Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that 
are required for the operation of an expandable controller. It also includes all the necessary fasteners, 
connectors, and mounting hardware. Code E2313 is separately billable in addition to an expandable controller 
both at initial issue and with complete replacement of the expandable controller. Code K0108 must not be used 
for any component or feature of an expandable controller at the time of initial issue. The reimbursement for any 
type of complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. 
However, if individual components of the harness are replaced, code K0108 should be used. 
  
A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are 
not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or 
E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will 
be denied as non-covered. 
  
You can find this information in the Local Coverage Article (LCA) 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 that a determination of the type of foot 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 SACH foot. Other prosthetic feet are considered for coverage based upon functional classification. 
 
An external keel SACH foot (L5970) or single axis ankle/foot (L5974) is covered for beneficiaries whose 
functional level is 1 or above. A flexible-keel foot (L5972) or multiaxial ankle/foot (L5978) is covered for 
beneficiaries whose functional level is 2 or above. 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. The microprocessor foot or ankle system addition with 
power assist which includes any type motor (L5969) is not covered because there is insufficient information to 
demonstrate that the item meets the Medicare standard to be considered reasonable and necessary as per PIM 
Chapter 13. Claims for L5969 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 foot. This information must be retained in the treating practitioner's or 
prosthetist's files. A user-adjustable heel height feature (L5990) will be denied as not reasonable and necessary. 
An axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or 
above. A pneumatic or hydraulic polycentric hip joint (L5961) is covered for beneficiaries whose functional 
level is 3 or above. You can find this information in Medicare's 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.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that procedures and examinations which are not covered under the portable x-ray provision 
include procedures involving the use of contrast media. 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 80.4.4. 
 
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 when submitting a prosthetic claim, the billed code for knee, foot, ankle and hip (HCPCS 
codes L5610, L5611, L5613, L5614, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, 
L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, 
L5840, L5848, L5856, L5857, L5858, L5859, L5930, L5961, L5970, L5971, L5972, L5973, L5974, L5975, 
L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987) components must be submitted 
with modifiers K0 - K4, indicating the expected beneficiary functional level. This expectation of functional 
ability information must be clearly documented and retained in the prosthetist's records. The simple entry of a 
K modifier in those records is not sufficient. There must be information about the beneficiarys history and 
current condition which supports the designation of the functional level by the prosthetist. 
 
Addition codes for lower extremity prostheses, L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979, 
L5980, L5981, L5987 are considered an upgrade to the SACH foot. The beneficiary may qualify for an 
upgraded prosthetic foot based on their assigned K-level modifier (K0-K4) as referenced in the LCD. A single 
addition code (L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5987) can fully 
describe a complete foot and thus the use of more than one code would be considered incorrect coding 
(unbundling). 
 
L5968, L5982, L5984, L5985, L5986, L5988, L5990 are additional features and/or functions that do not 
describe a complete prosthetic foot and may be used in combination with L5970, L5971, L5972, L5974, 
L5975, L5976, L5978, L5979, L5980, L5981, and L5987. The use of additional feature L-codes may also 
depend on the assigned K-Level modifier (K0-K4) as referenced in the LCD. 
 
L5981 describes a product that can be used for either endoskeletal or exoskeletal lower limb construction. The 
Flex Walk has an energy storing J-shaped keel design. Heel component is attached to the J-shaped keel section. 
The Flex Walk J-shaped keel design proximally terminates at a nonadjustable fixed height determined and 
modified by the prosthetic foot manufacturer. L5981 includes foot cover. 
 
You can find this rule in the Local Coverage Article for Lower Limb Prostheses - Policy Article, A52496. 
 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 power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered. 
 
Codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more 
of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional 
interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, 
power seat elevation, power standing. It includes a function selection switch which allows the beneficiary to 
select the motor that is being controlled and an indicator feature to visually show which function has been 
selected. When the wheelchair drive function has been selected, the indicator feature may also show the 
direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate 
display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for 
fixed mounting hardware for the control box and for the display box (if present). 
 
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. (Note: Control of the power seating 
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) 
 You can find these rules in the Local Coverage Article Wheelchair Options/Accessories - Policy Article 
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 patient's medical records must establish medical necessity for a hospital bed due to one of the following reasons:

1. The patient's condition requires positioning of the body; e.g., to alleviate pain, promote good body alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or

2. The patient's condition requires special attachments that cannot be fixed and used on an ordinary bed. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, National Coverage Determinations Manual, Section 280.7(A).

