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 High frequency chest wall oscillation devices (HFCWO) (E0483) are covered for 
beneficiaries who meet: 
A. Criterion 1, 2, or 3, and 
B. Criterion 4 
   1. There is a diagnosis of cystic fibrosis. 
   2. There is a diagnosis of bronchiectasis which has been confirmed by a high resolution, spiral, or standard 
CT scan. Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed 
diagnosis of bronchiectasis do not meet this criterion. 
   3. The beneficiary has one of the following neuromuscular disease diagnoses: 
   Post-polio 
   Acid maltase deficiency 
   Anterior horn cell diseases 
   Multiple sclerosis 
   Quadriplegia 
   Hereditary muscular dystrophy 
   Myotonic disorders 
   Other myopathies 
   Paralysis of the diaphragm 
4. There must be well-documented failure of standard treatments to adequately mobilize retained secretions. 
You can find this information in the Local Coverage Determination (LCD): High Frequency Chest Wall 
Oscillation Devices (L33785). 
 
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 Medicare covers leadless pacemakers when procedures are performed in Food and Drug 
Administration (FDA) approved studies. Medicare also covers, in prospective longitudinal studies, leadless 
pacemakers that are used in accordance with the FDA approved label for devices that have either: 
 
    - an associated ongoing FDA approved post-approval study; or 
    - completed an FDA post-approval study. 
 
You can find this information in the National Coverage Determination (NCD): Leadless Pacemakers (20.8.4). 
 
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 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 51 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 state that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered. 
 
POWER WHEELCHAIR DRIVE CONTROL SYSTEMS: 
 
If an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be 
denied as non-covered. (See the related LCD for situations in which it is provided in place of a beneficiary-
operated system.) 
 
MISCELLANEOUS ACCESSORIES: 
 
Swingaway, retractable, or removable hardware (E1028) is non-covered if the primary indication for its use is 
to allow the beneficiary to move close to desks or other surfaces. If it is ordered for this indication, a GY 
modifier must be added to the code. 
 
A manual standing system for a manual wheelchair (E2230) is non-covered (no benefit category) because it is 
not primarily medical in nature. 
 
You can find this information in the Local Coverage Article Wheelchair Options/Accessories - Policy Article 
A52504.  
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. 
Repeat treatments with Intraarticular Knee Injections of Hyaluronan are considered medically necessary for 
patients being treated for osteoarthritis of the knee, who meet both of the following criteria: 
 Significant improvement in knee pain and known improvement in functional capacity resulted from the 
previous series of injections which has been documented in the record; and 
 At least six (6) months have elapsed since the last injection in the series. 
You can find this rule in the Local Coverage Article-Billing and Coding: Intraarticular Knee Injections of 
Hyaluronan (A56157). 
 
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 polyethylene-glycol (PEG) hydrogel is covered ONCE in patients with clinically localized 
prostate cancer with BOTH the following:  
1. Inclusion criteria including ALL of the following: 
a. Low* or Favorable Intermediate Prostate Cancer Risk Group (1-5)  
b. Dose escalated conventional fractionation or moderate hypofractionation (HFX) IG-IMRT 
planned  
c. Eastern Cooperative Oncology Group (ECOG) performance status less than or equal to 1  
d. Modern localization techniques insufficient to improve oncologic cure rates and/or reduce side 
effects due to AT LEAST ONE of the following: 
i. Anatomic geometry precluding ideal rectal constraints  
o Conventional fractionation  
o Moderate HPX (dose constraints not yet standardized; employ those used in the 
supporting phase III trials)  
ii. Medication usage (e.g., anticoagulants)  
iii. Comorbid conditions (e.g., increased age, Hx MI or CHF) 
2. No Exclusion criteria including ALL of the following: 
a. Less than 5-year life-expectancy and asymptomatic  
b. Prior prostate cancer treatment (surgery or RT)  
c. Active bleeding disorder or clinically significant coagulopathy  
d. Active inflammatory or infectious disease in the perineum or injection area (e.g., prostatitis, 
anorectal IBD)  
e. Prostate volume greater than 80 cc  
*Life expectancy greater than or equal to 20 years (very low risk); more than or equal to 10 years (low risk)  
 
Prostate rectal spacers are various materials or devices placed between the prostate and anterior wall of the 
rectum for use in men receiving radiation therapy for prostate cancer. The anterior wall of the rectum is 
considered a major dose-limiting factor in radiation therapy of prostate cancer. Physical separation is proposed 
to allow reduced toxicity and treatment intensification. 
 
