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 Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
1.            The person must have a personal mobility deficit;  
2.            The deficit must impair their participation in mobility related activities of daily living (MRADLs) 
such as toileting, feeding, grooming and bathing in customary locations within the home;  
3.            The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; 
and 
4.            The person must be capable of safely operating the PMD.  
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 280.3(B). 
 
The rules state that a Group 3 power wheelchair may be covered for enrollees with a mobility limitation that is 
due to a neurological condition, myopathy, or congenital skeletal deformity. A Group 3 power wheelchair with 
multiple power options requires that the enrollee meet coverage criteria for a power tilt and recline seating 
system, or that the enrollee use a ventilator which is mounted on the wheelchair.  
 
The rules also say if the power wheelchair base is not covered, then related accessories will be denied. 
 
You can find this in the Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
 
 The rules say that a power seating system  tilt only, recline only, or combination tilt and recline  with or 
without power elevating legrests will be covered if the enrollee is at high risk for development of a pressure 
ulcer and is unable to perform a functional weight shift; or, the enrollee utilizes intermittent catheterization for 
bladder management and is unable to independently transfer from the wheelchair to bed; or, the power seating 
system is needed to manage increased tone or spasticity. You can find this in the Local Coverage 
Determination (LCD): Wheelchair Options/Accessories (L33792). 
 
You can find this information in the Local Coverage Article for Wheelchair Options/Accessories - Policy 
Article (A52504). 
 
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 only 
those items and services specifically listed in your Plan contract. Core buildup, including any pins when 
required (D2950) is not covered under the Plans dental benefits. You can find this information on pages 74-77 
and 87-89 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. 
 
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 we will cover one non-Medicare covered routine vision exam per calendar year including 
refraction. Refraction is only covered when performed during a routine vision exam. Note: Our provider 
network for routine vision services is different than our provider network for medical vision services. Non-
Medicare covered vision services are administered by EyeMed and must be performed by a provider in 
EyeMed's network. You can find this information on page 92 of the Plan's 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 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 $310 copayment per day for days 1-7 of each in-network inpatient 
hospital stay. Enrollees then pay a $0 copayment per day for days 8-90 of each in-network inpatient hospital 
stay. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The 
day before you are discharged is your last inpatient day. You can find this information on pages 77-80 of the 
Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that there is an out-of-pocket maximum of $4,200. This is the most you have to pay 
out-of-pocket in the Plan year for covered in-network Part A and Part B items/services. You can find this 
information on page 46 of the Plans 2022 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 it is expected that an injection (Synvisc-One TM, Gel-One, Durolane) or course of the 
injections (Synvisc, Hyalgan, Supartz or Visco-3TM, EuflexxaTM, Orthovisc, GelSyn-3TM, GenVisc 
850, Hymovis, TriViscTM, SynojoyntTM, TriluronTM) will not be repeated within six months. 
 
A repeat series of injections may be allowed when: 
1. The indications continue to be met; and 
2. Significant improvement in pain and functional capacity from the prior series of injections is 
documented in the medical record; and 
3. The last injection (in a prior course) was given at least six (6) months ago. 
 
You can find this information in Local Coverage Determination (LCD): Billing and Coding: Hyaluronans 
Intra-articular Injections of (A52420). 
 
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 Group 2 Multiple Power Option power wheelchair (PWC) (K0841, K0842, K0843) is 
covered if all of the basic coverage criteria for a PWC are met and if:  
A. Criterion 1 or 2 is met; and 
B. Criteria 3 and 4 are met.  
1. The beneficiary meets coverage criteria for a power tilt and recline seating system and 
the system is being used on the wheelchair. 
2. The beneficiary uses a ventilator which is mounted on the wheelchair. 
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified 
medical professional, such as a physical therapist (PT) or occupational therapist (OT), or 
practitioner who has specific training and experience in rehabilitation wheelchair 
evaluations and that documents the medical necessity for the wheelchair and its special 
features. The PT, OT, or practitioner may have no financial relationship with the 
supplier. 
4. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and 
Assistive Technology Society of North America (RESNA) certified Assistive 
Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-
person involvement in the wheelchair selection for the beneficiary.  
If a Group 2 Multiple Power Option PWC is provided and if criterion (A) or (B) is not met, it will be 
denied as not reasonable and necessary. 
If the PWC base is not covered, then related accessories will be denied. 
 
You can find this information in the Local Coverage Determination (LCD) for 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 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 does not include 
a crown. You can find this information in Chapter 4 on page 52 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 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 20% coinsurance for in-network durable medical equipment and related 
supplies. You can find this information on page(s) 74 of the Plan's 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 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 pay a $0 copayment for in and out-of-network lab services, and basic radiological 
services provided in all places of service. You can find this information on pages 62 and 63 of the Plan's 2023 
Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees pay a $0 copayment for in and out-of-network physical therapy 
services provided in all places of service. You can find this information on page 68 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 fillings once every 24 months per surface, per tooth. White fillings on posterior teeth will be 
processed as a silver filling and the patient is responsible for up to the contracted fee. You pay 20% 
coinsurance for Class 2 Basic services. You can find this information on page 119 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 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 sacroiliac joint injections (SIJI) will be considered medically reasonable and necessary when 
all the following requirements are met: 
 
1. Moderate to severe low back pain primarily experienced over the anatomical location of the SI joints 
between the upper level of the iliac crests and the gluteal fold, and 
2. Low back pain duration of at least three (3) months, and 
3. Low back pain below L5 without radiculopathy, and 
4. Clinical findings and/or imaging studies do not suggest any other diagnosed or obvious cause of the 
lumbosacral pain (such as central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis 
or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, pseudoarthrosis, or 
pain related to spinal instrumentation), and  
5. At least three positive findings with provocative maneuvers: Flexion, Abduction and External Rotation 
(FABER), Gaenslen, Thigh Thrust or Posterior Shear, SI Compression, SI Distraction and Yeoman Tests, and 
6. Low back pain persists despite a minimum of four weeks of conservative therapies. 
 
You can find this information in the Local Coverage Determination (LCD) L39464: Sacroiliac Joint Injections 
and Procedures. 
 
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 single photon emission computed tomography (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. 
Frequency limitations: Medicare Administrative Contractor discretion. 
In the case of myocardial viability, FDG positron emission tomography (PET) may be used following a SPECT 
that was found to be inconclusive. However, SPECT may not be used following an inconclusive FDG PET 
performed to evaluate myocardial viability. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual Section 220.12. 
 
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 no payment may be made for the implantation of dorsal column or depth brain stimulators or 
services and supplies related to such implantation, unless all of the conditions listed below have been met: 
 
1.The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic 
intractable pain, 
2.With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for 
the given patient, 
3.Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation), 
4.All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be available; and 
5.Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find this information in the National Coverage Determination (NCD): Electrical Nerve Stimulators 
(160.7). 
 
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.