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 the plan must pay for emergency and urgently needed services. This rule applies whether 
the services are obtained in or out of the plans network. This rule applies whether or not there is prior 
authorization for the services. The rules say that an emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules 
say that urgently needed services are those needed because of an unforeseen illness or condition and it is not 
reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside 
of the service area. You can find this rule at 42 CFR Section 422.113. 
 
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. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. You can find this rule at 42 CFR Section 422.111(a) and (b). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that urgent and emergent medical care is covered by the Plan world-wide. The Plan contract 
says that enrollees must pay a $40 copayment for services provided at an urgent care center. The Plan contract 
also says that enrollees only have to pay their cost-sharing amount when they get services that are covered by 
the Plan. You can find this information on pages 39, 53, 72, 123 and 124 of the Plans 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 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 Group 2 POVs (K0806, K0807, K0808) have added capabilities that are not needed for use 
in the home. Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary. you 
can find this rule in the Local Coverage Determination (LCD) Power Mobility Devices L33789. 
 
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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 24 one-way trips to Plan-approved locations every year. You can find this information on pages 
108-109 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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 48 one-way trips to Plan-approved locations every year. You can find this information on pages 
121-122 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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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. If you are outside the service area and need medical care, you 
can get this care from an out-of-network provider. You will need to obtain authorization from the plan prior to 
seeking care. The Point-of-Service benefit covers the United States and its territories. Providers rendering 
services under this option must be state-licensed or state certified. You can find this information on page 34 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 state that total knee replacement surgery will be considered medically necessary in the following 
circumstances:  
1. Advanced joint disease demonstrated by:  
a. Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance 
imaging (MRI) and/or computed tomography (CT) (in situations when MRI is non-diagnostic or not able to be 
performed) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint 
subluxation, joint space narrowing, avascular necrosis); and 
b. Pain or functional disability from injury due to trauma or arthritis of the joint; and 
c. If appropriate, history of unsuccessful conservative therapy (non-surgical medical management) that is 
clearly addressed in the pre-procedure medical record. (If conservative therapy is not appropriate, the medical 
record must clearly document why such approach is not reasonable). Non-surgical medical management is 
usually but not always implemented prior to scheduling total joint surgery. Non-surgical treatment as clinically 
appropriate for the patients current episode of care typically includes one or more of the following:  
i. Anti-inflammatory medications or analgesics, or 
ii. Flexibility and muscle strengthening exercises, or 
iii. Supervised physical therapy [activities of daily living (ADLs) diminished despite completing plan of care], 
or 
iv. Assistive device use, or 
v. Weight reduction as appropriate, or 
vi. Therapeutic injections into the knee as appropriate.  
d. In some circumstances, for example, if the patient has bone on bone articulation, severe deformity, pain or 
significant disabling interference with activities of daily living, the surgeon may determine that non-surgical 
medical management would be ineffective or counterproductive, and that the best treatment option, after 
explaining the risks, is surgical. If medical management is deemed inappropriate, the medical record should 
indicate the rational for and circumstances under which this is the case.  
2. Failure of previous osteotomy; or 
3. Distal femur fracture; or 
4. Malignancy of the distal femur, proximal tibia, knee joint, or adjacent soft tissues; or 
5. Failure of previous unicompartmental knee replacement; or 6. Avascular necrosis of the knee; or 
7. Proximal tibia fracture 
 
You can find this information in the Local Coverage Determination (LCD): Total Knee Arthroplasty (L36577). 
 
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 says that effective for services performed on or after May 16, 2023, power seat elevation equipment 
is reasonable and necessary for individuals using complex rehabilitative power-driven wheelchairs, when the 
following conditions are met: 

1. The individual has undergone a specialty evaluation that confirms the individual's ability to safely operate 
the seat elevation equipment in the home. This evaluation must be performed by a licensed/certified medical 
professional such as a physical therapist (PT), occupational therapist (OT), or other practitioner, who has 
specific training and experience in rehabilitation wheelchair evaluations; and, 
2. At least one of the following apply: 
a. The individual performs weight bearing transfers to/from the power wheelchair while in the home, 
using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower 
extremities during a sit to stand transfer. Transfers may be accomplished with or without caregiver 
assistance and/or the use of assistive equipment (e.g. sliding board, cane, crutch, walker, etc.); or, 
b. The individual requires a non-weight bearing transfer (e.g. a dependent transfer) to/from the power 
wheelchair while in the home. Transfers may be accomplished with or without a floor or mounted lift; 
or, 
c. The individual performs reaching from the power wheelchair to complete one or more mobility related 
activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in 
customary locations within the home. MRADLs may be accomplished with or without caregiver 
assistance and/or the use of assistive equipment. 
You can find this information in National Coverage Determination (NCD): Seat Elevation Equipment (Power 
Operated) on Power Wheelchairs (280.16). 
 
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 effective for services performed on or after September 26, 2022, cochlear implantation may 
be covered for treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in 
individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined 
by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of 
open-set sentence recognition. Patients must meet all of the following criteria. 
 
   - Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from 
appropriate hearing (or vibrotactile) aids; 
   - Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation; 
   - Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, 
and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system; 
   - No contraindications to surgery; and 
   - The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling. 
 
You can find this rule in the National Coverage Determination (NCD) for Cochlear Implantation (50.3). 
 
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.
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 up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are 
allowed if required for a power wheelchair. You can find this information in Local Coverage Determination 
(LCD): Wheelchair Options/Accessories (L33792). 
 
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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c).  
 
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 there is a $0 copayment for up to one pair of eyeglass lenses (standard plastic single, bifocal, 
trifocal, or lenticular lenses) every two calendar years. The Plan contract also says there is a $0 copay for up to 
1 pair of eyeglass frames or 1 pair of contact lenses (or 2 six packs) every two calendar years for eyeglass 
frames or contact lenses. The Plan contract also says that they pay up to $200 every two calendar years for 
eyeglass frames or contact lenses. You can find this information on page 87 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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 36 one-way trips each year. You can find this information on pages 89-90 of the Plans 2023 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that home health claims must be submitted with type of bill (TOB) 329. You can find this rule at 
Centers for Medicare and Medicaid Services, Internet-Only Publication 100-04, Medicare Claims Processing 
Manual, Chapter 10, Section 10.1.10.4. 
 
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 for facet joint injections, one to two levels, either unilateral or bilateral, are allowed per 
session per spine region. The need for a 3 or 4-level procedure bilaterally may be considered under unique 
circumstances and with sufficient documentation of medical necessity on appeal. A session is a time period, 
which includes all procedures (i.e., MBBs, IA injections, facet cyst ruptures, and RFAs) that are performed 
during the same day. You can find this information in 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.
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 it has not been established that a moist electric heating pad (E0215) or water circulating heat 
pad with pump (E0217) is reasonable and necessary compared to a standard electric heating pad (E0210); 
therefore, if code E0215 or E0217 is provided it will be denied as not reasonable and necessary. You can find 
this rule in the Local Coverage Determination for Heating Pads and Heat Lamps, L33784. 
 
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). 
 
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.