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. 
 
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). 
 
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. 
 
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 
offers a supplemental (extra) benefit to cover routine vision services that are not covered by Original Medicare. 
This benefit includes one routine eye exam every year and a $100 allowance toward the purchase of frames; 
standard lenses are covered in full, or a $0 copayment for up to 8 boxes of contact lenses from a select list, or a 
$100 allowance toward the cost of other contact lenses. Standard lenses and frames are limited to one pair of 
lenses and frames every 2 years, or contact lenses instead of lenses and frames every 2 years.  
 
Standard lenses that are covered in full include standard single vision, lined bifocal, lined trifocal, lenticular 
and standard progressive lenses. Additional lens options including, but not limited to, deluxe, premium or 
platinum progressive lenses, blended bifocal, hi-index, tinting, scratch coating, ultraviolet or anti-reflective 
coating, and polycarbonate are not covered. You can find this information on pages 4-53 to 4-54 of the Plan's 
2021 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 four-week trial of conservative therapy demonstrating failed response to treatment with and 
E0650 or E0651 is required. The four-week trial of conservative therapy must include all of the following: 
 
At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person 
fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the 
appliance provided Compliant use of an appropriate compression bandage system or compression garment to 
provide adequate graduated compression Adequate compression is defined as (1) sufficient pressure at the 
lowest pressure point to cause fluid movement and (2) sufficient pressure across the gradient (from highest to 
lowest pressure point) to move fluid from distal to proximal. The compression used must not create a 
tourniquet effect at any point. The garment may be prefabricated or custom-fabricated but must provide 
adequate graduated compression starting with a minimum of 30 mmHg distally.  
Regular exercise 
Elevation where appropriate, Manual lymphatic drainage (where available) and self-manual lymphatic drainage 
(MLD) for at least 30 minutes per day 
Evaluation of diet and implementation of any necessary change 
Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.) 
Correction (where possible) of anemia and/or hypoprotenemia 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Pneumatic Compression 
Devices (L33829). 
 
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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules say that Medicare covers services in an emergency department only if the emergency clinic is 
affiliated with a hospital. You can find this rule at SSA 1861, 42 CFR 489.24, and 42 CFR 413.65. 
 
The rules say that CMS is creating additional flexibilities to allow licensed independent freestanding 
emergency departments (EDs) to participate in Medicare and Medicaid to help address the urgent need to 
increase hospital capacity to provide care to patients. The following ways to participate include: 
Becoming affiliated with a Medicare/Medicaid-certified hospital under the temporary expansion 1135 
emergency waiver. Participating in Medicaid under the clinic benefit if permitted by the State, or Enrolling 
temporarily as a Medicare/Medicaid-certified hospital to provide hospital services. 
 
You can find this information in The Centers for Medicare and Medicaid Services (CMS) Guidance for 
Licensed Independent Freestanding Emergency Departments (EDs) to Participate in Medicare and Medicaid 
during the COVID-19 Public Health Emergency. 
 
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. 
 
A pneumatic compression device (PCD) coded as E0652 is covered for the treatment of lymphedema extending 
onto the chest, trunk and/or abdomen when all of the following are met: 
 
1. The beneficiary has lymphedema of an extremity. 
 
2. The coverage criteria for an E0650 or E0651 PCD are met. 
 
3. The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits 
of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve 
with a four-week trial. 
 
A four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651 
is required. The four-week trial of conservative therapy must include all of the following: 
 
 At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 PCD after 
careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and 
successfully uses the appliance provided 
 Compliant use of an appropriate compression bandage system or compression garment to provide 
adequate graduated compression 
 Regular exercise 
 Elevation where appropriate 
 Manual lymphatic drainage (where available) and self-manual lymphatic drainage (MLD) for at least 30 
minutes per day 
 Evaluation of diet and implementation of any necessary change 
 Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.) 
 Correction (where possible) of anemia and/or hypoproteinemia 
 
You can find this information at Local Coverage Determination (LCD): Pneumatic Compression Devices 
(L33829). 
 
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 if an independent lab bills for services, the place where the sample was taken is reported as 
the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of 
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 26, Section 10.6. 
 
The rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other 
supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two 
exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or 
outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You 
can find this information in the MLN Matters article number MM7631, Revised and Clarified Place of Service 
(POS) Coding Instructions. 
 
