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 the administration of continuous subcutaneous insulin for the treatment of diabetes mellitus 
(Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses.) if criterion A or B is 
met and if criterion C or D is met: 
 
   A. C-peptide testing requirement  must meet criterion 1 or 2 and criterion 3: 
       1. C-peptide level is less than or equal to 110 percent of the lower limit of normal of the laboratory's 
measurement method. 
        2. For beneficiaries with renal insufficiency and a creatinine clearance (actual or calculated from age, 
weight, and serum creatinine) less than or equal to 50 ml/minute, a fasting C-peptide level is less than or equal 
to 200 per cent of the lower limit of normal of the laboratorys measurement method. 
        3. A fasting blood sugar obtained at the same time as the C-peptide level is less than or equal to 225 
mg/dl. 
   B. Beta cell autoantibody test is positive. 
   C. The beneficiary has completed a comprehensive diabetes education program, has been on a program of 
multiple daily injections of insulin (i.e., at least 3 injections per day) with frequent self-adjustments of insulin 
dose for at least 6 months prior to initiation of the insulin pump, and has documented frequency of glucose self-
testing an average of at least 4 times per day during the 2 months prior to initiation of the insulin pump, and 
meets one or more of the following criteria (1 - 5) while on the multiple injection regimen: 
        1. Glycosylated hemoglobin level (HbA1C) greater than 7 percent 
        2. History of recurring hypoglycemia 
        3. Wide fluctuations in blood glucose before mealtime 
        4. Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL 
        5. History of severe glycemic excursions 
   D. The beneficiary has been on an external insulin infusion pump prior to enrollment in Medicare and has 
documented frequency of glucose self-testing an average of at least 4 times per day during the month prior to 
Medicare enrollment. 
 
If criterion A or B is not met, the pump and related accessories, supplies, and insulin will be denied as not 
reasonable and necessary. If criterion C or D is not met, the pump and related accessories, supplies, and insulin 
will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) for External Infusion Pumps 
(L33794).  
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that certain services and codes are automatically denied as non-covered services. Code 0202U is 
listed as a non-covered code. You can find this information in the Centers for Medicare and Medicaid Services, 
Local Coverage Article (LCA): Billing and Coding: Respiratory Pathogen Panel Testing (A58575). 
 
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 an L4396 or L4397 (Static or dynamic positioning ankle-foot orthosis) is covered if either all of 
criteria 1 - 4 or criterion 5 is met: 
 
    1. Plantar flexion contracture of the ankle (refer to the Group 1 Codes in the ICD-10 code list in the LCD-
related Policy Article for applicable diagnoses) with dorsiflexion on passive range of motion testing of at least 
10 degrees (i.e., a nonfixed contracture); and 
 
    2. Reasonable expectation of the ability to correct the contracture; and 
 
    3. Contracture is interfering or expected to interfere significantly with the beneficiary's functional abilities; 
and 
 
    4. Used as a component of a therapy program which includes active stretching of the involved muscles 
and/or tendons. 
 
    5. The beneficiary has plantar fasciitis (refer to the Group 1 Codes in the ICD-10 code list in the LCD-
related Policy Article for applicable diagnoses). 
 
If an L4396 or L4397 is used for the treatment of a plantar flexion contracture, the pre-treatment passive range 
of motion must be measured with a goniometer and documented in the medical record. There must be 
documentation of an appropriate stretching program carried out by professional staff (in a nursing facility) or 
caregiver (at home). 
 
An L4396 or L4397 and replacement interface (L4392) will be denied as not reasonable and necessary if the 
contracture is fixed. Codes L4396, L4397 and L4392 will be denied as not reasonable and necessary for a 
beneficiary with a foot drop but without an ankle flexion contracture. A component of a static/dynamic AFO 
that is used to address positioning of the knee or hip will be denied as not reasonable and necessary because the 
effectiveness of this type of component is not established. You can find this rule in the Local Coverage 
Determination (LCD) Ankle-Foot/Knee-Ankle-Foot Orthosis L33686. 
 
