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

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $0 copayment per day for days 1-20 and a $100 copayment per day for 
days 21-100 for skilled nursing facility (SNF). You can find this information on pages 105-106 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 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 on pages 35-40 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. 
 
Certain cardiac event monitors capture electrical activity with a single electrode attached to the skin. Other 
devices may employ multiple electrodes in order to record more complex EKG tracings. Additionally, devices 
may be individually programmed to detect patient-specific factors, electrode malfunction, or other factors. 
Cardiac event monitors can be further categorized as either pre-event or post-event recorders, based on 
their memory capabilities: 
a. Pre-symptom Memory Loop Recorder (MLR) 
Upon detecting symptoms, the wearer presses a button, which activates the recorder to save (i.e., memorize) an 
interval of pre-symptom EKG data along with data during and subsequent to the symptomatic event. Self-
sensing recorders (also known as event-activated or automatic trigger) do not require patient input to capture 
these data. Single or multiple events may be recorded. The device is worn at all times, usually for up to 30 
days. 
o Implantable (or Insertable Loop) Recorder (ILR) 
Another type of pre-symptom MLR, it is implanted subcutaneously in a patients upper left chest and may 
remain implanted for many months. An ILR is used when syncope is thought to be cardiac-related but is too 
infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom MLR. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual Section 20.15. 
 
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.
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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
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 states that prostate cancer screening exams are covered for men aged 50 and older once every 12 
months. Additional cost share may apply when other services are performed. You can find this information on 
page 119 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 includes 
coverage for the requested items or services, but only when they are received from an in-network provider. You 
can find this information on pages 85-88 and 93 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 heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one 
of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not 
exceed 600 pounds. 
 
For any of the above hospital beds (plus those coded E1399 - see Policy Article Coding Guidelines), if 
documentation does not justify the medical need of the type of bed billed, payment will be denied as not 
reasonable and necessary. 
 
If the beneficiary does not meet any of the coverage criteria for any type of hospital bed it will be denied as not 
reasonable and necessary. You can find these rules in the Local Coverage Determination (LCD) Hospital Beds 
and Accessories L33820. 
 
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 manual wheelchair for use inside the home (K0003) is covered if: 
 
    Criteria A, B, C, D, and E are met; and 
    Criterion F or G is met. 
 
    The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. A mobility limitation is one that: 
 
      1.  Prevents the beneficiary from accomplishing an MRADL entirely, or 
      2.  Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to 
the attempts to perform an MRADL; or 
      3.  Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
 
    The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted 
cane or walker. 
    The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for use 
of the manual wheelchair that is provided. 
    Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in MRADLs 
and the beneficiary will use it on a regular basis in the home. 
    The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the 
home. 
    The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to 
safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of 
strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both 
upper extremities are relevant to the assessment of upper extremity function. 
    The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair. 
 
A lightweight wheelchair (K0003) is covered when a beneficiary meets both criteria (1) and (2): 
 
    Cannot self-propel in a standard wheelchair in the home; and 
    The beneficiary can and does self-propel in a lightweight wheelchair. 
 You can find this information in Medicare's Local Coverage Determination (LCD): Manual Wheelchair Bases 
(L33788). 
 
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 changes in myocardial thickness (hypertrophy and thinning) in derived parameters of 
contractility, and in chamber volume and morphology, can be quantitated and charted over time by TTE. 
Cardiac responses to volume perturbations, chronic pressure excess and therapeutic interventions can be 
monitored. Recognition of the relative contributions of myocardial and valvular functional perturbations to a 
clinical presentation is facilitated. TTE aids in the recognition of myopathies and their classification into 
hypertrophic, dilated and restrictive types. Without clinically documented, discrete (abrupt change in signs and 
symptoms) episodes of deterioration, it is not generally medically necessary to repeat TTE assessments more 
frequently than annually, unless done to evaluate the response to therapeutic intervention. You can find this 
information in Local Coverage Determination (LCD): Echocardiography (L37379). 
 