The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing 
procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 
If no CPT code accurately describes the procedure performed, the laboratory may report CPT code 81479 
(Unlisted molecular pathology procedure) with one unit of service or may report multiple individual CPT codes 
describing the component test results when medically reasonable and necessary. Procedures reported together 
must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician 
who is treating the beneficiary and using the results in the management of the beneficiary's specific medical 
problem. You can find this information in Chapter X: Pathology/Laboratory Services (CPT codes 80000-8999) 
for National Correct Coding Initiative Policy Manual for Medicare Services. 
 
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 a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered. 
 
Expandable Controller -- An electronic system that is capable of accommodating one or more of 
the following additional functions: 
a. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head 
control, etc.) other than a standard proportional joystick. 
b.  Non-proportional input devices (e.g., sip and puff, head array, etc.) 
c.  Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating 
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) 
An expandable controller may also be able to operate one or more of the following: 
d.  separate display (i.e., for alternate control devices) 
e.  Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's 
drive control) 
f.  An attendant control 
 
A power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a solid back; any 
frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway 
detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable 
speed programmability; a switch control which is independent of the power wheelchair drive control interface. 
 
A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or 
without variable speed programmability which allows the legrest to be raised and lowered independently of the 
recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with 
the power tilt and/or recline control(s). 
 You can find this information in the Local Coverage Article: Wheelchair Options/Accessories -- Policy Article 
(A52504). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 1. Epidural steroid injection (ESI) will be considered medically reasonable and necessary when 
the following three (3) requirements are met: 
 
6. Repeat ESI when the first injection directly and significantly provided improvement of the condition being 
treated may be considered medically reasonable and necessary when the medical record documents at least 
50% of sustained improvement in pain relief and/or improvement in function measured from baseline using the 
same scale* for at least three months. If a patient fails to respond well to the initial ESI, a repeat ESI after 14 
days can be performed, using a different approach, level and/or medication if appropriate, with the rationale 
and medical necessity for the second ESI documented in the medical record. You can find this information in 
Medicare's Local Coverage Determination (LCD): Epidural Steroid Injections for Pain Management (L39036). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
  
   
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
For a treatment to be considered medically reasonable and necessary per 1862(a)(1)(A) of The Act the 
treatment must be appropriate, including duration and frequency furnished in accordance with accepted 
standards of medical practice for the condition. Novitas Solutions determines that the existing evidence and 
lack of accepted standards of medical practice for PRP injections do not meet the requirement of medically 
reasonable and necessary. Thus, Novitas Solutions considers PRP injection and PRP combined with stem cells 
for musculoskeletal injuries and/or joint conditions, whether primary or adjunctive use, not medically 
reasonable and necessary. Once PRP preparations are standardized, trials can more precisely highlight which 
factors are associated with better outcomes, yielding more effective PRP preparations and patient selection 
criteria. Novitas Solutions will continue to monitor scientific developments and may adjust this coverage policy 
in accordance. You can find this information in the Local Coverage Determination (LCD) Platelet Rich Plasma. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that effective for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement 
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following 
requirements are met: 
 
1. Patient has: 
 
-either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and, 
-either not been previously tested using the same NGS test for the same primary diagnosis of cancer, or repeat 
testing using the same NGS test only when a new primary cancer diagnosis is made by the treating physician; 
and, 
-decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
2. The diagnostic laboratory test using NGS must have: 
- Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
- an FDA-approved or -cleared indication for use in that patients cancer; and, 
- results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
You can find this rule in National Coverage Determination (NCD) for Next Generation Sequencing (NGS) 
(90.2) - Effective March 16, 2018. 
 
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. 
Effective for services performed on or after March 16, 2018, the Centers for Medicare & Medicaid Services 
(CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable 
and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments 
(CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements 
are met: 
   a. Patient has: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
   b. The diagnostic laboratory test using NGS must have:  
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; 
and, 
ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
iii. results provided to the treating physician for management of the patient using a report template to 
specify treatment options. 
You can find this information in Medicare's National Coverage Determination (NCD): Next Generation 
Sequencing (NGS) (90.2). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will pay for durable medical equipment (DME) that is mainly used to serve a 
medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment 
that are clearly used for medical purposes. 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.  
 
The rules also say that prosthetic devices (other than dental) which replace all or part of an internal body organ 
(including contiguous tissue), or replace all or part of the function of a permanently inoperative or 
malfunctioning internal body organ are covered when furnished on a physician's order. You can find this in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 15, Section 120. 
 
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 Health 
Plan contract also says that wigs and other primarily non-medical equipment are not covered under any 
condition. You can find this information on page 4-77 of the Plan's 2021 EOC.