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 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. The contract also says that 
enrollees may be billed by the out-of-network provider for any charged amount greater than the payment made 
by the Plan. This benefit also includes cleanings but is limited to 2 procedures per plan year. The Plans 
contract also says that enrollee must pay a 50% coinsurance for extractions. You can find this information on 
pages 4-59 to 4-69 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 fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or 
more of the following criteria (1-4) are met: 
 
    The beneficiary has a medical condition which requires positioning of the body in ways not feasible with an 
ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a 
hospital bed, or 
    The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to 
alleviate pain, or 
    The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration, or 
    The beneficiary requires traction equipment, which can only be attached to a hospital bed. 
 
A semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if the beneficiary meets one 
of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate 
need for a change in body position. 
 
You can find this information in the Local Coverage Determination (LCD) for Hospital Beds and Accessories 
(L33820). 
 
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 pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment, first-aid or precautionary-type equipment 
(such as preset portable oxygen units), and self-help devices such as grab bars. 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. 
 
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 special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The Plan must have written policies for determining enrollee eligibility and 
must document its determination that an enrollee is a chronically ill enrollee. You can find this information in 
42 CFR 422.102. 
 
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 if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. You can find this information on pages 55 to 
57, and on page 104 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 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 page 42 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 say that mattresses are only covered where hospital bed is medically necessary. You can find this rule 
in the National Coverage Determination (NCD): Durable Medical Equipment Reference List (280.1). 
 
The rules say that sales taxes are included in the calculation of the Medicare fee schedule. For this reason, 
Medicare does not make separate payment for sales tax. You can find this rule in the Medicare Claims 
Processing Manual, Chapter 23, Section 80.3.1. 
 
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 items and services furnished outside the United States are excluded from coverage except for 
the following services, and certain services rendered on board a ship: 
- Emergency inpatient hospital services where the emergency occurred: 
~ While the beneficiary was physically present in the United States; or 
~ In Canada while the beneficiary was traveling without reasonable delay and by the most direct 
route between Alaska and another State. 
- Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the 
United States, if the hospital was closer to, or substantially more accessible from, the beneficiary's 
United States residence than the nearest participating United States hospital which was adequately 
equipped to deal with and available to provide treatment of the illness or injury; 
- Physician and ambulance services furnished in connection with a covered foreign hospitalization. 
Program payment may not be made for any other Part B medical and other health services, including 
outpatient services furnished outside the United States; 
- Services rendered on board a ship in a United States port, or within 6 hours of when the ship arrived at, 
or departed from, a United States port, are considered to have been furnished in United States territorial 
waters. Services not furnished in a United States port, or within 6 hours of when the ship arrived at, or 
departed from, a United States port, are considered to have been furnished outside United States 
territorial waters, even if the ship is of United States registry; and 
 
The term "United States" means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the 
Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of services rendered 
on a ship, includes the territorial waters adjoining the land areas of the United States. You can find these rules 
in Medicare Benefit Policy Manual Chapter 16, Section 60. 
 
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 the Plan covers worldwide emergency care and emergency ambulance services. You can find 
this information in Chapter 4 on pages 82 to 83 of the Plans 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 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 does not include 
coverage for dental service codes D4266 or D7953. You can find this information in Chapter 4 on page 108 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 state that claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing 
information. You can find this rule in the Local Coverage Article for Patient Lifts (A52516). 
 
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). 
 
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 worldwide emergency care applies to emergency care outside the United States and its 
territories. Coverage includes services furnished by a provider qualified to furnish emergency services and 
needed to evaluate or stabilize an emergency medical condition, as well as services provided after stabilization 
and provided to maintain the condition. You can find this information on pages 67-68 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 SBRT is not considered medically necessary under the following circumstances for any 
condition: 
 
a. Treatment is unlikely to result in clinical cancer control and/or functional improvement. 
b. The tumor burden cannot be completely targeted with acceptable risk to critical normal structures. 
c. The patient has a poor performance status (Karnofsky Performance Status less than 40 or Eastern 
Cooperative Oncology Group (ECOG) Status of 3 or worse). Note that the higher a Karnofsky 
Performance Status is, the better a patient is doing. However, the lower an Eastern Cooperative 
Oncology Group (ECOG) Performance Status is, the better a patient is doing. 
d. Recurrent (other than pelvic and head and neck tumors) or metastatic disease could be treated by 
conventional methods (record must describe why other radiation therapy measures are not appropriate 
or safe for the particular patient). 
e. Since the goal of SBRT is to maximize the potency of the radiotherapy by completing an entire course 
of treatment within an extremely accelerated time frame, any course of radiation treatment extending 
beyond five fractions is not considered SBRT. SBRT is meant to represent a complete course of 
treatment and not to be used as a boost following a conventionally fractionated course of treatment. 
 
You can find this information in Local Coverage Determination (LCD): Stereotactic Radiation Therapy: 
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (L35076). 
 
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
 
2. The services require the skills or direct supervision of a therapist,  
 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. 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 220.2. 
 
The rules say that Cognitive skill training may be medically necessary for patients with acquired cognitive 
deficits resulting from head trauma, or acute neurologic events including cerebrovascular accidents. Impaired 
functions may include but are not limited to ability to follow simple commands, attention to tasks, problem 
solving skills, memory, ability to follow numerous steps in a process, perform in a logical sequence and ability 
to compute. Conditions without potential for improvement or restoration, such as chronic progressive brain 
conditions, would not be appropriate. Evidence-based reviews indicate that cognitive rehabilitation (and 
specifically memory rehabilitation) is not recommended for patients with severe cognitive dysfunction. 
Cognitive skill training should be aimed towards improving or restoring specific functions which were 
impaired by an identified illness or injury and expected outcomes should be reasonably attainable by the patient as specified by the plan of care. You can find this information in the Local Coverage Determination (LCD): 
Outpatient Physical and Occupational Therapy Services (L33631). 
 
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 provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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 the Plan offers additional benefits  called special supplemental benefits for the chronically 
ill  for certain members at no cost. To qualify for these benefits the member must meet specific criteria, 
including having an active diagnosis for one or more qualifying comorbid and medically complex conditions. 
You can find this information in Chapter 4 on pages 52-56 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 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 Chapter 4 on pages 76 to 78 of the Plan's 2023 Evidence of Coverage.