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 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. You can find this information in the Local Coverage Determination (LCD): 
Lower Limb Prostheses (L33787). 
 
The rules also state that  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. 
 
Protective outer surface covering systems (L5962, L5964, and L5966) are specialized covers intended to be 
worn over an existing prosthesis. They are used by a beneficiary who has special needs for protection against 
unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the 
level of protection  hat is afforded by L5704, L5705, L5706, and L5707. They are not for cosmetic or 
convenience reasons, or for everyday usage in a typical environment. Protective outer surface coverings are 
different from the covering that is already reimbursed as part of L5704, L5705, L5706, and L5707. You can 
find this information in the Local Coverage Article: 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 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 a Medicare plan may restrict enrollees 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 an enrollees medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community based 
services. You can find this rule at 42 CFR Section 422.112. 
 
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 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 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. 
 
The rules say that Initial Hospital Care codes 99221, 99222 and 99223 are used to report the first hospital 
inpatient encounter of a new or established patient by the admitting physician. These codes are used per day 
and require three key components: detailed/comprehensive history, detailed/comprehensive examination and 
medical decision making of straightforward, low, moderate, or high complexity. For initial inpatient encounters 
by physicians other than the admitting physician, initial inpatient consultation codes (99251-99255) or 
subsequent hospital care codes (99231-99233), as appropriate, should be reported. Only one initial hospital care 
service is payable per patient per hospital stay. You can find this information in the American Medical 
Association, Current Procedural Terminology (CPT) Manual. 
 
The rules say that in the inpatient hospital setting all physicians (and qualified nonphysician practitioners where 
permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 - 99223) or nursing 
facility care codes (99304 - 99306). A/B MACs (B) consider only one M.D. or D.O. to be the principal 
physician of record (sometimes referred to as the admitting physician.) The principal physician of record is 
identified in Medicare as the physician who oversees the patients care from other physicians who may be 
furnishing specialty care. Only the principal physician of record shall append modifier -AI (Principal 
Physician of Record) in addition to the E/M code. Follow-up visits in the facility setting shall be billed as 
subsequent hospital care visits and subsequent nursing facility care visits. You can find this information in the Medicare Claims Processing Manual, Chapter 12, 30.6.9, Section G. 
 
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 a Group 1 mattress overlay or mattress (E0181, E0182, E0184, E0185, E0186, E0187, 
E0188, E0189, E0196, E0197, E0198, E0199 and A4640) is covered if one of the following three criteria are 
met: 
 
    The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without 
assistance, or 
    The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body position 
significant enough to alleviate pressure and at least one of conditions A-D below, or 
    The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below. 
 
Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition 
sufficiently to demonstrate the medical necessity for a pressure reducing support surface): 
 
    Impaired nutritional status 
    Fecal or urinary incontinence 
    Altered sensory perception 
    Compromised circulatory status 
 
When the coverage criteria for a Group 1 mattress overlay or mattress are not met, the claim will be denied as 
not reasonable and necessary. 
 
The support surface provided for the beneficiary should be one in which the beneficiary does not "bottom out". 
Bottoming out is the finding that an outstretched hand, placed palm up between the undersurface of the 
mattress overlay or mattress and the beneficiary's bony prominence (coccyx or lateral trochanter), can readily 
palpate the bony prominence. This bottoming out criterion should be tested with the beneficiary in the supine 
position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), 
and in the side-lying position. A support surface which does not meet the characteristics specified in the 
Coding Guidelines section of the Policy Article will be denied as not reasonable and necessary. You can find 
this information in Medicare's Local Coverage Determination (LCD): Pressure Reducing Support Surfaces - 
Group 1 (L33830). 
 
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. 
 
Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of 
chronic pain in patients who meet ALL the following criteria: 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale* 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant 
deformity. 
You can find this rule in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L38765). 
 
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.