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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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 only covered chiropractic service is manual manipulation of the spine to correct 
subluxation. You can find this information on page 4-13 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 oxygen is coverable when medically necessary for patients with acute or chronic conditions, 
short- or long- term, when the patient exhibits hypoxemia. Patients exhibiting hypoxemia are defined using the 
clinical criteria below.  
 
1. Arterial PO2 (partial pressure of oxygen) at or below 55 mm Hg or arterial O2 (oxygen) saturation at or 
below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for patients who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
In reviewing the arterial PO2 levels and the arterial oxygen saturation percentages specified above, variations 
in oxygen measurements that may result from such factors as the patient's age, the patients skin pigmentation, 
the altitude level, or the patient's decreased oxygen carrying capacity, must be taken into account.  
 
For patients who do not exhibit hypoxemia according to the above criteria, oxygen may be coverable when 
medically reasonable and necessary for patients who do not have a non-covered indication.  
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Sections 240.2. 
 
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 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 10 to 11 of the Plan's 
2021 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. 
 
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 says that covered eyeglasses after cataract surgery includes standard frames and lenses as defined by 
Medicare; any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive 
lenses or anti-reflective coating).
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 Nationally Covered Indications 
 
1. Effective for services performed on or after April 4, 2005, cochlear implantation may be covered for 
treatment of bilateral pre- or-post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals 
who demonstrate limited benefit from amplification. Limited benefit from amplification is defined by test 
scores of less than or equal to 40% correct in the best-aided listening condition on tape-recorded tests of open-
set sentence cognition. Medicare coverage is provided only for those patients who meet all of the following 
selection guidelines. 
 
    Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from 
appropriate hearing (or vibrotactile) aids; 
    Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation; 
    Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, 
and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system; 
    No contraindications to surgery; and 
    The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling. 
 
2. Effective for services performed on or after April 4, 2005, cochlear implantation may be covered for 
individuals meeting the selection guidelines above and with hearing test scores of greater than 40% and less 
than or equal to 60% only when the provider is participating in, and patients are enrolled in, either an FDA-
approved category B investigational device exemption clinical trial as defined at 42 CFR 405.201, a trial under 
the Centers for Medicare & Medicaid (CMS) Clinical Trial Policy as defined at section 310.1 of the National 
Coverage Determinations Manual, or a prospective, controlled comparative trial approved by CMS as 
consistent with the evidentiary requirements for National Coverage Analyses and meeting specific quality 
standards. 
 
C. Nationally Non-Covered Indications 
 
Medicare beneficiaries not meeting all of the coverage criteria for cochlear implantation listed are deemed not 
eligible for Medicare coverage under section 1862(a)(1)(A) of the Social Security Act. 
 
D. Other 
 
All other indications for cochlear implantation not otherwise indicated as nationally covered or non-covered above remain at local Medicare Administrator Contractor discretion. 
 
You can find this information in Medicare's National Coverage Determination (NCD): Cochlear Implantation 
(50.3). 
 
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 effective for dates of service on or after October 9, 2014, The CologuardTM test is covered 
once every three years for Medicare beneficiaries that meet all of the following criteria: 
 
    - Age 50 to 85 years, and, 
    - Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower  
      gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test (gFOBT) or fecal  
      immunochemical test (iFOBT)), and, 
    - At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal  
      cancer, or inflammatory bowel disease, including Crohn's Disease and ulcerative colitis; no family history  
      of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis  
      colorectal cancer). 
 
You can find this information in the National Coverage Determination (NCD): Colorectal Cancer Screening 
Tests (210.3).  
 
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. 
 
The rules say the implantation of spinal cord stimulators (SCS) may be covered as therapies for the relief of 
chronic intractable pain. SCS is best suited for neuropathic pain but may have some limited value in other types 
of nociceptive severe, intractable pain. Therapy consists of a short trial with a percutaneous implantation of 
neurostimulator electrode(s) in the epidural space for assessing a patients suitability for ongoing treatment 
with a permanent surgically implanted nerve stimulator. Performance and documentation of an effective trial is 
a prerequisite for permanent nerve stimulation. In situations where the spinal cord stimulator has been working 
well but is in need of replacement for battery change, malfunction or end of stimulator life, a new trial is not 
needed to replace the stimulator. 
 
Selection of patients for implantation of spinal cord stimulators is critical to success of this therapy. SCS 
therapy should be considered as a late option after more conservative attempts such as medications, physical 
therapy, psychological therapy or other modalities have been tried. 
 
