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 does not cover chiropractic maintenance care. When further clinical improvement 
cannot be reasonably expected from ongoing care, the care is considered maintenance. You can find this rule in 
the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 15, Section 240.1.3. 
 
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 Plan 
contract says that the only covered chiropractic service is manual manipulation of the spine to correct 
subluxation. You can find this information on page 50 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 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 40 in the Plan's 2024 
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 chemotherapy and other drugs covered by Medicare 
Part B. You can find this information on page 84 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay 20% coinsurance for chemotherapy and other drugs covered 
by Medicare Part B. You can find this information on page 73 of the Plan's 2023 EOC.  
 
The Plan contract also says that enrollees must pay a $130 copayment for each covered x-ray in the outpatient 
department of a network hospital or facility. You can find this information on page 76 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 no payment may be made for the implantation of dorsal column or depth brain stimulators or 
services and supplies related to such implantation, unless all of the conditions listed below have been met: 
 
a. The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic 
intractable pain; 
b. With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for 
the given patient; 
c. Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
d. All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be available; and 
e. Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find this rule in the National Coverage Determination (NCD) - Electrical Nerve Stimulatoras (160.7). 
 
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 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 & 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. The Plan 
contract says that customers are required to contact the Plan's transportation vendor at least 48 hours in advance 
of their appointment to schedule non-emergent transportation services to plan-approved locations, such as 
doctors appointments. Transportation arranged outside of the transportation vendor will not be covered and 
will be the responsibility of the member. You can find this information on page 56 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 & 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. Covered dental services are 
listed on pages 72-74 in the Plan's 2024 Evidence of Coverage. Any service not listed is not covered.
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 Medicare payment for home use of the air-fluidized bed for treatment of pressure sores can 
be made if such use is reasonable and necessary for the individual patient. 
 
A decision that use of an air-fluidized bed is reasonable and necessary requires that: 
 
The patient has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure sore; 
The patient is bedridden or chair bound as a result of severely limited mobility; 
In the absence of an air-fluidized bed, the patient would require institutionalization; 
The air-fluidized bed is ordered in writing by the patient's attending physician based upon a comprehensive 
assessment and evaluation of the patient after completion of a course of conservative treatment designed to 
optimize conditions that promote wound healing. This course of treatment must have been at least one month in 
duration without progression toward wound healing. This month of prerequisite conservative treatment may 
include some period in an institution as long as there is documentation available to verify that the necessary 
conservative treatment has been rendered. 
Use of wet-to-dry dressings for wound debridement, begun during the period of conservative treatment and 
which continue beyond 30 days, will not preclude coverage of air-fluidized bed. Should additional debridement 
again become necessary, while a patient is using an air-fluidized bed (after the first 30-day course of 
conservative treatment) that will not cause the air-fluidized bed to become non-covered. In all instances 
documentation verifying the continued need for the bed must be available. 
A trained adult caregiver is available to assist the patient with activities of daily living, fluid balance, dry skin 
care, repositioning, recognition and management of altered mental status, dietary needs, prescribed treatments, 
and management and support of the air-fluidized bed system and its problems such as leakage; 
A physician directs the home treatment regimen, and reevaluates and recertifies the need for the air-fluidized 
bed on a monthly basis; and 
All other alternative equipment has been considered and ruled out. 
 
You can find this information in the National Coverage Determination (NCD) Air-Fluidized Bed 280.8. 
 
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 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 person's 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 & Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.3(B).

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 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. Although the Plan has a Point-of-Service (POS) option to cover certain out-of-network services, this benefit only applies to covered routine dental services. You can find this information on page(s) 3-4 of the Plan's 2022 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 & 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 only certain codes/services are covered under the Plan. The Evidence of Coverage (EOC) 
lists specific services which are a covered benefit and any service not listed in this section is not a covered 
benefit. You can find this information in Chapter 4 on pages 56-58 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 state that stress testing with cardiac imaging will be considered medically reasonable and necessary 
for: 
 
Patients experiencing new, recurrent, or worsening cardiac symptoms, including otherwise unexplained angina 
equivalent symptoms, AND any of the following: 
Physical inability to perform a maximum exercise workload2,5,6,8-10,15,20; OR 
 
New or previously unrecognized uninterpretable ECG2,5,6,8-10 OR; 
ECG is uninterpretable for ischemia due to any one of the following2,5,8,9,15,21: 
 
Complete left bundle branch block (right bundle branch does not render ECG uninterpretable for ischemia),21 
 
Ventricular paced rhythm, 
 
Pre-excitation pattern such as Wolff-Parkinson-White, 
 
A > 1 mm ST segment depression (NOT nonspecific ST/T wave changes), 
 
Left ventricular hypertrophy (LVH) with repolarization abnormalities, also called LVH with strain (NOT 
without repolarization abnormalities or by voltage criteria), or 
 
Patient on digoxin therapy. 
 