You can find this information in the Local Coverage Determination (LCD): Prostate Rectal Spacers (L37485). 
 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 pages 4-36 to 4-39 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 state that POWER WHEELCHAIRS (K0013, K0814, K0815, K0816, K0820, K0821, K0822, 
K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, 
K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, 
K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, 
K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898): 
 
A power wheelchair is covered if: 
 
    All of the basic coverage criteria (A-C) are met; and 
    The beneficiary does not meet coverage criterion D, E, or F for a POV; and 
    Either criterion J or K is met; and 
    Criteria L, M, N, and O are met; and 
    Any coverage criteria pertaining to the specific wheelchair type (see below) are met. 
 
    The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is 
provided; or 
 
    If the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who is 
unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to 
safely operate the power wheelchair that is provided; and 
 
    The beneficiarys weight is less than or equal to the weight capacity of the power wheelchair that is provided 
and greater than or equal to 95% of the weight capacity of the next lower weight class PWC  i.e., a Heavy 
Duty PWC is covered for a beneficiary weighing 285  450 pounds; a Very Heavy Duty PWC is covered for a 
beneficiary weighing 428  600 pounds; an Extra Heavy Duty PWC is covered for a beneficiary weighing 570 
pounds or more. 
 
    The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the power wheelchair that is provided. 
 
    Use of a power wheelchair will significantly improve the beneficiarys ability to participate in MRADLs and 
the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical impairments, 
participation in MRADLs may require the assistance of a caregiver.  
    The beneficiary has not expressed an unwillingness to use a power wheelchair in the home. 
 
If a PWC will be used inside the home and if coverage criteria (a)-(e) are not met, it will be 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.
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). 
 
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 health 
plan contract says What is a "PCP" and what does the primary care physician (PCP) do for you? When you 
become a member of our plan, you must choose a plan provider to be your PCP. Your PCP is a provider who 
meets state requirements and is trained to give you basic medical care. Your Provider Directory will indicate 
which providers may act as your PCP. As we explain below, you can get your routine or basic care from your 
PCP. Your PCP can also coordinate the rest of the covered services you get as a plan member. For example, in 
order to see a network specialist, you usually need to get your PCP's approval first (this is called getting a 
"referral" to a specialist). This includes: X-rays, Laboratory tests, Therapies, Care from doctors who are 
specialists, Hospital admissions, Follow-up care. "Coordinating" your services includes checking or consulting 
with other plan providers about your care and how it is going. If you need certain types of covered services or 
supplies from network providers, you must get approval in advance from your PCP (such as giving you a 
referral). In some cases, your PCP will need to get prior authorization (prior approval). Chapter 4 has more 
information on which services require prior authorization. Since your PCP can provide and coordinate your 
medical care, you should have all of your past medical records sent to your PCP's office. Chapter 8 tells you 
how we will protect the privacy of your medical records and personal health information. You can find this 
information in Chapter 3 in Section 2.1 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 MRIs are covered when medically necessary and reasonable for the diagnosis or treatment of 
the specific patient involved. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 220.2(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.
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 also state that a fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, 
L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, 
L5858) is covered for beneficiaries whose functional level is 3 or above.  
 
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 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 a continuous passive motion device will be covered for patients who have received a total 
knee replacement. There is insufficient evidence to justify coverage of these devices for longer periods of time 
or for other applications. You can find this rule in Centers for Medicare and Medicaid Services (CMS), 
Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, 
Durable Medical Equipment Reference List (280.1). 
 
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 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 
crowns/post and core or crown buildup. The Plan contract also says that prior authorization may be required. 
You can find this information on pages 67 and 69 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 computed tomography (CT) scans are covered if there is literature to support its use for the 
patients condition and the scan is reasonable and necessary for the patient. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National 
Coverage Determinations Manual, Section 220.1(A). 
 
The rules say that the single photon emission computed tomograph (SPECT) acquires information on the 
concentration of radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical 
conditions including: 
 
stress fracture. 
spondylosis. 
infection (e.g., discitis). 
tumor (e.g., osteoid osteoma). 
analyze blood flow to an organ, as in the case of myocardial viability. 
differentiate ischemic heart disease from dilated cardiomyopathy. 
 
You can find this information in the National Coverage Determination (NCD) for Single Photon Emission 
Computed Tomography (SPECT) (220.12). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.