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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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 43 to 51 of the Plan's 
2022 Evidence of Coverage (EOC)v.
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 Coverage for NMES/FES for walking will be covered in spinal cord injury (SCI) patients 
with all of the following characteristics: 
 
    Persons with intact lower motor units (L1 and below) (both muscle and peripheral nerve); 
    Persons with muscle and joint stability for weight bearing at upper and lower extremities that can 
demonstrate balance and control to maintain an upright support posture independently; 
    Persons that demonstrate brisk muscle contraction to NMES and have sensory perception electrical 
stimulation sufficient for muscle contraction; 
    Persons that possess high motivation, commitment and cognitive ability to use such devices for walking; 
    Persons that can transfer independently and can demonstrate independent standing tolerance for at least 3 
minutes; 
    Persons that can demonstrate hand and finger function to manipulate controls; 
    Persons with at least 6-month post recovery spinal cord injury and restorative surgery; 
    Persons without hip and knee degenerative disease and no history of long bone fracture secondary to 
osteoporosis; and 
    Persons who have demonstrated a willingness to use the device long-term. 
 
NMES/FES for walking will not be covered in SCI patient with any of the following: 
 
    Persons with cardiac pacemakers; 
    Severe scoliosis or severe osteoporosis; 
    Skin disease or cancer at area of stimulation; 
    Irreversible contracture; or 
    Autonomic dysflexia. 
 
You can find this information in the National Coverage Determination (NCD) Neuromuscular Electrical 
Stimulation (NMES) 160.12. 
 
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 state that the patient's medical record should contain documentation that fully supports the medical 
necessity for intra-articular injections of sodium hyaluronate (Hyalgan, Supartz or Visco-3TM, EuflexxaTM, 
MonoviscTM, GelSyn-3TM, GenVisc 850, Durolane, TriViscTM, SynojoyntTM, TriluronTM), hylan G-F 20 
(Synvisc, Synvisc-One TM), hyaluronic acid (Gel-One), high molecular weight hyaluronan (Orthovisc) 
and high molecular weight viscoelastic hyaluronan (Hymovis). This documentation includes, but is not 
limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or 
procedures, and history of pharmacologic therapy. Documentation of subsequent courses of treatment must 
clearly establish reduction of patient symptomatology and medication usage. This documentation must be 
submitted upon request. Claims submitted without requested supporting evidence in the medical record will be 
denied as being not medically necessary. 
 
You can find this information in the Local Coverage Article Billing and Coding Billing and Coding: 
Hyaluronans Intra-articular Injections of A52420. 
 
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. You can find this information 
on page 53 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 all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patients medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patients 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
The rules say that if the supplier utilizes a shipping service or mail order, the POD documentation must be a 
complete record tracking the item(s) from the DMEPOS supplier to the beneficiary. An example of acceptable 
POD would include both the suppliers own detailed shipping invoice and the delivery services tracking 
information. The suppliers record must be linked to the delivery service record by some clear method like the 
delivery services package identification number or suppliers invoice number for the package sent to the 
beneficiary. The POD document must include: 
 Beneficiarys name 
 Delivery address 
 Delivery services package identification number, supplier invoice number, or alternative method that 
links the suppliers delivery documents with the delivery services records 
 A description of the item(s) being delivered. The description can be either a narrative description (e.g., 
lightweight wheelchair base), a HCPCS code, the long description of a HCPCS code, or a brand 
name/model number 
 Quantity delivered 
 Date delivered 
 Evidence of delivery If a supplier utilizes a shipping service or mail order, suppliers have two options for the DOS to use on the 
claim: 
1. Suppliers may use the shipping date as the DOS. The shipping date is defined as the date the 
delivery/shipping service label is created or the date the item is retrieved by the shipping service for 
delivery. However, such dates should not demonstrate significant variation. 
2. Suppliers may use the date of delivery as the DOS on the claim.  
You can find this information in the Local Coverage Article (LCA) Standard Documentation Requirements for 
All Claims Submitted to DME MACs (A55426). 
 
