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 dorsal column stimulators may be covered as therapies for the relief of chronic intractable 
pain under the following circumstances: 
 
   1. To treat chronic pain caused by lumbosacral arachnoiditis that has not responded to medical management 
including physical therapy. (Presence of arachnoiditis is usually documented by presence of high levels of 
proteins in the Cerebrospinal Fluid [CSF] and/or by myelography or Magnetic Resonance Imaging [MRI]). 
   2. To treat intractable pain caused by nerve root injuries, post-surgical or post-traumatic including that of 
post-laminectomy syndrome (failed back syndrome). 
   3. To treat intractable pain caused by complex regional pain syndrome I & II. 
   4. To treat intractable pain caused by phantom limb syndrome that has not responded to medical 
management. 
   5. To treat intractable pain caused by end-stage peripheral vascular disease, when the patient cannot undergo 
revascularization or when revascularization has failed to relieve painful symptoms and the pain has not 
responded to medical management. 
   6. To treat intractable pain caused by post-herpetic neuralgia. 
   7. To treat intractable pain caused by plexopathy. 
   8. To treat intractable pain caused by intercostal neuralgia that did not respond to medical management and 
nerve blocks. 
   9. To treat intractable pain caused by cauda equina injury. 
   10. To treat intractable pain caused by incomplete spinal cord injury. 
 
You can find this rule in the Local Coverage Determination (LCD) for Spinal Cord Stimulation (Dorsal 
Column Stimulation) (L35450). 
 
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 LAAC devices are covered when the device has received Food and Drug Administration 
(FDA) Premarket Approval (PMA) for that devices FDA-approved indication and meet all of the conditions 
specified below: 
The patient must have: 
 A CHADS2 score  2 (Congestive heart failure, Hypertension, Age > 75, Diabetes, Stroke/transient 
ischemia attack/thromboembolism) or CHA2DS2-VASc score  3 (Congestive heart failure, 
Hypertension, Age  65, Diabetes, Stroke/transient ischemia attack/thromboembolism, Vascular 
disease, Sex category) 
 A formal shared decision making interaction with an independent non-interventional physician using an 
evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. 
Additionally, the shared decision making interaction must be documented in the medical record. 
 A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following 
the conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral 
anticoagulants. The patient (preoperatively and postoperatively) is under the care of a cohesive, 
multidisciplinary team (MDT) of medical professionals. The procedure must be furnished in a hospital 
with an established structural heart disease (SHD) and/or electrophysiology (EP) program. 
You can find this rule in the Center for Medicare Services (CMS) Publication 100-03, Medicare National 
Coverage Determination (NCD) Manual, Section 20.34. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
Medicare rules state that to repair means to fix or mend and to put durable medical equipment (DME) back in 
good condition after damage or wear. Repairs to equipment which a beneficiary owns are covered when 
necessary to make the equipment serviceable. If the expense for repairs exceeds the estimated expense of 
purchasing or renting another item of equipment for the remaining period of medical need, no payment can be 
made for the amount of the excess. In addition, payment for repair and maintenance may not include payment 
for parts and labor covered under a manufacturers or suppliers warranty. You can find this rule in Medicare 
Benefit Policy Manual Chapter 15, Section 110.2(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.
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 $20 copayment per day for outpatient diagnostic tests. The Plan contract 
also says that enrollees must pay a $50 copayment for each outpatient visit for services to diagnose and/or treat 
a disease or condition of the eye. You can find this information on pages 101 and 119 of the Plan's 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 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 $180 copayment for each advanced imaging service (e.g., MRI, CT and 
PET scans, nuclear medicine, and stress tests). You can find this information on page 102 of the Plan's 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 gynecomastia is the excessive growth of the male mammary glands. These conditions can 
cause significant clinical manifestations when the excessive breast weight adversely affects the supporting 
structures of the shoulders, neck, and trunk. 
 Persists more than 3 to 4 months after the pathological causes are ruled out (e.g. not limited to 
testosterone deficiency, testicular tumor, liver disease, or drug induced).
34
 
 Persists after 3 to 4 months of unsuccessful medical treatment for pathological gynecomastia.
16
 
