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 Negative Pressure Wound Therapy (NPWT) pumps are covered when the patient has a 
chronic Stage III or IV pressure ulcer, 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 described by criterion 1 and criteria 2, 3, or 4, as applicable depending on the type of wound, must 
have been tried or considered and ruled out prior to application of NPWT: 
 
1. For all ulcers or wounds, the following components of a wound therapy program must include a minimum of 
all of the following general measures, which should either be addressed, applied, or considered and ruled out 
prior to application of NPWT: Documentation in the beneficiary's medical record of evaluation, care, and 
wound measurements by a licensed medical professional, and a. b. Application of dressings to maintain a moist 
wound environment, and c. Debridement of necrotic tissue if present, and d. Evaluation of and provision for 
adequate nutritional status 
 
2. For Stage III or IV pressure ulcers: 
        a. The beneficiary has been appropriately turned and positioned, and 
        b. The beneficiary has used a group 2 or 3 support surface for pressure ulcers on the posterior trunk or 
pelvis and 
        c. The beneficiarys moisture and incontinence have been appropriately managed  
 3. For neuropathic (for example, diabetic) ulcers: a. The beneficiary has been on a comprehensive diabetic 
management program, and b. Reduction in pressure on a foot ulcer has been accomplished with appropriate 
modalities  
  
4. For Venous insufficiency ulcers: 
   a. Compression bandages and/or garments have been consistently applied, and 
   b. Leg elevation and ambulation have been encouraged 
 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination L33821 
entitled Negative Pressure Wound Therapy Pumps. 
 
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 Percutaneous Transluminal Angioplasty is covered when used under the following 
conditions: for treatment of atherosclerotic obstructive lesions, concurrent with carotid stent placement in Food 
and Drug Administration (FDA)-approved Category B investigational device exemption (IDE) clinical trials, 
concurrent with carotid stent placement in FDA-approved post approval studies and concurrent with carotid 
stent placement in patients at high risk for carotid endarterectomy (CEA). You can find the rules in National 
Coverage Determination (NCD) Percutaneous Transluminal Angioplasty (PTA) 20.7. 
 
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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2.  
 
The rules say that below is a list of individuals and entities that frequently attempt to enroll in Medicare, but are 
not eligible to do so. This list is not an all-inclusive list. If the contractor receives an enrollment application 
from any of these individuals or entities, the contractor shall deny the application: 
 
-Acupuncturist 
-Assisted Living Facility 
-Birthing Center 
-Certified Alcohol and Drug Counselor 
-Certified Social Worker 
-Drug and Alcohol Rehabilitation Counselor 
-Hearing Aid Center/Dealer 
-Intern (Graduate Medical Education) 
-Licensed Alcoholic and Drug Counselor 
-Licensed Massage Therapist 
-Licensed Practical Nurse 
-Licensed Professional Counselor 
-Marriage Family Therapist 
-Master of Social Work 
-Medicare Beneficiaries 
-Mental Health Counselor 
-National Certified Counselor 
-Naturopath 
-Occupational Therapist Assistant 
-Physical Therapist Assistant -Registered Nurse 
-Speech and Hearing Center 
-State Medicaid Agency 
-Substance Abuse Facility 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-08, Medicare Program Integrity Manual, Chapter 1, 10.2.8. 
 
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 Facet Joint Interventions for Pain Management are covered under certain conditions: 
 Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale; AND* 
 Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive 
conservative care management (as tolerated); AND 
 Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint 
synovial cyst); AND 
 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. 
Diagnostic Facet Joint Injection: 
A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in 
patients who meet BOTH of the following criteria: 
 The patient meets the criteria for the first diagnostic procedure; AND 
 After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% 
relief of primary (index) pain (with the duration of relief being consistent with the agent used 
 You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L34892) 
 
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. You can find this information 
on pages 104-112 of the Plans 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 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 in 
general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered 
by Original Medicare. We cover preventive dental services. This benefit can be used for 2 oral exams, 2 adult 
prophylaxis (cleanings), and 2 preventative x-ray services per calendar year. Osseous surgery  one to three 
contiguous teeth or tooth - bounded spaces per quadrant (D4261), occlusal adjustment - limited (D9951), bone 
replacement graft for ridge preservation - per site (D7953), extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), and guided 
tissue regeneration - resorbable barrier, per site (D4266) are not covered by the Plans dental benefit. You can 
find this information on page 83 of the Plans 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 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 dental 
consultations and extractions but only covered when performed by a participating general dentist. You can find 
this information on pages 69 to 71 of the Plans 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 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. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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 dental 
x-rays every 12 to 36 months depending on the type of x-ray. You can find this information on pages 71-72 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 Medicare will cover hyperbaric oxygen therapy for the treatment of diabetic wounds of the 
lower extremities in patients who meet the following three criteria: 
 
1. The patient has Type 1 or Type II diabetes and has a lower extremity wound that is due to diabetes; 
2. the patient has a wound classified as Wagner grade III or higher; and 
3. the patient has failed an adequate course of standard wound therapy. 
 
The use of 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 at Centers for Medicare and Medicaid Services, Internet-Only Manual 100-3, Medicare 
National Coverage Determinations Manual Section 20.29.    (Please note that the full text of the rule is in the 
case file on pages 99-103 
 
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 
consultations but only when performed by a participating general dentist. You can find this information on 
pages 69 to 71 of the Plans 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 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 one denture every five years. You can find this information on pages 
63 to 64 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 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. 
 
You can find this rule in the Local Coverage Article for 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 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 page 116 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 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 services. However, the surgical placement of an endosteal implant (D6010) is an 
excluded benefit. You can find this information on pages 4-60 to 4-73 of the Plans 2022 Evidence of Coverage 
(EOC).