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 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 male external catheters (condom-type) or female external urinary collection devices are 
covered for beneficiaries who have permanent urinary incontinence when used as an alternative to an 
indwelling catheter. 
 
You can find this information in the Local Coverage Determination (LCD): Urological Supplies (L33803). 
 
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). 
 
Percutaneous thermal intradiscal procedures (TIPs) involve the insertion of a catheter(s)/probe(s) in the spinal 
disc under fluoroscopic guidance for the purpose of producing or applying heat and/or disruption within the 
disc to relieve low back pain. 
 
The scope of this national coverage determination on TIPs includes percutaneous intradiscal techniques that 
employ the use of a radiofrequency energy source or electrothermal energy to apply or create heat and/or 
disruption within the disc for coagulation and/or decompression of disc material to treat symptomatic patients 
with annular disruption of a contained herniated disc, to seal annular tears or fissures, or destroy nociceptors for 
the purpose of relieving pain. This includes techniques that use single or multiple probe(s)/catheter(s), which 
utilize a resistance coil or other delivery system technology, are flexible or rigid, and are placed within the 
nucleus, the nuclear-annular junction, or the annulus. You can find this information in the National Coverage 
Determination 150.11. 
 
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 also state that a power scooter which has not been reviewed by the Pricing, Data Analysis, and 
Coding (PDAC) contractor or which has been reviewed by the PDAC and found not to meet the definition of a 
specific POV/PWC will be denied as not reasonable and necessary and should be coded as K0899. This rule 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 state that repeat epidural steroid injections (ESIs) 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 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 Local Coverage Determination (LCD): Epidural Steroid 
Injections for Pain Management (L33906). 
 
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 the term interface in the code narrative and definitions describes the mechanism for 
controlling the movement of a power wheelchair. Examples of interfaces include, but are not limited to, 
joystick, sip and puff, chin control, head control, etc.  The term controller describes the microprocessor and 
other related electronics that receive and interpret input from the joystick (or other drive control interface) and 
convert that input into power output which controls speed and direction. A high-power wire harness connects 
the controller to the motor and gears. 
An expandable controller is capable of accommodating one or more of the following additional functions: 
 Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin 
control, head control, etc.) 
 Non-proportional input devices (e.g., sip and puff, head array, etc.) 
 Operate 3 or more powered seating actuators through the drive control. 
 A separate display (i.e., for alternate control devices) 
 Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's 
drive control) 
 An attendant control 
 
You can find this rule in the Local Coverage Article for Wheelchair Options/Accessories, 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 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 $340 copayment for in-network Medicare-covered surgery or other 
services provided at an outpatient hospital, including but not limited to hospital or other facility charges and 
physician or surgical charges. You can find this information on page 4-54 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 a custom fabricated mandibular advancement oral appliance (E0486) used to treat obstructive 
sleep apnea (OSA) is covered if criteria A - D are met. 
 
A. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to 
assess the beneficiary for obstructive sleep apnea testing. 
B. The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 -3): 
  1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 
events per hour with a minimum of 30 events: or, 
   2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum 
of 10 events and documentation of: 
       a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or 
       b. Hypertension, ischemic heart disease, or history of stroke; or 
   3. If the AHI> 30 or the RDI> 30 and meets either of the following(a or b): 
     a. The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or, 
     b. The treating practitioner determines that the use of a PAP device is contraindicated. 
C. The device is ordered by the treating practitioner following a review of the report of the sleep test. (The 
practitioner who provides the order for the oral appliance could be different from the one who performed the 
clinical evaluation in criterion A.) 
D. The device is provided and billed for by a licensed dentist (DDS or DMD). 
 
If all of these criteria (A-D) are not met, the custom fabricated oral appliance (E0486) will be denied as not 
reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Oral Appliances for Obstructive 
Sleep Apnea (L33611).
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 Sacroiliac joint injections (SIJI) will be considered medically reasonable and necessary when 
all the following requirements are met: 
1. Moderate to severe low back pain primarily experienced over the anatomical location of the SI joints 
between the upper level of the iliac crests and the gluteal fold, and 
2. Low back pain duration of at least three (3) months, and 
3. Low back pain 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 three positive findings with provocative maneuvers: Faber, Gaenslen, Thigh Thrust or Posterior 
Shear, SI Compression, SI Distraction and Yeoman Tests, and 
6. Low back pain persists despite a minimum of four weeks of conservative therapies. 
You can find this information in your Local Coverage Determination (LCD) L39464: Sacroiliac Joint 
Injections and Procedures. 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1.  
 
The rules also say that codes paid via the Physician Fee Schedule (PFS) have an assigned Professional 
Component (PC)/Technical Component (TC) Indicator. A PC/TC indicator of 3 means that the code is a stand-
alone code that describes the technical component (i.e., staff and equipment costs) of selected diagnostic tests 
for which there is an associated code that describes the professional component of the diagnostic tests only. A 
PC/TC indicator of 5 identifies codes that describe services covered incident to a physicians service when they 
are provided by auxiliary personnel employed by the physician and working under his or her direct supervision. 
Payment may not be made by carriers for these services when they are provided to hospital inpatients or 
patients in a hospital outpatient department. Modifiers 26 and TC cannot be used with these codes. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, Section 50.6. 
 
  
 
 
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.
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 effective January 1, 1998, Medicare also covers self-administered anti-emetics, which are 
necessary for the administration and absorption of the anti-neoplastic chemotherapeutic agents when a high 
likelihood of vomiting exists.  The anti-emetic drug is covered as a necessary means for administration of the 
anti-neoplastic chemotherapeutic agents. Oral drugs prescribed for use with the primary drug, which enhance 
the anti-neoplastic effect of the primary drug or permit the patient to tolerate the primary anti-neoplastic drug in 
higher doses for longer periods, are not covered. Self-administered anti-emetics to reduce the side effects of 
nausea and vomiting brought on by the primary drug are not included beyond the administration necessary to 
achieve drug absorption.   
 
Section 1861(s)(2) of the Social Security Act extends coverage to oral anti-emetic drugs that are used as full 
replacement for intravenous dosage forms of a cancer regimen under the following conditions:   
 
 Coverage is provided only for oral drugs approved by the Food and Drug Administration (FDA) for use as 
anti-emetics;   
 
 The oral anti-emetic must either be administered by the treating physician or in accordance with a written 
order from the physician as part of a cancer chemotherapy regimen;   
 
 Oral anti-emetic drugs administered with a particular chemotherapy treatment must be initiated within 2 hours 
of the administration of the chemotherapeutic agent and may be continued for a period not to exceed 48 hours 
from that time;   
 
 The oral anti-emetic drugs provided must be used as a full therapeutic replacement for the intravenous anti-
emetic drugs that would have otherwise been administered at the time of the chemotherapy treatment.   
 
Only drugs pursuant to a physicians order at the time of the chemotherapy treatment qualify for this benefit. 
The dispensed number of dosage units may not exceed a loading dose administered within two hours of the 
treatment, plus a supply of additional dosage units not to exceed 48 hours of therapy.   
You can find this information in the Medicare Benefit Policy Manual Chapter 15 Section 50.5.4. 
 
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 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 the 
requested complete denture - maxillary (D5110) but replacement of a denture or a partial denture requires the 
existing denture to be 5+ years old. You can find this information on pages 3-4 of the Plan's 2023 Schedule of 
Benefits.
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 in the contract on page 63.
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 Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
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. 
 
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 $250 copayment for outpatient hospital surgery services. You can find 
this information 69 of the Plan's 2023 Evidence of Coverage (EOC).