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 MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands 
and manufacturers, as long as the following conditions are met (42 CFR 422.100(l)): 
 
 The MA plan provides all categories of DME covered under original Medicare Part B; 
 The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
 The MA plans contracted suppliers provide access to all preferred DME brands; 
 During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 
90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year; 
 Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
 The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
 The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the Evidence of Coverage and Annual Notice of Change and on its website; and 
 The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by CMS to require full coverage. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS) Medicare Managed 
Care Manual Chapter 4, Section 10.12.2- Specifying Brands or Manufacturers of DME. 
 
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 coverage for glucose monitors and test strips to the Plan's preffered brands. You can find 
this on pages 53 to 54 of the Plan's 2023 Evidence of C0verage.
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). 
 
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 
preventive and comprehensive dental services along with specific dental codes that are listed on the dental 
benefit chart. The application of fluoride is not covered by the Plan's dental benefits. You can find this 
information on pages 106 to 140 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 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. 
 
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 Plan 
contract says that enrollees must pay a $15 copayment for per service during the visit for covered routine dental 
services. You can find this information on page 61 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 continuous subcutaneous insulin infusion (CSII) and related drugs/supplies are covered as 
medically reasonable and necessary in the home setting for the treatment of diabetic patients who: (1) either 
meet the updated fasting C-Peptide testing requirement, or are beta cell autoantibody positive; and, (2) satisfy 
the remaining criteria for insulin pump therapy as described below. Patients must meet either Criterion A or B 
as follows: 
 
Criterion A: The patient has completed a comprehensive diabetes education program, and has been on a 
program of multiple daily injections of insulin (i.e., at least 3 injections per day), with frequent self-adjustments 
of insulin doses for at least 6 months prior to initiation of the insulin pump, and has documented frequency of 
glucose self-testing an average of at least 4 times per day during the 2 months prior to initiation of the insulin 
pump, and meets one or more of the following criteria while on the multiple daily injection regimen: 
- Glycosylated hemoglobin level (HbAlc) > 7.0%; 
- History of recurring hypoglycemia; 
- Wide fluctuations in blood glucose before mealtime; 
- Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl; or, 
- History of severe glycemic excursions. 
 
Criterion B: The patient with diabetes has been on a pump prior to enrollment in Medicare and has documented 
frequency of glucose self-testing an average of at least 4 times per day during the month prior to Medicare 
enrollment. 
 
In addition to meeting Criterion A or B above, the following general requirements must be met: 
The patient with diabetes must be insulinopenic per the updated fasting C-peptide testing requirement, or, as an 
alternative, must be beta cell autoantibody positive. 
 
Updated fasting C-peptide testing requirement: 
 
- Insulinopenia is defined as a fasting C-peptide level that is less than or equal to 110% of the lower limit 
of normal of the laboratory's measurement method. 
- For patients with renal insufficiency and creatinine clearance (actual or calculated from age, gender, 
weight, and serum creatinine)  50 ml/minute, insulinopenia is defined as a fasting C-peptide level that 
is less than or equal to 200% of the lower limit of normal of the laboratory's measurement method. - Fasting C-peptide levels will only be considered valid with a concurrently obtained fasting glucose  
225 mg/dL. 
- Levels only need to be documented once in the medical records. 
 
You can find this information in National Coverage Determination (NCD): Infusion pumps (280.15). 
 
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 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 state that an implantable (or insertable loop) recorder (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 
memory loop recorder (MLR). You can find this information in National Coverage Determination (NCD): 
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 state that implantable (or insertable loop) recorder (ILR) 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 
memory loop recorder (MLR). You can find this information in National Coverage Determination (NCD): 
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 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 24 one-way rides every year to and from medically related appointments and the pharmacy. The Plan 
contract also says each one-way trip must not exceed 50 miles. A trip is one-way transportation; a round trip is 
2 trips. You can find this information on page 106 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 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 one 
upper and one lower complete denture every five calendar years. You can find this information on pages 80-82 
and 87-88 of the Plan's 2022 Evidence of Coverage (EOC).