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 as part of a 
Healthy at Home post-discharge program. This benefit covers up to 12 one-way rides to or from medically 
related appointments and to the pharmacy. You are eligible for this benefit for up to 30 days following all 
inpatient and skilled nursing facility discharges. A referral for this benefit is required following each discharge. 
If you have been recently discharged and would like to be referred into the benefit you must call the phone 
number located on the back of your plan member ID card. You can find this information on pages 4-22 to 4-23 
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 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 100 one-way trips to Plan approved locations per calendar year. You can find this information on 
page 4-54 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 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. The Plan 
contract also says that private duty nursing is not a covered benefit. You can find this information on page 116 
of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will pay for durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers 
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment 
already available to an enrollee. You can find these rules in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(C). 
 
The rules say that payment is made for only one wheelchair at a time. Backup chairs are denied as not 
reasonable and necessary. You can find this information 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 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 repeat bariatric surgery is generally not reasonable and necessary. Claims for more than one 
bariatric surgical procedure may be submitted for individual consideration, and potentially covered when 
clinical circumstances demonstrate reasonability and necessity (such as replacing a defective device or 
correcting a complication in a patient who had met medical necessity for the original procedure and has 
achieved acceptable weight loss). You can find this information in Local Coverage Determination (LCD) 
Surgical Management of Morbid Obesity L33411. 
 
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 Transcranial Magnetic Stimulation (TMS) is a non-invasive treatment that uses pulsed 
magnetic fields to induce an electric current in a localized region of the cerebral cortex. An electromagnetic 
coil placed on the scalp induces focal current in the brain that temporarily modulates cerebral cortical function. 
Capacitor discharge provides electrical current in alternating on/off pulses. Stimulation parameters may be 
adjusted to alter the excitability of the targeted structures in specific cortical regions. Repetitive TMS (rTMS) 
has been investigated as treatment for pharmacoresistant depression.  
 
TMS may be covered if prescribed and administered by a licensed physician who is knowledgeable in the use 
of rTMS. Outpatient rTMS may be indicated for patients with Diagnostic and Statistical Manual of Mental 
Disorders, Fifth Edition (DSM-5) defined Major Depressive Disorder (MDD) who have failed to benefit from 
initial treatment of their depression.  
 
You can find this rule in the Local Coverage Determination (LCD) Repetitive Transcranial Magnetic 
Stimulation (rTMS) in Adults L34869. 
 
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 sedation only when medically necessary. You can find this information on page 48 of the Plans 
2022 dental benefit 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 PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in 
beneficiaries with chronic and severe lymphedema when all of the following three requirements are met: 
 
    - The beneficiary has a diagnosis of lymphedema as defined above, and 
    - The beneficiary has persistence of chronic and severe lymphedema as identified by the documented  
      presence of at least one of the following clinical findings: 
        - Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
        - Papillomatosis cutis lymphostatica, 
        - Deformity of elephantiasis, 
        - Skin breakdown with persisting lymphorrhea, 
        - Detailed measurements over time confirming the persistence of the lymphedema with a history  
          evidencing a likely etiology, and 
    - In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other 
clinical treatment over the course of a required four-week trial. 
 
A PCD coded as E0650 or E0651 used to treat edema from causes other than lymphedema is not eligible for 
reimbursement. Claims will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Pneumatic Compression Devices 
(L33829). 
 
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 the indications for surgical treatment are 
 
1. A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive 
therapy, and avoidance of prolonged immobility where appropriate, has failed, AND 
 
2. The patient is symptomatic and has one, or more, of the following: 
 a. Pain or burning in the extremity severe enough to impair mobility 
 b. Recurrent episodes of superficial phlebitis 
 c. Non-healing skin ulceration 
 d. Bleeding from a varicosity 
 e. Stasis dermatitis 
 f. Refractory dependent edema 
 
You can find this in the Local Coverage Determination (LCD): Treatment of Varicose Veins of the Lower 
Extremities (L34010). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that a Medicare plan may restrict enrollees to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the plan must 
arrange for specialty care outside of the plan provider network when network providers are unavailable or 
inadequate to meet an enrollees medical needs. You can find this rule at 42 CFR Section 422.112. 
 
The rules say that plans must ensure continuity of care for enrollees. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 4, Section 
110.6. 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the plan ensures that all covered 
services are available and accessible under the plan. The plan must arrange for specialty care outside of the 
plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community based 
services. You can find this rule at 42 CFR Section 422.112. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 48-53 of the Plan's 2022 
Evidence of Coverage.