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 417.414. 
 
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 Functional blepharoplasty procedures and surgical procedures of the brow will be considered 
medically reasonable and necessary in the following situations: 
1. When the goal of the surgery is to restore function and normalcy to a structure that has been altered by 
trauma, infection, inflammation, degeneration, neoplasia, or developmental errors or; 
2. When there is interference with visual field, near or far visual impairment, or difficulty reading due to 
any of the following: 
 Dermatochalasis 
 Blepharochalasis 
 Blepharoptosis 
 Brow ptosis causing malposition of the upper eyelid
1
 and demonstrating a MRD1 (Margin reflex 
distance) of 2 mm or less 
 Looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis 
 Pseudoptosis 
 When there is visual impairment secondary to redundant skin weighing down on upper 
lashes
1
 resulting in eye strain, headache and loss of vision. 
 When there is chronic, symptomatic dermatitis
3
 of pretarsal skin
1
 caused by redundant upper lid 
skin which has not been successfully treated by conservative measures such as education 
regarding hygiene, antibiotics, etc.; or 
3. Visual field testing demonstrating a 12-to-15-degree superior field loss or 24% to 30% superior visual 
field impairment; or 
4. When there is the presence of prosthesis difficulties in an anophthalmic socket; or 
5. When there is laxity of the lower eyelid tissues causing lower eyelid ectropion resulting in eye irritation 
and inflammation and excessive tearing; or 
6. When there is inward rotation of the eyelid margin causing entropion where the eyelashes are 
contacting the cornea resulting in discomfort, redness, tearing, and foreign body sensation; or 
7. Lower eyelid edema, tumor or mass causing signs and symptoms of eyelid ectropion 
 
You can find this rule in the Local Coverage Determination for Blepharoplasty, Blepharoptosis Repair and 
Surgical Procedures of the Brow, L35004. 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. 
 
Payment due to an HHA for a period of care will be made based on a claim submitted at the end of the 30-day 
period, or after the patient is discharged, whichever is earlier. HHAs may not submit this claim until after all 
services are provided for the period and the physician has signed the plan of care and any subsequent verbal 
order. 
 
All HH PPS claims must be submitted with Type of Bill (TOB) 0329. The HH PPS claim will include line item 
detail describing all the services provided in the period of care. At a providers option, any durable medical 
equipment, oxygen or prosthetics, and orthotics provided may also be billed on the HH PPS claim, and this 
equipment will be paid in addition to the period of care payment. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
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 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. You can find this information on pages 53 to 62 of the Plan's 
(2021) 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 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. 
 
A multi-positional patient transfer system (E0636, E1035, E1036) is covered if both of the following criteria 1 
and 2 are met: 
 
    The basic coverage criteria for a lift are met; and 
    The beneficiary requires supine positioning for transfers 
 
If either criterion 1 or 2 is not met, codes E0636, E1035, and E1036 will be denied as not reasonable and 
necessary. 
 
If coverage is provided for code E1035 or E1036, payment will be discontinued for any other mobility assistive 
equipment, including but not limited to: canes, crutches, walkers, rollabout chairs, transfer chairs, manual 
wheelchairs, power-operated vehicles, or power wheelchairs. 
 
Code E0621 is covered as an accessory when ordered as a replacement for a covered patient lift. 
 
You can find this information 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.
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 36 one-way trips. You can find this information on pages 4-55 to 4-56 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 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 page 53 of the Plan's Member 
Handbook.
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 $150 copayment for Outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information on page 88 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 only a stationary gaseous oxygen system (E0424) and related contents (E0441) are covered 
for the treatment of cluster headaches for beneficiaries enrolled in a clinical trial approved by CMS which are 
in compliance with the requirements described in the CMS National Coverage Determination Manual (Internet 
Only Manual 100-03) 240.2.2 for dates of service on or after 01/04/2011. This section states, in part: 
 
Only those beneficiaries diagnosed with the condition of cluster headache are eligible for participation in a 
clinical study. CMS adopts the diagnostic criteria used by the International Headache Society to form a 
definitive diagnosis of CH. Therefore, the home use of oxygen to treat CH is covered by Medicare only when 
furnished to Medicare beneficiaries who have had at least five severe to very severe unilateral headache attacks 
lasting 15-180 minutes when untreated. (Intensity of pain: Degree of pain usually expressed in terms of its 
functional consequence and scored on a verbal 5-point scale: 0=no pain; 1=mild pain, does not interfere with 
usual activities; 2=moderate pain, inhibits but does not wholly prevent usual activities; 3=severe pain, prevents 
all activities; 4=very severe pain. It may also be expressed on a visual analogue scale.) 
 
The headaches must be accompanied by at least one of the following findings: 
 
    Ipsilateral conjunctival injection and/or lacrimation; or 
    Ipsilateral nasal congestion and/or rhinorrhea; or 
    Ipsilateral eyelid edema; or 
    Ipsilateral forehead and facial sweating; or 
    Ipsilateral miosis and/or ptosis; or 
    A sense of restlessness or agitation 
 
Claims for oxygen equipment not meeting the criteria above will be denied as not reasonable and necessary. 
 
Claims for stationary oxygen equipment other than E0424 and all portable oxygen equipment used for cluster 
headaches will be denied as not reasonable and necessary. 
 
Claims for E0424 and E0441 used to treat cluster headaches follow the same payment rules for all other 
covered oxygen equipment. Refer to the related Policy Article for information on statutory payment rules and 
coding guidelines to be used for these claims. 
 You can find this information in the Local Coverage Determination (LCD) Oxygen and Oxygen Equipment 
L33797. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  
  The rules say that Medicare 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.
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 $250 copayment for outpatient hospital services. You can find this 
information on pages 87-88 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 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 $335 copayment per day for days 1-6 for inpatient hospital care. You 
can find this information on pages 67-68 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 an NPWT pump and supplies are denied when 4 months (including the time NPWT was 
applied in an inpatient setting prior to discharge to the home) have elapsed using a NPWT pump in the 
treatment of the most recent wound. You can find this rule at Local Coverage Determination (LCD) L33821: 
Negative Pressure Wound Therapy Pumps (eff. 5/1/21). 
 
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 each year. You can find this information on pages 4-52 and 4-53 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 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 $50 copayment for Physician/Practitioner services, including doctors 
office visits. You can find this information on pages 100 and 101 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 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 $225 copayment for advanced imaging services, including CT scans. 
You can find this information on pages 106-108 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 contact lens, scleral, gas permeable, per lens (V2531) is subject to the Medicare refractive 
lens statutory coverage exclusion. Refractive lenses are covered when they are used to restore the vision 
normally provided by the natural lens of the eye of an individual lacking the organic lens because of surgical 
removal or congenital absence. Covered diagnoses are limited to pseudophakia, aphakia, and congenital 
aphakia. Lenses provided for other diagnoses will be denied as noncovered. You can find this information in 
the Local Coverage Article: Refractive Lenses  Policy Article (A52499). 
 
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.