In order to qualify for a semi-electric hospital bed, the patient's condition must require frequent change in body position and/or there may be an immediate need for a change in body position (i.e., no delay can be tolerated) and the patient can operate the controls and cause the adjustments. Exceptions may be made to this last requirement in cases of spinal cord injury and brain damaged patients. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.7(D).

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 for purposes of rental and purchase of DME a beneficiary's home may be his/her own dwelling, 
an apartment, a relative's home, a home for the aged, or some other type of institution (such as an assisted 
living facility, or an intermediate care facility for individuals with intellectual disabilities (ICF/IID)). However, 
an institution may not be considered a beneficiary's home if it: 
- Meets at least the basic requirement (see Section 1861(e)(1) of the Social Security Act (the Act)) in the 
definition of a hospital, i.e., it is primarily engaged in providing by or under the supervision of physicians, to 
inpatients, diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, 
and sick persons, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons; or 
- Meets at least the basic requirement (see Section 1819(a)(1) of the Act) in the definition of a skilled nursing 
facility, i.e., it is primarily engaged in providing to inpatients skilled nursing care and related services for 
patients who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, 
disabled, or sick persons. 
Thus, if an individual is a patient in an institution or distinct part of an institution which provides the services 
described in the bullets above, the individual is not entitled to have separate Part B payment made for rental or 
purchase of DME. This is because such an institution may not be considered the individual's home (see Section 
1861(s)(6) and 1861(n) of the Act, the implementing regulations at 42 CFR 410.38(b), and Section 2160B in 
the State Operations Manual (SOM, Pub. 100-07), Chapter 2). You can find this information in the Medicare 
Benefit Policy Manual, Chapter 15, Section 110.1, letter D. 
 
The rules say DME is covered under Part B as a medical or other health service (1861(s)(6) of the Social 
Security Act [the Act]) and is equipment that: 
a. Can withstand repeated use; 
b. Is primarily and customarily used to serve a medical purpose; 
c. Generally, is not useful to a person in the absence of an illness or injury; and 
d. Is appropriate for use in the home. 
All requirements of the definition must be met before an item can be considered to be durable medical 
equipment. You can find this information in the Medicare Claims Processing Manual, Chapter 20, Section 
10.1.1. 

 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 state that the Medicare approved amount for global surgery procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery.

- Preoperative Visits 
- Intra-operative Services 
- Complications Following Surgery
- Postoperative Visits 
- Postsurgical Pain Management 
- Supplies - Miscellaneous Services

You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 12, Section 40.1.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 following is a list of suppliers who frequently attempt to enroll in Medicare but are not eligible to do so. (This list is not all-inclusive, however.). If the contractor receives an enrollment application from any of these individuals or entities, the contractor shall deny the application with the exception of entities eligible to enroll using the Form CMS-20134, which is specific to the furnishing of Medicare Diabetes Prevention Program (MDPP) service: Licensed Professional Counselor. You can find this rule in the Medicare Program Integrity Manual, Chapter 10, Section 10.2.8 - Providers/Suppliers Not Eligible to Enroll.
 
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 only 
those items and services specifically listed in your Plan contract. Placement of intra-socket biological dressing 
to aid in hemostasis or clot stabilization per site (D7922) is not covered under the Plans dental benefits. You 
can find this information on page 83 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 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 services but is limited to up to two (2) implants covered per year, or up to (4) implants covered per 
year for edentulous patients, covered one (1) per tooth per life. Surgical placement of implant body, endosteal 
implant and second stage implant surgery are covered one (1) per tooth per life. Abutment supported porcelain 
(noble metal and/or high noble metal) crown. Abutment supported porcelain/ceramic crown. Implant supported 
porcelain crown (ceramic). You can find this information on page 129-130 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. This benefit includes 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. The guided tissue regeneration and sinus augmentation are not covered by the Plan's dental 
benefits. You can find this information on pages 125 to 135 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 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 
dental implants. You can find this information in Chapter 4 on page 108 of the Plans 2023 Evidence of 
Coverage (EOC).