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 state that platelet rich plasma (PRP) injections and/or applications as a means of managing 
musculoskeletal injuries and/or joint conditions is not covered. You can find this information in Local 
Coverage Determination (LCD): Platelet Rich Plasma Injections for Non-Wound Injections (L39058). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
Medicare rules say that percutaneous vertebral augmentation will be considered medically reasonable and 
necessary when all of the following criteria are met: 
 
Acute (<6 weeks) or subacute osteoporotic vertebral compression fracture, based on symptom onset and 
documented by advanced imaging demonstrating bone marrow edema on magnetic resonance imaging or bone-
scan/single photon emission computed tomography scan/computed tomography uptake and the beneficiary is 
symptomatic and is hospitalized with severe pain or is non-hospitalized with moderate to severe pain despite 
optimal non-surgical management. You can find this information in the Local Coverage Determination (LCD): 
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L35130). 
 
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 includes 
restorative services once every 12 to 84 months depending on the type of service. You can find this information 
in Chapter 4 on pages 60 to 62 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. 
 
 
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 to qualify for a group 3 power wheelchair with single power option, there must be medical 
need for a special drive control (including, but not limited to, head control, sip and puff, switch control) or for 
single power option: power tilt or power recline. This information is found in Local Coverage Determination 
(LCD): 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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that family history codes are for use when a patient has a family member(s) who has had a 
particular disease that causes the patient to be at higher risk of also contracting the disease. The reason for the 
encounter (for example, screening or counseling) should be sequenced first and the appropriate personal and/or 
family history code(s) should be assigned as additional diagnos(es). You can find this rule in the 2022 
international classification of diseases, tenth edition, clinical modification (ICD-10-CM) Diagnosis Codebook, 
Section I, Chapter 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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that coverage of NMES to treat muscle atrophy is limited to the treatment of disuse atrophy 
where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-
neurological reasons for disuse atrophy. Some examples would be casting or splinting of a limb, contracture 
due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins). 
(See 160.13  of the NCD Manual for an explanation of coverage of medically necessary supplies for the 
effective use of NMES.) You can find this rule in National Coverage Determination (NCD) Neuromuscular 
Electrical Stimulation (NMES) 160.12. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
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 health plan must pay for a medical service or item if regular Medicare would 
pay for it in this case. This rule can be found at 42 CFR Part 422.101. 
 
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 physical exams and other services required by third parties such as obtaining or maintaining 
employment or participation in employee programs, required for insurance or licensing, requested sports 
physicals, or on court order or required for parole or probation are not covered under any condition. You can 
find this information on page 134 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 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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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, 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 in Chapter 3 on pages 29-30 of 
the Plan's 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 power mobility device (PMD) bases require a standard written order (SWO) prior to 
delivery. The SWO may also list all associated options and accessories that are billed separately. You can find 
this rule in Local Coverage Determination (LCD) 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 the phrenic nerve stimulator provides electrical stimulation of the patient's phrenic nerve to 
contract the diaphragm rhythmically and produce breathing in patients who have hypoventilation (a state in 
which an abnormally low amount of air enters the lungs).  The device has been used successfully to treat 
hypoventilation caused by a variety of conditions, including respiratory paralysis resulting from lesions of the 
brain stem and cervical spinal cord and chronic pulmonary disease with ventilatory insufficiency. The phrenic 
nerve stimulator is intended to be an alternative to management of patients with respiratory insufficiency who 
are dependent upon the usual therapy of intermittent or permanent use of a mechanical ventilator as well as 
maintenance of a permanent tracheotomy stoma. 
 
However, an implanted phrenic nerve stimulator can be effective only if the patient has an intact phrenic nerve 
and diaphragm. Moreover, nerve injury may occur during the surgical procedure and if sufficient injury is 
incurred, the device will not prove useful to the patient. Consequently, it is possible for such a device to be 
indicated for a patient but, due to injury sustained during implant, fail to assist the patient, resulting in a return 
to the use of mechanical ventilation. The implantation of a phrenic nerve stimulator is covered for selected 
patients with partial or complete respiratory insufficiency. You can find this rule in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determination 
for Phrenic Nerve Stimulator, 160.19. 
 
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 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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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, 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 28-29 of the Plan's 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 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 in order to be eligible for coverage under Medicare Part B, a drug or biological must be 
administered by a physician or personnel under the physicians supervision. In addition, the charge must be 
included in the physicians bill and the cost of the drug or biological must represent an expense to the 
physician. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.3. 
 
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.
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that the Plan covers non-Medicare covered eyewear. Plan pays up to $100 every year for 
non-Medicare covered prescription eyewear. You are responsible for any amount above the eyewear coverage 
limit. You can find this information on page 138 of the Plan's 2022 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 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 pages 72 to 74 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 there are certain diagnosis codes which support the medical necessity of code 87086. Any 
codes which are not listed are considered not medically necessary for code 87086. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, 
National Coverage Determinations (NCD) Manual: Urine Culture, Bacterial (190.12) Coding Policy Manual 
and Change Report (ICD-10-CM). 
 
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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Medicare approved amount for certain procedures includes payment for the following 
services related to the surgery when furnished by the physician who performs the surgery. The services 
included in the global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, physicians' 
offices. Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon. 
However, critical care services (99291 and 99292) are payable separately in some situations.  
 
 Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day 
before the day of surgery for major procedures and the day of surgery for minor procedures;  
 Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a 
surgical procedure;  
 Complications Following Surgery - All additional medical or surgical services required of the surgeon 
during the postoperative period of the surgery because of complications which do not require additional trips to 
the operating room;  
 Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to 
recovery from the surgery;  
 Postsurgical Pain Management - By the surgeon;  
 Supplies - Except for those identified as exclusions; and   Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative 
pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, 
irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; 
and changes and removal of tracheostomy tubes.  
 
You can find this information in the Medicare Claims Processing Manual, Chapter 12, 40.1. 
 
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.