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 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 $298 copayment per day, days 1 to 5, for inpatient hospital care. 
Additionally, the Plan contract says that the day before enrollees are discharged is their last inpatient day. You 
can find this information on page 56 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 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. You can find this information 
on pages 96-102 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 a determination of the type of knee for the prosthesis will be made by the treating
practitioner and/or the prosthetist based upon the functional needs of the beneficiary. Basic lower extremity
prostheses include a single axis, constant friction knee. Other prosthetic knees are considered for coverage
based upon functional classification. A microprocessor-controlled ankle foot system (L5973), energy storing
foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk
system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries
whose functional level is 3 or above. A fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613,
L5614, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848,
L5856, L5857, L5858) is covered for beneficiaries whose functional level is 3 or above and meets all of the
criteria below: 1. Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee 2.
K3 functional level only 3. Has a documented comorbidity of the spine and/or sound limb affecting hip
extension and/or quadriceps function that impairs K-3 level function with the use of a microprocessorcontrolled
knee alone 4. Is able to make use of a product that requires daily charging 5. Is able to understand
and respond to error alerts and alarms indicating problems with the function of the unit If these coverage
criteria for the knee component are not met, L5859 will be denied as not reasonable and necessary. Coverage is
extended only if there is sufficient clinical documentation of functional need for the technologic or design
feature of a given type of knee. This information must be retained in the treating practitioner's or prosthetist's
files. You can find these rules in Local Coverage Determination (LCD) Lower Limb Prostheses L33787.
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).

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).

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 1 pair of eyeglasses per plan year and that you pay any amount over $400. You can find
this information on page 87 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 state that to be eligible for coverage of a continuous glucose monitor (CGM) and related supplies, the 
beneficiary must meet all of the following initial coverage criteria (1)-(5): 
  
   
1. The beneficiary has diabetes mellitus; and, 
2. The beneficiarys treating practitioner has concluded that the beneficiary (or beneficiarys caregiver) has  
    sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
3. The CGM is prescribed in accordance with its Food and Drug Administration (FDA) indications for use;  
    and, 
4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the  
    criteria below: 
     A. The beneficiary is insulin-treated; or, 
     B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the    
          following: 
          -     Recurrent level 2 hypoglycemic events that persist despite multiple attempts to adjust  
                medication(s) and/or modify the diabetes treatment plan; or, 
         -     A history of one level 3 hypoglycemic event characterized by altered mental and/or physical state    
               requiring third-party assistance for treatment of hypoglycemia 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare- 
     approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria  
     (1)-(4) above are met.  
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
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 diagnostic and/or surveillance (performed for signs/symptoms of disease) colon capsule 
colonoscopy (CCE) is medically necessary for the detection of colon polyps when EITHER of the following 
criteria are met:  
1. Secondary procedure after an incomplete diagnostic optical colonoscopy (OC) with adequate 
preparation, and a complete evaluation of the colon was not technically possible (1,2) when EITHER of 
the following criteria are met: 
a. Detection or surveillance of colon polyp(s) OR 
b. Diagnostic procedure when ANY of the following criteria are met (3): 
i. Fecal Occult Blood Test (FOBT) positive (guaiac or immunochemical) OR 
ii. Multitarget Stool Deoxyribonucleic acid (DNA) (sDNA) Test positive OR 
iii. Other evidence of lower GI bleed in hemodynamically stable patients 
2. Primary procedure in patients with major risks for OC or moderate sedation as indicated from an 
evaluation of the patient by a board certified or board eligible gastroenterologist, a surgeon trained in 
endoscopy, or a physician with equivalent endoscopic training when EITHER of the following criteria 
are met: 
a. Surveillance of colon polyp(s) in previously diagnosed patients OR 
b. Diagnostic procedure when ANY of the following criteria are met (3): 
i. Fecal Occult Blood Test (FOBT) positive (guaiac or immunochemical) OR 
ii. Multitarget Stool DNA (sDNA) Test positive OR 
iii. Other evidence of lower GI bleed in hemodynamically stable patients 
You can find this information in the Local Coverage Determination (LCD) for Colon Capsule Endoscopy 
(CCE) (L38571). 
 
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 high frequency chest wall oscillation devices (HFCWODs) are covered when they are 
medically necessary for enrollees who have: 
- cystic fibrosis; or 
- bronchiectasis that has been confirmed by CT scan; or  
- one of these neuromuscular diseases: post-polio, acid maltase deficiency, anterior horn cell diseases, 
multiple sclerosis, quadriplegia, hereditary muscular dystrophy, myotonic disorders, other myopathies, or 
paralysis of the diaphragm.  
 
Medical records must show failure of standard treatments to clear secretions. The rules also say that chronic 
bronchitis and chronic obstructive pulmonary disease (COPD) do not meet criteria for coverage when there is 
no diagnosis of bronchiectasis. You can find these rules in the Medicare Local Coverage Determination (LCD) 
L33785, High Frequency Chest Wall Oscillation Devices. 
 
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that Medicare payment may be made for routine foot care when the patient has a systemic 
disease, such as metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance of 
such services by a nonprofessional person would put the patient at risk (for example, a systemic condition that 
has resulted in severe circulatory embarrassment or areas of desensitization in the patients legs or feet).  
 
One of the modifiers listed below must be reported with codes 11055, 11056, 11057, 11719, G0127, and with 
codes 11720 and 11721 when the coverage is based on the presence of a qualifying systemic condition 
EXCEPT where the patient has evidence of neuropathy, but no vascular impairment, for which class findings 
modifiers are not required: 
Modifier Q7: One (1) Class A finding  
Modifier Q8: Two (2) Class B findings  
Modifier Q9: One (1) Class B finding and two (2) Class C findings. 
 
You can find this rule in the Local Coverage Determination and Article for Routine Foot Care and 
Debridement of Nails, L33636 and A57759.  
 
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 polysomnography (PSG) with positive airway pressure (PAP) titration is indicated in 
patients with sleep apnea previously diagnosed by a clinical evaluation and either a positive PSG or a positive 
home sleep test (HST). You can find this information in the Local Coverage Determination (LCD) for 
Polysomnography and Sleep Testing (L33405). 
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 lower limb prosthesis is covered when the beneficiary:
1. Will reach or maintain a defined functional state within a reasonable period of time; and
2. Is motivated to ambulate.
A determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiary's potential functional abilities. Potential functional ability is based on 
the reasonable expectations of the prosthetist, and treating practitioner, considering factors 
including, but not limited to:
1. The beneficiary's past history (including prior prosthetic use if applicable); and
2. The beneficiary's current condition including the status of the residual limb and the nature of 
other medical problems; and
3. The beneficiary's desire to ambulate.
A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic 
response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal 
(L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries 
whose functional level is 3 or above. An axial rotation unit (L5982, L5984, L5985, L5986) is 
covered for beneficiaries whose functional level is 2 or above.
You can find this information in the Local Coverage Determination (LCD): Lower Limb Prostheses 
(L33787).

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. You can find this information on pages 39 and 44 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 a Positron Emission Tomography (PET) scan is non-covered for a diagnosis of melanoma when
ordered for the initial staging of the regional lymph nodes. You can find this rule in the Centers for Medicare
and Medicaid Services, Internet Only Manual, Publication 100-03, National Coverage Determinations Manual,
Section 220.6.17.

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 the 
requested item or service but is limited to two D0140 every Plan year. You can find this information on page 
178 of the Plan's 2023 Medicare Quick Reference Guide.
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. 
 
The rules say that 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 Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.5.4 - Oral Anti-Nausea (Anti-
Emetic) Drugs. 
 
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.