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

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a lower limb prosthesis is covered when the beneficiary: 
1. Will reach or maintain a defined functional state within a reasonable period of time; and 
2. Is motivated to ambulate. 
  
   
A determination of the medical necessity for certain components/additions to the prosthesis is based on the 
beneficiarys potential functional abilities. Potential functional ability is based on the reasonable expectations 
of the prosthetist, and treating practitioner, considering factors including, but not limited to: 
1. The beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other 
medical problems; and 
3. The beneficiarys desire to ambulate. 
 
A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot 
with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot 
system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. 
 
An axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or 
above. 
 
You can find this information in the Local Coverage Determination (LCD): Lower Limb Prostheses (L33787). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that knee scooters (also called crutch substitutes) are not covered. There is insufficient published 
clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical 
necessity for these products. You can find this rule at Centers for Medicare and Medicaid Services, Durable 
Medical Equipment Administrative Contractor Noridian Jurisdiction A Bulletin entitled "E0118- Crutch 
Substitutes." 
 
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 incompetent perforator veins (IPVs) are the most common cause of recurrent varicose veins 
after treatment. Minimally invasive treatments have replaced traditional surgical treatments for 
IPVs. Ultrasound-guided foam sclerotherapy (UGFS) and endovenous thermal ablation with either 
radiofrequency or laser energy sources will be considered reasonable and necessary with the following 
conditions: 
- Demonstrated perforator reflux >500 msec; and 
- No saphenous reflux (greater, small, or accessory) and/or symptomatic varicose tributaries; and 
- An active venous ulcer; and 
- The IPV is at least 3.5 mm in diameter; and 
- The perforator is in the vicinity of the ulcer. 
You can find this information in Local Coverage Determination (LCD): Treatment of Varicose Veins of the 
Lower Extremities (L39121). 
 
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 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. You can find this rule at Local Coverage Determination (LCD) L33820: Hospital Beds 
And Accessories (eff. 1/1/20). 
 
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 thermal destruction of the intraosseous BVN will be considered medically reasonable and 
necessary for the treatment of chronic low back pain (cLBP) in patients who meet all the following criteria: 
1. Chronic lumbar back pain of greater than or equal to 6 months duration that causes functional deficit 
measured on a pain or disability scale, and 
2. Documented failure to respond to greater than or equal to 6 months of non-surgical management, and 
3. Absence of non-vertebrogenic 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, and 
4. Evidence of Type 1 or Type 2 Modic changes on magnetic resonance imaging (MRI), such as 
inflammation, edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized 
fibrous tissues within the adjacent marrow, hypotensive signals (Type 1 Modic change), and changes to 
the vertebral body marrow including replacement of normal bone marrow by fat, and hypertensive 
signals (Type 2 Modic change), in 1 or more vertebrae from L3-S1. 
You can find this information in Local Coverage Determination (LCD): Thermal Destruction of the 
Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain (L39420). 
 
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 the Ambulatory Surgical Center (ASC) list of covered procedures indicates procedures 
which are covered and paid for if performed in the ASC setting. The complete lists of ASC covered surgical 
procedures and ASC covered ancillary services, the applicable payment indicators, payment rates for each 
covered surgical procedure and ancillary service before adjustments for regional wage variations, and wage 
indices are available on the CMS Web-site at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ASCPayment/ASC-Regulations-and-Notices.html. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 14, Section 20. 
 
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. 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 provide a list of appropriate diagnosis codes for a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan. You can find this information in the Centers for 
Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 13, Section 60.16. 
 
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 all platelet rich plasma injections and/or applications as a means of managing 
musculoskeletal injuries and/or joint conditions are not covered. You can find this information in the Local 
Coverage Determination (LCD) L38937: Platelet Rich Plasma. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
 
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 133 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 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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
The rules say that TENS is covered for acute post-operative pain. Coverage is limited to 30 days (one month's 
rental) from the day of surgery. Payment will be made only as a rental. A TENS unit will be denied as not 
reasonable and necessary for acute pain (less than three months duration) other than for post-operative pain. 
TENS therapy for Chronic Low Back Pain (CLBP) will be denied as not reasonable and necessary. You can 
find this rule in Local Coverage Determination (LCD) Transcutaneous Electrical Nerve Stimulators (TENS) 
L33802. 
 
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 39 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 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 intravenous moderate (conscious) sedation/analgesia- first 15 minutes, and each subsequent 15 
minute increment  when medically necessary. You can find this information in the Plans 2023  Office 
Reference Manual.
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 urine culture testing is only covered when billed with certain diagnosis codes. You can find 
this rule at Centers for Medicare and Medicaid Services, Medicare National Coverage Determinations (NCD) 
Coding Policy Manual and Change Report (ICD-10-CM), Revision January 2023. 
 
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 providers must bill an accurate Place of Service (POS) code on their claims. POS code 21 
indicates the service was performed in an inpatient hospital setting. POS code 22 indicates the service was 
performed in an outpatient hospital setting.  You can find this rule at Centers for Medicare and Medicaid 
Services, Internet-Only Publication 100-04, Medicare Claims Processing Manual Chapter 26, Section 10.5. 
 
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 A sequela is the residual effect (condition produced) after the acute phase of an illness or 
injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent 
early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. 
Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and 
infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes 
sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is 
sequenced second. You can find this rule in the ICD-10-CM Official Guidelines for Coding and Reporting, FY 
2023, Section I.B.10. 
 
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).  
 
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 there is a $1000 deductible which applies to certain items and services. The Plan 
deductible applies to colonoscopy. You can find this information on page 3 of the Plan's 2023 Medical Benefits 
Chart.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
The rules say that a new 36-month rental period can begin only in the following situations: 
 Specific incident of damage beyond repair (e.g., dropped and broken, fire, flood, etc.) or the item is 
stolen or lost 
 Break-in-need for at least 60 days plus the days remaining in the month of discontinuation and new 
medical necessity is established (see BREAK-IN-SERVICE below) 
A new 36-month rental period does not start in the following situations: 
 Replacing equipment due to malfunction, wear and tear, routine maintenance, repair 
 Providing different equipment based on a treating practitioner order or beneficiary request for an 
upgrade 
 Break-in-need less than 60 days plus the days remaining in the month of discontinuation (see BREAK-
IN-SERVICE below) 
 Break-in-billing (see BREAK-IN-SERVICE below) 
 Changing suppliers 
You can find these rules in Local Coverage Article Oxygen and Oxygen Equipment - Policy Article A52514. 
 
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 vacuum erection devices (L7900) and related accessories (L7902) are statutorily non-
covered. Vacuum erection devices (L7900) and related supplies are considered Prosthetic Devices under the 
Prosthetic Devices benefit category (Social Security Act 1861(s)(8)). For dates of service on or after July 1, 
2015, codes L7900 and L7902 are statutorily non-covered based on the Achieving a Better Life Experience 
(ABLE) Act of 2014 (see Social Security Act 1834(a)(1)(I)). You can find this rule in the Local Coverage 
Determination and Article for Vacuum Erection Devices, L34824 and A52712.  
 
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.