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. This benefit includes the 
endodontic therapy but is limited to one per lifetime. An unlisted dental code is not a covered benefit. You can 
find this information on pages 103-106 of the Plan's 2023 Evidence of Coverage (EOC), and on page 280 of the 
Plan's 2023 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 state that Medicare excludes from coverage items and services furnished to beneficiaries in state or 
local government custody under a penal statute, unless it is determined that the state or local government 
enforces a legal requirement that all prisoners/patients repay the cost of all healthcare items and services 
rendered while in such custody and also pursues collection efforts against such individuals in the same way, 
and with the same vigor, as it pursues other debts. Medicare presumes that a state or local government that has 
custody of a Medicare beneficiary under a penal statute has a financial obligation to pay for the cost of 
healthcare items and services. Therefore, Medicares policy is to deny payment for items and services furnished 
to beneficiaries in state or local government custody. However, providers and supplies that render services or 
items to a prisoner or patient in a jurisdiction that meets the conditions of coverage should indicate this fact 
with the use of modifier -QJ for claims processed within a Part A, Part B, or Durable Medical Equipment 
(DME) jurisdiction. You can find these rules in Medicare Claims Processing Manual Chapter 1, Section 10.4. 
 
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 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 on pages 18-19 of the Plans 2023 Schedule of Cost Sharing.
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 Negative Pressure Wound Therapy (NPWT) pump and supplies are covered when criteria 
is met: 
A. Ulcers and Wounds in the Home Setting: 
The beneficiary has a chronic Stage 3 or 4 pressure ulcer (see Appendices Section), neuropathic (for 
example, diabetic) ulcer, venous or arterial insufficiency ulcer, or a chronic (being present for at least 
30 days) ulcer of mixed etiology. A complete wound therapy program as applicable depending on the 
type of wound, must have been tried or considered and ruled out prior to application of NPWT. 
 
You can find this rule in the Local Coverage Determination for Negative Pressure Wound Therapy Pumps, 
L33821.  
 
The rules say that the use of hyperbaric oxygen therapy (HBO) therapy is covered as adjunctive therapy only 
after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy 
and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds 
includes: assessment of a patients vascular status and correction of any vascular problems in the affected limb 
if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to 
remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist 
dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present. 
Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 
consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. 
Continued treatment with HBO therapy is not covered if measurable signs of healing have not been 
demonstrated within any 30-day period of treatment. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determination for 
Hyperbaric Oxygen Therapy, 20.29.  
 
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 specific 
dental procedures included in a dental benefits chart. Bone replacement graft, bone replacement graft each 
additional site in quadrant, biologic materials to aid in soft and osseous tissue regeneration, autogenous 
connective tissue graft procedure and autogenous connective tissue graft procedure each additional contiguous 
tooth, implant or edentulous tooth position in same graft site are not listed as covered dental benefits. You can 
find this information on pages 82-83 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 Plan 
contract includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. Oroantral fistula closure (D7260) and bone replacement graft for ridge 
preservation (D7953) are not included on this list and are not covered supplemental benefits. You can find this 
information on pages 103 to 109 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 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 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.  
 
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. 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 rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that a determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiarys 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 beneficiarys past history (including prior prosthetic use if applicable); and 
 
    2. The beneficiarys current condition including the status of the residual limb and the nature of other 
medical problems; and 
 
    3. The beneficiarys desire to ambulate. 
 
The rules say that a Level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical 
of the community ambulator who has the ability to traverse most environmental barriers and may have 
vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.  
The rules say that a flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 
or above. 
 
The rules say that a fluid, pneumatic, or electronic/microprocessor knee (L5828, L5848, L5856) is covered for 
beneficiaries whose functional level is 3 or above. 
 
You can find this information in the Local Coverage Determination (LCD) for 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 state that enteral nutrition is covered for a beneficiary who requires feedings via an enteral access 
device to provide sufficient nutrients to maintain weight and strength commensurate with the beneficiary's 
overall health status and has a permanent: 
    -full or partial non-function or disease of the structures that normally permit food to reach the small bowel; 
OR, 
    -disease that impairs digestion and/or absorption of an oral diet, directly or indirectly, by the small bowel. 
 
Enteral nutrition for temporary impairments will be denied as non-covered, no benefit. 
 
Enteral nutrition for beneficiaries with a functioning gastrointestinal tract whose need for enteral nutrition is 
not due to reasons related to the non-function or disease of the structures that normally permit food to reach the 
small bowel will be denied as non-covered, no benefit. 
 
You can find this information in Local Coverage Determation (LCD): Enteral Nutrition (L38955) and related 
Policy Article: Enteral Nutrition (A58833). 
 
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 indications for surgical treatment: For example venous ligation, vein stripping and/or 
sclerotherapy. 
 
1. A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive 
therapy, and avoidance of prolonged immobility where appropriate, has failed, AND 
 
2. The patient is symptomatic and has one, or more, of the following: 
a. Pain or burning in the extremity severe enough to impair mobility 
b. Recurrent episodes of superficial phlebitis 
c. Non-healing skin ulceration 
d. Bleeding from a varicosity 
e. Stasis dermatitis 
f. Refractory dependent edema 
 
B. Indications for ERFA or laser ablation 
 
In addition to the above (see A), the patient's anatomy and clinical condition are amenable to the proposed 
treatment including ALL of the following: 
 
1. Absence of aneurysm in the target segment. 
2. Maximum vein diameter of 12 mm for ERFA or 20 mm for laser ablation 
3. Absence of thrombosis or vein tortuosity, which would impair catheter advancement. 4. The absence of 
significant peripheral arterial diseases. 
 
You can find this information in the Local Coverage Determination (LCD) Treatment of Varicose Veins of the 
Lower Extremities L34010. 
 
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 A57674 provides a list of appropriate dual diagnosis "Z" codes. You can find this rule in the 
Local Coverage Article (LCA) for Billing and Coding: Emergency and Non-Emergency Ground Ambulance 
Services (A57674). 
 
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 all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patients medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patients 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
The rules say that a Standard Written Order (SWO) must be communicated to the supplier before a claim is 
submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, 
the claim shall be denied as not reasonable and necessary. 
A patient lift is covered if transfer between bed and a chair, wheelchair, or commode is required and, without 
the use of a lift, the beneficiary would be bed confined. 
A patient lift described by codes E0630, E0635, E0639, or E0640 is covered if the basic coverage criteria are 
met. If the coverage criteria are not met, the lift will be denied as not reasonable and necessary. You can find 
these rules in the Local Coverage Determination (LCD) Patient Lifts L33799. 
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 Column II code (including K0043 and K0052) is included in the allowance for the 
corresponding Column I code (K0856, group 3 standard power wheelchair) when provided at the same time. 
You can find this information in the Local Coverage Article for Wheelchair Options/Accessories - Policy 
Article (A52504). 
 
The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). You can find these rules in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D). 
 
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 once every 60 months. You can find this information on pages 101-
103 of the Plan's 2023 Evidence of Coverage (EOC).