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 treatments for symptomatic varicose tributaries are either compressive sclerotherapy or 
microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are greater than 4 millimeters (mm) in 
diameter and if the patient remains symptomatic after a six-week trial of conservative therapy. You can find 
this information in Local Coverage Determination (LCD): Varicose Veins of the Lower Extremity, Treatment 
of (L33575). 
 
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 indications for surgical treatment and sclerotherapy include: 
A. 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 
B. The patient is symptomatic and has 1, or more, of the following: 
1. Pain, aching, cramping, burning, itching and/or swelling during activity or after prolonged 
standing severe enough to impair mobility 
2. Recurrent episodes of superficial phlebitis 
3. Non-healing skin ulceration 
4. Bleeding from a varicosity 
5. Stasis dermatitis 
6. Refractory dependent edema 
C. The treatment of spider veins/telangiectasis will be considered medically necessary only if there is 
associated hemorrhage. 
You can find this information in Local Coverage Determination (LCD): Treatment of Varicose Veins of the 
Lower Extremities (L34536). 
 
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. The contract also says the 
Plan lists all covered procedures. Any code not listed is not covered. You can find this information on pages 
63-65 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 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 84 to 85
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 and cover any medically necessary covered benefit outside of the plan provider network, but at in-
network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollees 
medical needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 health 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 you may need a referral from your primary care provider (PCP) to see a specialist. Even if 
you have a referral for one type of care from a specialist, you may need another referral from your PCP if a 
new service or treatment is added. All in-network specialists are listed in the Plans provider directory. Just 
because providers are in-network does not mean that your PCP will provide referrals to all of them. You will 
need to ask which hospitals and specialists your PCP uses for referrals. You can find this information in 
Chapter 3 on pages 36 to 37 of the Plans 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 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 there is limited coverage for infectious pathogen panel testing of more than 5 pathogens. In 
addition to the regular criteria, extended panel testing of Urinary Tract Infection (UTI) panels require the 
following additional criteria: the patient is symptomatic and at higher risk for UTI complications (i.e., the 
elderly, patients with recurrent symptomatic UTIs and/or complicated urinary tract anatomy) AND/OR is seen 
in urogynecology or urology specialty care settings. You can find this information in the Centers for Medicare 
and Medicaid Services, Local Coverage Determination (LCD): MolDX: Molecular Syndromic Panels for 
Infectious Disease Pathogen Identification Testing (L39044). 
 
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 only those items and services specifically listed in your Plan contract. Bone replacement graft for 
ridge preservation - per site (D7953), and guided tissue regeneration  non-resorbable barrier, per implant 
(D6107) are not listed as covered. You can find this information on pages 119-126 of the Plans 2023 Evidence 
of Coverage (EOC). 
 
This benefit includes coverage for the surgical placement of implant body: endosteal implant (D6010) but is 
limited to 2 every calendar year, 1 per tooth every 5 calendar years. Coverage is also included for the custom 
fabricated abutment  includes placement (D6057) but is limited to 2 (D6056, D6057) every calendar year, 1 
per tooth every 5 calendar years, and the abutment supported porcelain/ceramic crown (D6068) but is limited to 
2 (D6058-D6077, D6194) every calendar year, 1 per tooth every 5 calendar years. You can find this 
information on page 124 of the Plans 2023 EOC, and in the Plans 2023 Benefits coverage booklet.
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 treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are greater than 4 millimeters (mm) in 
diameter and if the patient remains symptomatic after a six-week trial of conservative therapy. You can find 
this information in Local Coverage Determination (LCD): Varicose Veins of the Lower Extremity, Treatment 
of (L33575). 
 
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 L36089 is a non-coverage policy for genetic testing for thrombophilia testing for the Factor 
V Leiden (FVL) variant in the F5 gene, the 20210G>A (G20210A) variant in the F2 gene, and the MTHFR 
gene which encodes the 5,10-methylenetetrahydrofolate reductase enzyme. Genetic testing for these genes for 
all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-
covered except for pregnant patients. You can find this rule in the Local Coverage Determination (LCD) for 
MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and 
MTHFR) (L36089). 
 
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 pneumatic devices when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. You can find 
this in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare 
National Coverage Determinations Manual, Chapter 1, Section 280.6. 
 
The rules say 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: 
1. The beneficiary has a diagnosis of lymphedema as defined above, and 
2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented 
presence of at least one of the following clinical findings:  
o Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
o Papillomatosis cutis lymphostatica, 
o Deformity of elephantiasis, 
o Skin breakdown with persisting lymphorrhea, 
o Detailed measurements over time confirming the persistence of the lymphedema with a history 
evidencing a likely etiology, and 
3. 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. (See below for trial guidelines.) 
A PCD coded as E0650 or E0651 used to treat lymphedema that does not meet all of the requirements above is 
not eligible for reimbursement. Claims will be denied as not reasonable and necessary. 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 rule in 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. 
 
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 you pay a 0% coinsurance for an out-of-network routine eye exam every year. You can find this 
information on pages 85 to 86 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 state that Oncotype DX Breast was developed for patients with the following findings: 
 
-estrogen-receptor positive, node-negative carcinoma of the breast 
-estrogen-receptor positive micrometastases of carcinoma of the breast, and 
-estrogen-receptor positive breast carcinoma with 1-3 positive nodes 
 
You can find this rule in the Local Coverage Article Billing and Coding: MolDX: Oncotype DX Breast 
Cancer Assay. 
 
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 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. 
 
Expandable Controller - An electronic system that is capable of accommodating one or more of the following 
additional functions: 
a. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head 
control, etc.) other than a standard proportional joystick. 
b. Non-proportional input devices (e.g., sip and puff, head array, etc.) 
c. Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating 
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) 
 
An expandable controller may also be able to operate one or more of the following: 
d. A separate display (i.e., for alternate control devices) 
e. Other electronic devices (e.g., control of an augmentative speech device or computer through the chairs 
drive control) 
f. An attendant control 
 
A power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a solid back; any 
frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway 
detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable 
speed programmability; a switch control which is independent of the power wheelchair drive control interface; 
 
A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or 
without variable speed programmability which allows the legrest to be raised and lowered independently of the 
recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with 
the power tilt and/or recline control(s). You can find this information in Medicare's 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. 
 
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 cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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.