Patients must have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation). Documentation of 
the history and careful screening must be available in the patient chart if requested. Patients being selected for a 
trial 
 
    Must not have active substance abuse issues. 
    Must undergo proper patient education, discussion, and disclosure including an extensive discussion of the 
risks and benefits of this therapy. 
    Must undergo appropriate psychological screening 
 
 
Many experts recommend that the temporary neurostimulator be placed in an ASC or outpatient hospital 
setting. However, the temporary neurostimulator trial can be done in an office setting if all the sterility, 
equipment, professional training and support personnel required for the proper surgery, and follow up of the 
patient are available. Permanent neurostimulators must be placed in an ASC or hospital. Physicians performing 
SCS trials in the office setting must have like privileges at a local hospital or ASC, or the providers must be 
sub-specialty boarded in Pain Medicine by the American Board of Anesthesiology. You can find this 
information in Medicare's Local Coverage Determination (LCD): Spinal Cord Stimulators for Chronic Pain 
(L35136). 
 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 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). 
 
Certain conditions have both an underlying etiology and multiple body system manifestations due to the 
underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying 
condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, 
there is a use additional code note at the etiology code, and a code first note at the manifestation code. 
These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. 
 
In most cases the manifestation codes will have in the code title, in diseases classified elsewhere. Codes with 
this title are a component of the etiology/ manifestation convention. The code title indicates that it is a 
manifestation code. In diseases classified elsewhere codes are never permitted to be used as first listed or 
principal diagnosis codes. They must be used in conjunction with an underlying condition code, and they must 
be listed following the underlying condition. See category F02, Dementia in other diseases classified 
elsewhere, for an example of this convention. You can find this information in the ICD-10-CM Official 
Guidelines for Coding and Reporting FY 2022. 
 
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 says that you must pay a $35 copay for Level 1 physician services to diagnose and treat diseases and 
conditions of the eye. You can find this information on page 103 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 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 $100 per day for Medicare-covered diagnostic radiology services such as 
ultrasounds, nuclear cardiac imaging, PET, MRI, and CT scans. You can find this information on page 95 of 
the Plan's 2021 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 ultrasound diagnostic procedures utilizing low energy sound waves are being widely 
employed to determine the composition and contours of nearly all body tissues except bone and air-filled 
spaces. This technique permits noninvasive visualization of even the deepest structures in the body. The use of 
the ultrasound technique is sufficiently developed that it can be considered essential to good patient care in 
diagnosing a wide variety of conditions. You can find this rule in the National Coverage Determination (NCD) 
 Ultrasound Diagnostic Procedures (220.5)  Effective May 22, 2007. 
 
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 you are allowed a one-time (once per lifetime) abdominal aortic aneurysm screening 
ultrasound for people at risk. You can find this information on page 4-8 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 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. 
 
Noridian, a Medicare Administrative Contractor (MAC), provides a list of valid occurrence codes and the 
information they are intended to represent. You can find this information on the Noridian website at 
https://med.noridianmedicare.com/web/jea/topics/claim-submission/occurrence-codes. 
 
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 the noninvasive stimulator device is covered only for the following indications: 
 
    - Nonunion of long bone fractures; 
    - Failed fusion, where a minimum of 9 months has elapsed since the last surgery; 
    - Congenital pseudarthroses; 
    - Effective July 1, 1996, as an adjunct to spinal fusion surgery for patients at high risk of pseudarthrosis due 
      to previously failed spinal fusion at the same site or for those undergoing multiple level fusion. A multiple  
      level fusion involves 3 or more vertebrae (e.g., L3-L5, L4-S1, etc). 
    - Effective September 15, 1980, nonunion of long bone fractures is considered to exist only after 6 or more 
       months have elapsed without healing of the fracture. 
    - Effective April 1, 2000, nonunion of long bone fractures is considered to exist only when serial radiographs 
      have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
      electrical osteogenic stimulator. Serial radiographs must include a minimum of 2 sets of radiographs, each 
      including multiple views of the fracture site, separated by a minimum of 90 days. 
 
You can find this information in the National Coverage Determination (NCD): Osteogenic Stimulators (150.2). 
 
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 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 $120 copayment an emergency room visit. You can find this 
information in Chapter 4, on page 73, of the Plan's 2022 Evidence of Coverage (EOC).