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

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 26 one-way trips each year. You can find this information on pages 91-92 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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) 
procedures will be considered medically reasonable and necessary for the following indications: 

1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have 
not responded to non-surgical medical management (e.g. narcotic and/or non- narcotic medication, 
physical therapy modalities) with and without methods of immobility (e.g. rest, bracing). 
- Both PVP and PVA will be considered reasonable and necessary when ALL of the following 
criteria are met: 
o Acute (<6 wks) or subacute (6-12 wks)
18,28,42 
osteoporotic VCF (T1- L5), based on 
symptom onset, and documented by advanced imaging demonstrating bone marrow 
edema on MRI or bone-scan/SPECT/CT uptake 
1-3,8,26,43
 and 
o The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating 
Scale [NRS] or Visual Analog Scale [VAS] pain score  8)
4-7
 or is non-hospitalized with 
moderate to severe pain (NRS or VAS 5) despite optimal non-surgical management 
(NSM)
8
 with one of the following: 
 Worsening Pain or 
 Stable to improved pain (but NRS or VAS 5) when 2 or more of the following 
are present: 
o Progression of vertebral body height loss 
o > 25% vertebral body height reduction 
o Kyphotic deformity 
o Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire [RDQ] >17) 
You can find this rule at Local Coverage Determination (LCD) L35130: Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (eff. 7/11/21). 
 
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 a manual wheelchair for use inside the home (E1037, E1038, E1039, E1161, K0001, K0002, 
K0003, K0004, K0005, K0006, K0007, K0008, K0009) is covered if: 
 
    Criteria A, B, C, D, and E are met; and 
    Criterion F or G is met. 
 
    The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. A mobility limitation is one that: 
 
      1.  Prevents the beneficiary from accomplishing an MRADL entirely, or 
 
      2.  Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to 
the attempts to perform an MRADL; or 
 
      3.  Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
 
    The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted 
cane or walker. 
 
    The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for use 
of the manual wheelchair that is provided. 
 
    Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in MRADLs 
and the beneficiary will use it on a regular basis in the home. 
 
    The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the 
home. 
     The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to 
safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of 
strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both 
upper extremities are relevant to the assessment of upper extremity function. 
 
    The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair. 
 
A transport chair (E1037, E1038 or E1039) is covered as an alternative to a standard manual wheelchair 
(K0001) and if basic coverage criteria A-E and G above are met. 
 
Payment is made for only one wheelchair at a time. Backup chairs are denied as not reasonable and necessary. 
One month's rental for a standard manual wheelchair (K0001) is covered if a beneficiary-owned wheelchair is 
being repaired. 
 
You can find these rules in the Local Coverage Determination (LCD) Manual Wheelchair Bases L33788. 
 
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 on page 20 in the Plans 2023 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 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 3-3 through 3-8 of the 
Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers 24 one-way trips to and from plan-approved locations every year. You can find this information on 
pages 32-33 of the Plans 2023 Schedule of Cost Sharing.
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 this policy, the term PAP (positive airway pressure) device will refer to both a single-level 
continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up 
rate (E0470) when it is used in the treatment of obstructive sleep apnea. 
 
    An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A  C are met: 
 
        The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to 
assess the beneficiary for obstructive sleep apnea. 
 
        The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2): 
 
            The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 
events per hour with a minimum of 30 events; or, 
 
            The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a 
minimum of 10 events and documentation of: 
 
                Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
                Hypertension, ischemic heart disease, or history of stroke. 
 
        The beneficiary and/or their caregiver has received instruction from the supplier of the device in the 
proper use and care of the equipment. 
 
If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not 
reasonable and necessary. 
 
    An E0470 device is covered for those beneficiaries with OSA who meet criteria A-C above, in addition to 
criterion D: 
         An E0601 has been tried and proven ineffective based on a therapeutic trial conducted in either a facility 
or in a home setting. 
 
Ineffective is defined as documented failure to meet therapeutic goals using an E0601 during the titration 
portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and 
fitting and appropriate pressure settings). You can find these rules in the Local Coverage Determination (LCD) 
Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea L33718. 
 
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 say that carriers must pay for the PC of radiology services furnished by a physician to an individual 
patient in all settings under the fee schedule for physician services regardless of the specialty of the physician 
who performs the service. You can find this information in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 13, 20.1 
 
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.
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 
guided tissue regeneration. You can find this information on pages 54, and 90-102 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 non-spinal electrical osteogenesis stimulator (E0747) is covered only if any of the 
following criteria are met: 
 
        Nonunion of a long bone fracture (see Appendices section) defined as radiographic evidence that fracture 
healing has ceased for three or more months prior to starting treatment with the osteogenesis stimulator, or 
        Failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last 
surgery, or 
        Congenital pseudarthrosis. 
 
Nonunion of a long bone fracture must be documented by a minimum of two sets of radiographs obtained prior 
to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each including 
multiple views of the fracture site, and with a written interpretation by a treating practitioner stating that there 
has been no clinically significant evidence of fracture healing between the two sets of radiographs. 
 
A non-spinal electrical osteogenesis stimulator will be denied as not medically necessary if none of the criteria 
above are met. 
You can find this information in the Local Coverage Determination (LCD): Osteogenesis Stimulators 
(L33796). 
 
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 follow-up polysomnography or sleep studies are not routinely indicated for patients treated 
with continuous positive airway pressure (CPAP) whose symptoms continue to be resolved with CPAP 
treatment. Follow-up polysomnography studies may be indicated, however, for the following conditions: 
 
    After substantial weight loss has occurred in patients on CPAP for treatment of sleep-related breathing 
disorders to ascertain whether CPAP is still needed at the previously titrated pressure; 
    After substantial weight gain has occurred in patients previously treated with CPAP successfully, who are 
again symptomatic despite the continued use of CPAP, to ascertain whether pressure adjustments are needed; 
or 
    When clinical response is insufficient or when symptoms return despite a good initial response to treatment 
with CPAP. 
 
You can find this information in the Local Coverage Determination (LCD) for Outpatient Sleep Studies 
(L35050). 
 
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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 routine vision services are offered through The Plans Vision Care. Please contact Member Services 
to see if your vision provider is in the network. Services are only covered when received by a participating 
provider. You can find this information on pages 100 to 101 of the Plan's 2023 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 while electric nerve stimulation has been employed to control chronic intractable pain for 
some time, its use in the treatment of motor function disorders, such as multiple sclerosis, is a recent 
innovation, and the medical effectiveness of such therapy has not been verified by scientifically controlled 
studies. 
 
Indications and Limitations of Coverage 
 
Where electric nerve stimulation is employed to treat motor function disorders, no reimbursement may be made 
for the stimulator or for the services related to its implantation since this treatment cannot be considered 
reasonable and necessary. 
 
You can find these rules in the National Coverage Determination (NCD) Treatment of Motor Function 
Disorders with Electric Nerve Stimulation 160.2. 
 
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.