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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112. 
 
The rules say that the plan must pay for emergency and urgently needed services. This rule applies whether the 
services are obtained in or out of the plans network. This rule applies whether or not there is prior 
authorization for the services. The rules say that an emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules 
say that urgently needed services are those needed because of an unforeseen illness or condition, and it is not 
reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside 
of the service area. You can find this rule at 42 CFR Section 422.113. 
 
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. 
 
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 Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all the following criteria:
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale 2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative management (as tolerated) 3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst) 4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity.
You can find this information in Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L35936).
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 beginning January 1, 2022, home health agencies (HHAs) will no longer submit Requests for Anticipated Payment (RAPs). Instead, for each admission to home health the HHA notifies Medicare systems via submission of a Notice of Admission (NOA). The NOA is a one-time submission to establish that the beneficiary is under a home health period of care and trigger home health consolidated billing edits. The NOA covers contiguous 30-day periods of care until the individuals is discharged from Medicare home health services. All HHAs must submit an NOA to their Medicare contractor within 5 calendar days from the start of care date to establish that the beneficiary is under a Medicare home health period of care and also to trigger home health consolidated billing edits. In instances where an NOA is not timely-filed, Medicare shall reduce the payment for a period of care, including outlier payments, by the number of days from the home health admission date until the date the NOA is submitted to, and accepted by, the contractor, divided by 30. This reduction shall be a provider liability, and the provider shall not bill the beneficiary for it. You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 10.4.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 Plans contract provides supplemental (extra) coverage for hearing aids/services. This benefit includes 
coverage for hearing aids only when purchased through the Plans select hearing aid provider. Additionally, 
this benefit includes coverage for one routine hearing exam and hearing aid fitting/evaluation every year. 
Hearing aid earmolds are not a covered benefit. You can find this information on pages 67-68 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 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 
gingivectomy or gingivoplasty to allow access for restorative procedure. You can find this information on 4-63 
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 for care in a skilled nursing facility (SNF) when all of the following four 
factors are met: 
 
1. The patient requires skilled nursing or skilled rehabilitation services; 
2. The patient requires these services daily; 
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and 
4. The services are reasonable and necessary for the treatment of the patients illness or injury, or the services 
must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from 
getting worse.  
 
You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30.   
 
The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need 
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of 
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, 
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also 
custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
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 also state that the Professional Component (PC)/Technical Component (TC) Indicator of 9 means the concept of a professional/technical component does not apply. You can find this in the Medicare Claims Processing Manual, Chapter 23, Section 50.6
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 
limited oral evaluation - problem focused, intraoral - periapical first radiographic images and intraoral - 
periapical each additional radiographic image. You can find this information in Chapter 4 on pages 81 through 
83 of the Plans 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that a microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above.
An axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or above.
You can find this information in the Local Coverage Determination (LCD) Lower Limb Prostheses L33787.
Codes L5968, L5982, L5984, L5985, L5986 and L5988 describe separate products which provide either a single motion or a combination of motions generally attributed to functional movement of the lower limb during ambulation. The use of these codes can be used to fully describe additional features or functions not found in the prosthetic foot system (L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979 L5980, L5981 and L5987).
You can find this information in the Local Coverage Article Lower Limb Prostheses - Policy Article A52496.
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 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: 
 
  
   The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with 
chronic intractable pain; 
 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; 
 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); 
 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 
 Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 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.
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 viscosupplementation therapy for the knee via intra-articular injections of hyaluronic 
preparations will be considered medically reasonable and necessary when ALL of the following conditions are 
met: 
 The patient is symptomatic. Such symptoms may include pain which interferes with the activities of 
daily living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee 
stiffness  
 The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint 
space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts 
 If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, 
laboratory and imaging studies (i.e. the pain and functional disability is not considered likely to be due 
to a diagnosis other than osteoarthritis of the knee.) 
 The patient has failed at least three months of conservative therapy. Conservative therapy is defined as: 
o Nonpharmacologic therapy (such as but not limited to home exercise program, education, 
weight loss, physical therapy if indicated); and 
o If not contraindicated, simple analgesics and NSAIDS. 
 The patient has failed to respond to aspiration of the knee and intra-articular corticosteroid injection 
therapy when inflammation is a significant component of the patients symptoms and intra-articular 
corticosteroids are not contraindicated. 
 
If the first course of treatment produces relief, subsequent courses of treatment may be reasonable if symptoms 
return. Subsequent courses of treatment will be allowed six (6) months after the last injection of a previous 
course of treatment. You can find this rule in the Local Coverage Determination for Viscosupplementation 
Therapy for Knee, L33767.  
 
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 harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that 
are required for the operation of an expandable controller. It also includes all the necessary fasteners, 
connectors, and mounting hardware. Code E2313 is separately billable in addition to an expandable controller 
both at initial issue and with complete replacement of the expandable controller. Code K0108 must not be used 
for any component or feature of an expandable controller at the time of initial issue. The reimbursement for any 
type of complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. 
However, if individual components of the harness are replaced, code K0108 should be used. 
 
The rules also say 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. 
 
You can find this information in the Local Coverage Article (LCA) Wheelchair Options/Accessories (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 the 
comprehensive oral evaluation but is limited to 1 procedure every 3 plan years. The 2d photographic images, 
gingival irrigation, and unspecified periodontal procedures are not covered by the Plan's dental benefits. You 
can find this information on pages 4-81 to 4-95 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 state that to report a Molecular Diagnostic Test service, please submit the following claim 
information: 
 
   - Select appropriate CPT code 
   - Enter 1 unit of service (UOS) 
   - Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for 
the following Part B claim field/types: 
       -- Loop 2400 or SV101-7 for the 5010A1 837P 
       -- Box 19 for paper claim 
   - Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for 
the following Part A claim field/types: 
       -- Line SV202-7 for 837I electronic claim 
       -- Block 80 for the UB04 claim form. 
 
You can find this rule in the Local Coverage Article (LCA) for Billing and Coding: MolDX: Molecular 
Diagnostic Tests (MDT) (A56973). 
 
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 microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above.
The microprocessor foot or ankle system addition with power assist which includes any type motor (L5969) is not covered because there is insufficient information to demonstrate that the item meets the Medicare standard to be considered reasonable and necessary as per PIM Chapter 13. Claims for L5969 will be denied as not reasonable and necessary.
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. This information must be retained in the treating practitioner's or prosthetist's files.
You can find more information in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.