 Pain or tenderness directly related to the breast tissue which has a clinically significant impact upon 
activities of daily living. 
 Clinical symptoms refractory to a trial of analgesics or anti-inflammatory agents. 
 For significant clinical manifestations when the excessive breast weight adversely affects the supporting 
structures of the shoulders, neck and trunk. 
American Society of Plastic Surgeons gynecomastia scale:
16
 
 Grade I: Small breast enlargement with localized button of tissue that is concentrated around the areola. 
 Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from 
the chest. 
 Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from 
the chest with skin redundancy present. 
 Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast 
You can find this rule at Local Coverage Determination (LCD) L39051: Cosmetic and Reconstructive Surgery 
(eff. 11/14/21). 
 
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 Medicare Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
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 covered drugs include: Drugs that usually arent self-administered by the patient and are 
injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. 
You can find this information in Chapter 4 on page 4-42 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 fluid used to administer the drug (s) is incidental hydration and is not separately payable. 
This rule is found in Medicare Local Coverage Determination (LCD): Hydration Therapy (L34960). 
 
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 a comprehensive oral evaluation but only when received by a participating general dentist. You 
can find this information on pages 70-72 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. 
 
Medicare guidance says oral drugs for nausea and vomiting due to chemotherapy (anti-emetic drugs) are only 
covered under the Medicare medical benefit (Part B) when they are started within 2 hours of the administration 
of the chemotherapy, not used in excess of 48 hours from that time, are used as full replacement for intravenous 
(IV) anti-nausea medications. You can find this guidance in the Medicare Benefit Policy Manual Chapter 15, 
Section 50.5.4. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that definitive urinary drug testing (UDT) is reasonable and necessary for the following 
circumstances: 
 Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT; 
 Definitively identify specific drugs in a large family of drugs; 
 Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, 
meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
 Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., 
discontinuation of THC use according to a treatment plan); 
 Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients 
self-report, presentation, medical history, or current prescribed pain medication plan; 
 Rule out an error as the cause of a presumptive UDT result; 
 Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; 
and 
 Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
You can find these rules in the Local Coverage Determination (LCD) for Lab: Controlled Substance 
Monitoring and Drugs of Abuse Testing, L35724. 
 
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 Coverage for the use of NMES/FES is limited to spinal cord injury (SCI) patients for 
walking, who have completed a training program which consists of at least 32 physical therapy sessions with 
the device over a period of three months. The trial period of physical therapy will enable the physician treating 
the patient for his or her spinal cord injury to properly evaluate the person's ability to use these devices 
frequently and for the long term. Physical therapy necessary to perform this training must be directly performed 
by the physical therapist as part of a one-on-one training program. You can find this rule in National Coverage 
Determination (NCD) Neuromuscular Electrical Stimulation (NMES) 160.12. 
 
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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say home health agencies (HHAs) shall no longer submit Requests for Anticipated Payment (RAPS -
TOB 0322) for any HH period of care with a From date on or after January 1, 2022. Instead, for each admission 
to home health, the HHA notifies Medicare systems via submission of a notice of admission (NOA) An NOA 
must be submitted timely. A timely-filed NOA is submitted to and accepted by the A/B MAC (HHH) within 
five calendar days after admission date. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 
10.1.10.3. 
 
The rules say that HHAs must submit HH PPS claims with the 4th digit of "9." These claims may be adjusted 
with code "7" or cancelled with code "8." A/B MACs (HHH) do not accept late charge bills, submitted with 
code "5," on HH PPS claims. To add services within the period of a paid HH claim, the HHA must submit an 
adjustment. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 40.2. 
 
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 state that a fluid, pneumatic, or electronic/microprocessor knee is covered for beneficiaries whose 
functional level is 3 or above. You can find this rule in the Local Coverage Determination (LCD) for 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. 
 
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 that certain vision care services are covered. Gas permeable contact lenses (V2531) are excluded 
from this benefit. You can find this information on page 79 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 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 $67.80 copayment for Emergency care. You can find this information 
on page(s) 46 of the Plan's 2022 Evidence of Coverage.