A history of CAD based on a prior anatomic evaluation of the coronary arteries OR a history of CABG or 
PCI;6,8,15 OR 
 
Syncope and collapse (an abrupt, transient, complete loss of consciousness) for patients with an intermediate or 
high CHD risk (ATP III risk criteria) and where cardiac etiology is suspected based on an initial evaluation, 
including history, physical examination, or ECG and patient is unable to exercise;6,8,10,15,16 OR  
Evidence or high suspicion of ventricular arrhythmias:6,7,8,10 OR 
 
Worsening or continuing symptoms in a patient who had a normal or submaximal exercise stress test and there 
is suspicion of a false negative result;20,22 OR 
 
Patients with recent equivocal or borderline testing where ischemia remains a concern;8,15,20 OR 
 
Patients on beta blocker, calcium channel blocker, and/or antiarrhythmic medication when the documentation 
supports that an adequate workload may not be attainable to enable a fully diagnostic exercise study;2,5 OR 
 
History of false positive exercise stress test (e.g., one that is abnormal, but the abnormality does not appear to 
be due to macrovascular CAD);8,22 OR 
 
Evaluation of chest pain syndrome after revascularization or in patients with intermediate to high pre-test 
probability for CAD regardless of ECG interpretability or ability to exercise;7,8 OR 
 
High pre-test probability for CAD regardless of ECG interpretability or the ability to exercise, and a decision to 
perform cardiac catheterization or other angiography has not already been made;7,8,10,15 OR 
 
Patients with HCM 
 
You can find this information in the Local Coverage Determination (LCD) Cardiology Non-emergent 
Outpatient Stress Testing L38396. 
 
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 tumor treatment field therapy (E0766) is covered for the treatment of newly diagnosed 
Glioblastoma Multiforme (GBM) only when all of the following criteria are met: 
 
The beneficiary has histologically confirmed (World Health Organization (WHO) grade IV astrocytoma), 
newly diagnosed, supratentorial GBM; and, 
 
The beneficiary has received initial treatment with maximal debulking surgery (when feasible), followed by 
chemotherapy and radiotherapy; and, 
 
Tumor treatment field therapy is initiated within 7 weeks from the last dose of concomitant chemotherapy or 
radiotherapy, whichever is later; and, 
 
The beneficiary has no evidence of progression by Response Assessment in Neuro-Oncology (RANO) criteria; 
and, 
 
The beneficiary has a Karnofsky Performance Score (KPS) of at least 70; and, 
 
The beneficiary will use TTFT for an average of 18 hours per day. 
 
If all of the coverage criteria above are not met, claims for code E0766 will be denied as not reasonable and 
necessary. 
 
 
CONTINUED COVERAGE FOR NEWLY DIAGNOSED GBM BEYOND THE FIRST THREE MONTHS 
OF THERAPY: 
 
Continued coverage of TTFT (E0766) beyond the first three months of therapy requires that no sooner than the 
60th day but no later than the 91st day after initiating therapy, the treating practitioner must conduct a clinical 
re-evaluation and document that the beneficiary is continuing to use and is benefiting from TTFT.  
Documentation of clinical benefit is demonstrated by: 
 
In-person clinical re-evaluation by the treating practitioner; and, 
 
Objective evidence of adherence to therapy, reviewed by the treating practitioner. 
 
Adherence to therapy is defined as the use of TTFT for an average of 18 hours per day (excluding days the 
treating practitioner has documented a medical need to limit or interrupt treatment). 
 
If the above criteria are not met, continued coverage of TTFT will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Tumor Treatment Field Therapy 
(TTFT) L34823. 
 
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 if the expense for repairs exceeds the estimated expense of purchasing or renting another 
item of equipment for the remaining period of medical need, no payment can be made for the amount of the 
excess. You can find this rule in the Centers for Medicare & Medicaid Services (CMS) Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 15, Section 110.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 Medicare covers pneumatic devices when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. You can find 
this in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-03, Medicare 
National Coverage Determinations Manual, Chapter 1, Section 280.6. 
 
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.