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. 
 
A fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or more of the 
following criteria (1-4) are met: 
 
1. The beneficiary has a medical condition which requires positioning of the body in ways not feasible with an 
ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a 
hospital bed, or 
2. The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to 
alleviate pain, or 
3. The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration, or 
4. The beneficiary requires traction equipment, which can only be attached to a hospital bed. 
 
A heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one of the criteria for 
a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 
pounds. 
 
You can find this information in the 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 if a positive airway pressure (PAP) device is replaced during the 5 year reasonable useful 
lifetime (RUL) because of loss, theft, or irreparable damage due to a specific incident, there is no requirement 
for a new clinical evaluation, sleep test, or trial period. 
 
If a PAP device is replaced following the 5 year RUL, there must be an in-person evaluation by their treating 
practitioner that documents that the beneficiary continues to use and benefit from the PAP device. There is no 
requirement for a new sleep test or trial period. 
 
You can find this information 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 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 thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint 
(medial branch (MB)) nerves are considered medically reasonable and necessary after the patient has had at 
least 2 medically reasonable and necessary diagnostic medical branch blocks (MBBs), with each 1 providing a 
consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being 
consistent with the agent used). You can find this information in the Local Coverage Determination (LCD) 
L33930: Facet Joint interventions for Pain Management. 
 
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 a power wheelchair is covered when the beneficiarys home provides adequate access 
between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided. 
You can find this rule in the Local Coverage Determination (LCD) for 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 SI joint injections will be considered medically reasonable and necessary when all the 
following requirements are met: 
1. Moderate to severe low back pain (LBP) primarily experienced over the anatomical location of 
the SIJs between the upper level of the iliac crests and the gluteal fold, AND 
2. LBP duration of at least 3 months, AND 
3. LBP below L5 without radiculopathy, AND 
4. Clinical findings and/or imaging studies do not suggest any other diagnosed or obvious cause of 
the lumbosacral pain (such as central spinal stenosis with neurogenic claudication/myelopathy, 
foraminal stenosis or disc herniation with concordant radicular pain/radiculopathy, infection, 
tumor, fracture, pseudoarthrosis, or pain related to spinal instrumentation), AND 
5. At least 3 positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or 
Posterior Shear, SI Compression, SI Distraction and Yeoman Tests,
3,4
 AND 
6. LBP persists despite a minimum of 4 weeks of conservative therapies.
5
 
You can find this rule at Local Coverage Determination (LCD) L39402: Sacroiliac Joint Injections and 
Procedures (eff. 3/19/23). 
 
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 pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). 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 110.1(D). 
 
The rules say that if the power wheelchair base is not covered, then related accessories will be denied. You can 
find this information in the Local Coverage Determination (LCD) for 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 Plan 
contract includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. Occlusal adjustment (D9951) is not included on this list and is not a 
covered supplemental benefit. You can find this information on pages 57 to 63 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.  
 
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 $45 copayment per visit, for an in-network specialist office visit. You 
can find this information on page 92 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $40 copayment per visit, for an in-network specialist. You 
can find this information on pages 87 to 88 of the Plan's 2023 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 page 36 in the Plan' 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 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. 
 
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 20% coinsurance for durable medical equipment and related supplies. 
You can find this information on page(s) 60 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 prior to sleep testing, the patient has a face-to-face clinical evaluation by the treating 
physician to assess the patient for OSA which must include, at a minimum, the following: 
1. Sleep history and symptoms including, but not limited to, snoring, daytime sleepiness, observed apneas, 
choking or gasping during sleep, morning headaches; and, 
2. Epworth Sleepiness Scale; and, 
3. Physical examination that documents body mass index, neck circumference and a focused 
cardiopulmonary and upper airway system evaluation. 
You can find this rule at Local Coverage Determination (LCD) L33405: Polysomnography and Sleep Testing 
(eff. 7/1/20). 
 
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 a Percutaneous Transluminal Angioplasty (PTA) is covered when used under the following 
conditions: 
 
1. Treatment of Atherosclerotic Obstructive Lesions 
 
2. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA)-Approved Category B 
Investigational Device Exemption (IDE) Clinical Trials 
 
3. Concurrent with Carotid Stent Placement in FDA-Approved Post Approval Studies 
 
4. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) 
 
Effective March 17, 2005, Medicare covers PTA of the carotid artery concurrent with the placement of an 
FDA-approved carotid stent with embolic protection for the following: 
 
- Patients who are at high risk for CEA and who also have symptomatic carotid artery stenosis greater than or 
equal to 70%. 
- Patients who are at high risk for CEA and have symptomatic carotid artery stenosis between 50% and 70%, in 
accordance with the Category B IDE clinical trials regulation, as a routine cost under the clinical trials policy, 
or in accordance with the NCD on carotid artery stenting (CAS) post-approval studies. 
- Patients who are at high risk for CEA and have asymptomatic carotid artery stenosis greater than or equal to 
80%, in accordance with the Category B IDE clinical trials regulation, as a routine cost under the clinical trials 
policy, or in accordance with the NCD on CAS post- approval studies. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 20.7. 
 
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 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. 
 
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 $20 copayment for outpatient diagnostic tests. You can find this 
information on page(s) 83-85 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 if a trial fails, a repeat trial is not appropriate unless there are extenuating circumstances that 
lead to trial failure. You can find this rule at Local Coverage Determination (LCD) L36204: Spinal Cord 
Stimulators for Chronic Pain (eff. 12/1/19). 
  
  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 percutaneous vertebroplasty (PVP) 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). 
2. Malignant Vertebral Fractures 
 
You can find this information in the Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L34976). 
 
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 treatment for lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH) will 
be considered reasonable and necessary when performed ONCE in patients with the following: 
 
    Indications including ALL of the following: 
        Age =80 
        Prostate volume of 30-150 cc by transrectal ultrasound (TRUS)1,2 
        Persistent moderate to severe symptoms despite maximal medical management including ALL of the 
following: 
            International Prostate Symptom Score (IPSS) =121 
            Maximum urinary flow rate (Qmax) of =15 mL/s (voided volume greater than 125 cc)1 
            Failure, contraindication or intolerance to at least three months of conventional medical therapy for 
LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
 
    Only treatment using an FDA approved/cleared device will be considered reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Fluid Jet System Treatment for 
LUTS/BPH L38367. 
 
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 echocardiography is indicated in the evaluation of derangements of valvular, myocardial and 
pericardial structure and function. The general applications for coverage include: 
 
- Ventricular Function, Cardiomyopathies and Heart Failure 
- Hypertensive Cardiovascular Disease 
- Acute Myocardial Infarction and Coronary Insufficiency 
- Exposure to Cardiotoxic Agents (chemotherapeutic and external) 
- Cardiac Transplant and Rejection Monitoring 
- Native Valvular Heart Disease 
- Prosthetic Heart Valves (Mechanical & Bio-prostheses) 
- Acute Endocarditis 
- Pericardial Disease 
- Abnormalities of the Great Vessels 
- Congenital Heart Disease 
- Suspected Cardiac Thrombi and Embolic Sources 
- Cardiac Tumors and Masses 
- Critically Ill and Trauma Patients 
- Arrhythmias and Palpitations 
- Syncope 
- Pulmonary Hypertension 
 
You can find this information in the Local Coverage Determination (LCD): Transthoracic Echocardiography 
(TTE) (L33577). 
 
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.