedule (MPFS) is determined by the Place of service (POS) code that is used to identify the 
setting where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner 
(NPP) or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the 
face-to-face service and determines whether the facility or nonfacility payment rate is paid. You can find this 
information at the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 12, Section 20.4.2 
 
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.
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 Request for Anticipated Payment (RAP) and a claim must be submitted for all episodes for 
which Medicare makes payment based on HIPPS codes. You can find this rule in Medicare Claims Processing 
Manual, Chapter 10, 40.3. 
 
The rules say all home health agencies (HHAs) must submit a RAP, which is to be paid at 0 percent, within 
five calendar days after the start of care and within five calendar days after the "from date" for each subsequent 
30-day period of care. You can find this rule in 42 CFR  484.205 - Basis of Payment. 
 
The rules say that split percentage payments for periods beginning on or after January 1, 2021, through 
December 31, 2021. All Home Health Agencies (HHAs) must submit a request for anticipated payment within 
5 calendar days after the start of care date for initial 30-day periods and within 5 calendar days after the from 
date for each subsequent 30-day period of care, which is set at 0 percent at the beginning of every 30-day 
period. HHAs receive a single payment for a 30-day period of care after the final claim is submitted. You can 
find this information in 42 CFR 484.205 (g)(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 items that do not contribute meaningfully to the treatment of an illness or injury, or the 
functioning of a malformed body member are not covered. You can find this rule in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 16, Personal Comfort 
Items, Section 80. 
 
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.