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 pays for outpatient rehabilitation therapy services only when they are provided by 
those trained specifically in physical therapy, occupational therapy or speech-language pathology. This means 
that the services of massage therapists may not be billed as covered therapy services. 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 230.5. 
 
The rules say that Medicare plans may not offer a massage therapy benefit. 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 30.4. 
 
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. 
The Plan contract says that the Plan offers a supplemental (extra) benefit for massage therapy. This benefit 
includes up to 10 massage therapy visits by a licensed massage therapist when medically necessary and 
referred by the enrollees provider. Additional visits are not covered. You can find this information on page 43 
of the Plans 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 Percutaneous Electrical Nerve Stimulation (PENS) is a diagnostic procedure which 
involves stimulation of peripheral nerves by a needle electrode inserted through the skin is performed only in a 
physician's office, clinic, or hospital outpatient department. Therefore, it is covered only when performed by a 
physician or incident to physician's service. If pain is effectively controlled by percutaneous stimulation, 
implantation of electrodes is warranted. 
 
As in the case of TENS (described in subsection A), generally the physician should be able to determine 
whether the patient is likely to derive a significant therapeutic benefit from continuing use of an implanted 
nerve stimulator within a trial period of 1 month. In a few cases, this determination may take longer to make. 
The medical necessity for such diagnostic services which are furnished beyond the first month must be 
documented. 
 
You can find these rules in the Medicare National Coverage Determination (NCD) Assessing Patient's 
Suitability for Electrical Nerve Stimulation Therapy, Section 160.7.1. 
 
The rules say that Acupuncture for stimulation of auricular points is not a covered Medicare benefit. You can 
find this rule in the Medicare National Coverage Determination (NCD) for Acupuncture, 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.
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 equipment which the beneficiary owns or is a capped rental item may be replaced in cases of 
loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, 
flood). A physician's order and/or new Certificate of Medical Necessity (CMN), when required, is needed to 
reaffirm the medical necessity of the item. In the absence of program instructions, A/B MACS (B) may 
determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years. You can find 
this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 110.2. 
 
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.
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 Contract suppliers are not required to furnish a specific brand name item or mode of delivery 
to a beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical outcome. 
You can find this information in the Medicare Claims Processing Manual, Chapter 36, Section 30.4 - 
Prescription for Particular Brand, Item, or Mode of Delivery. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 121 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 diagnostic testing is required prior to placement of a nerve stimulator. This diagnostic 
procedure which involves stimulation of peripheral nerves by a needle electrode inserted through the skin is 
performed only in a physician's office, clinic, or hospital outpatient department. Therefore, it is covered only 
when performed by a physician or incident to physician's service. If pain is effectively controlled by 
percutaneous stimulation, implantation of electrodes is warranted. You can find this information in the National 
Coverage Determination (NCD): Assessing Patient's Suitability for Electrical Nerve Stimulation Therapy 
(160.7.1). 
 
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 state that a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and 
necessary. You can find these rules in the Local Coverage Determination (LCD) for Cold Therapy, L33735. 
 
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 Orally administered enteral nutrition products, related supplies and equipment will be denied 
non-covered, no benefit. You can find this rule at Local Coverage Article (LCA) A58833: Enteral Nutrition 
(eff. 9/5/21). 
 
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 a custom fabricated mandibular advancement oral appliance (E0486) used to treat obstructive 
sleep apnea (OSA) is covered if criteria A - D are met. 
A. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to 
assess the beneficiary for obstructive sleep apnea testing. Refer to the ICD-10 code list in the LCD-
related Policy Article for applicable diagnoses. 
B. The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 - 3):  
1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or 
equal to 15 events per hour with a minimum of 30 events; or, 
2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a 
minimum of 10 events and documentation of:  
a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
b. Hypertension, ischemic heart disease, or history of stroke; or, 
3. If the AHI> 30 or the RDI> 30 and meets either of the following(a or b):  
a. The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or, 
b. The treating practitioner determines that the use of a PAP device is contraindicated. 
C. The device is ordered by the treating practitioner following a review of the report of the sleep test. (The 
practitioner who provides the order for the oral appliance could be different from the one who 
performed the clinical evaluation in criterion A.) 
D. The device is provided and billed for by a licensed dentist (DDS or DMD). 
If all of these criteria (A-D) are not met, the custom fabricated oral appliance (E0486) will be denied as not 
reasonable and necessary. You can find this information in Local Coverage Determination (LCD) Oral 
Appliances for Obstructive Sleep Apnea L33611. 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 in Chapter 4 on page 73 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 36 one-way trips to plan-approved locations every year. You can find this information on page 91 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). 
 
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 Percutaneous Vertebroplasty or Vertebral Augmentation including cavity creation is not to 
be considered a prophylactic procedure for osteoporosis of the spine. It also should not be used for chronic 
back pain of long-standing duration, even if associated with old compression fractures, unless pain is localized 
to a specific chronic fracture and medical therapy has failed. You can find these rules in Local Coverage 
Determination (LCD) Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) 
L38213. 
 
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 the noninvasive stimulator device is covered only for the following indications: 
 Nonunion of long bone fractures; 
 Failed fusion, where a minimum of 9 months has elapsed since the last surgery; 
 Congenital pseudarthroses; 
 Effective July 1, 1996, as an adjunct to spinal fusion surgery for patients at high risk of pseudarthrosis 
due to previously failed spinal fusion at the same site or for those undergoing multiple level fusion. A 
multiple level fusion involves 3 or more vertebrae (e.g., L3-L5, L4-S1, etc). 
 Effective September 15, 1980, nonunion of long bone fractures is considered to exist only after 6 or 
more months have elapsed without healing of the fracture. 
 Effective April 1, 2000, nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting 
treatment with the electrical osteogenic stimulator. Serial radiographs must include a minimum of 2 sets 
of radiographs, each including multiple views of the fracture site, separated by a minimum of 90 days. 
You can find these rules in National Coverage Determination (NCD) Osteogenic Stimulators 150.2. 
 
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.
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 24 one-way trips per calendar year. You can find this information on page 88 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 if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report CPT code 81479 
(Unlisted molecular pathology procedure) with one unit of service. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, National Correct Coding Initiative (NCCI) 
Manual, Chapter 10, Section F(8). 
 
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.