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 all services billed by the skilled nursing facility (SNF) (including those furnished under 
arrangements with an outside supplier) for a resident of a SNF in a covered Part A stay are included in the 
SNFs Part A bill. If a resident is not in a covered Part A stay (Part A benefits exhausted, posthospital or level 
of care requirements not met), the SNF is required to bill for all physical therapy, occupational therapy, and/or 
speech-language pathology services provided to a SNF resident under Part B. You can find this information in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 6, Section 10. 
 
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 pages 66-67 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 costs of certain end-stage renal disease (ESRD) laboratory services performed by either the ESRD facility 
or an independent laboratory are included in the composite rate and are not separately payable. These tests are 
either performed by the facility, in which case payment is included in the composite rate, or by an outside 
laboratory for the facility, in which case the laboratory bills the facility directly. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 8, Section 50.1. 
 
The rules say that with the implementation of the End Stage Renal Disease Prospective Payment System 
(ESRD PPS), effective for claims with dates of service on or after January 1, 2011, all ESRD-related injectable 
drugs and biologicals and oral equivalents of those injectable drugs and biologicals are included in the ESRD 
PPS. 
 
If the renal dialysis facility needs to report a drug that was furnished to an ESRD beneficiary that was not 
related to the treatment of ESRD, they must include the modifier AY to indicate the item or service is not for 
the treatment of ESRD. ESRD-related drugs and biologicals that were separately paid under the basic case-mix 
composite rate payment system is considered in the calculation of any applicable outlier payment under the ESRD PPS. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 50.2. 
 
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 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(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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 on page(s) 12 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 a fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or 
more of the following criteria (1-4) are met: 
1. The beneficiary has a medical condition which requires positioning of the body in ways not feasible 
with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the 
use of a hospital bed, or 
2. The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to 
alleviate pain, or 
3. The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due 
to congestive heart failure, chronic pulmonary disease, or problems with aspiration, or 
4. The beneficiary requires traction equipment, which can only be attached to a hospital bed. 
 
A semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if the beneficiary meets one 
of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate 
need for a change in body position. You can find these rules in Local Coverage Determination (LCD) Hospital 
Beds and Accessories (L33820). 
 
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 the panoramic radiographic image but is limited to once every three plan years and is considered a 
similar code to services D0210, D0330, D0701, D0709, D0372, D0387. You can find this information on page 
179 of the Plan's 2023 Medicare quick reference guide.
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 pneumatic compression device (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: 
 
The beneficiary has a diagnosis of lymphedema as defined above, and 
The beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence of 
at least one of the following clinical findings: 
Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
Papillomatosis cutis lymphostatica, 
Deformity of elephantiasis, 
Skin breakdown with persisting lymphorrhea, 
Detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a 
likely etiology, and 
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. 
 
A PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone even if the 
criteria in this section are met. Claims will be denied as not reasonable and necessary. Refer below to the 
sections III - LYMPHEDEMA EXTENDING ONTO THE CHEST, TRUNK AND/OR ABDOMEN and PCD 
Code Selection for additional information about the limited coverage for PCD coded as E0652. 
 
Four-Week Trial for Lymphedema 
 
A four-week trial of conservative therapy demonstrating failed response to treatment is required. The four-week trial of conservative therapy must include all of the following: 
 
Regular and compliant use of an appropriate compression bandage system or compression garment to provide 
adequate graduated compression 
Adequate compression is defined as (1) sufficient pressure at the lowest pressure point to cause fluid 
movement, and (2) sufficient pressure across the gradient (from highest to lowest pressure point) to move fluid 
from distal to proximal. The compression used must not create a tourniquet effect at any point. 
The garment may be prefabricated or custom-fabricated but must provide adequate graduated compression 
starting with a minimum of 30 mmHg distally. 
Regular exercise 
Elevation of the limb 
 
You can find this information in the 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.
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 the covered indications for urinary drug testing are: 
- Group A  Symptomatic patients, multiple drug ingestion, and/or patients with unreliable history 
- Group B  Treatment for substance abuse or dependence 
- Group C  Chronic pain management drug testing for patients on chronic opioid therapy 
 
Criteria to establish medical necessity for drug testing must be based on patient-specific elements identified 
during the clinical assessment, and documented by the clinician in the patients medical record and minimally 
include the following elements: 
- Patient history, physical examination and previous laboratory findings 
- Current treatment plan 
- Prescribed medication(s) 
- Risk assessment plan 
 
You can find these rules in Local Coverage Determination (LCD) Controlled Substance Monitoring and Drugs 
of Abuse Testing (L36393). 
 
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 
complete series of x-ray images (D0210) but is limited to one procedure ever three years. You can find this 
information in the dental rider 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 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(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
The rules say that the Secretarys authority in Section 1135 of the Social Security Act (the Act), allowed 
CMS to issue several temporary emergency statutory and regulatory waivers and flexibilities to help providers 
respond to the COVID-19 Public Health Emergency (PHE) and focus on the needs of beneficiaries while 
working to prevent the spread of COVID-19. Since the Secretary has announced the PHE will end on May 11, 
2023, the authority to issue and maintain 1135 waivers ends on that date. You can find this in the Centers for 
Medicare and Medicaid Services Guidance for the Expiration of the Covid-19 Public Health Emergency. 
 
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 receive your care from a provider who is eligible to provide services under 
Original Medicare. If you use an out-of-network provider, your share of the costs for your covered services 
may be higher. While you are a member of the Point of Service (POS) plan, you may use either network 
providers or out-of-network providers. Certain covered services may only be received from network providers. 
You can find this information on pages 32-33 of the Plans 2023 Evidence of Coverage. 
 
The Plan contract says that durable medical equipment is not covered out-of-network. You can find this 
information on page 66 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 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 this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that L5781 describes a complete device that is an addition to a lower limb prosthesis. The 
primary function of the vacuum pump is to suspend the prosthetic limb. Additionally, products coded L5781 
provide residual limb volume management and moisture evacuation. The pump mechanism evacuates air and 
accumulated moisture between the limb and socket walls. The pump mechanism can be actuated by either 
external power and/or mechanical system(s). You can find this rule in the Local Coverage Article (LCA) - 
Lower Limb Prostheses - Policy Article (LCA) (A52496). 
 
The rules say that L5988 describes a separate product which provides 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. L5988 describes an endoskeletal pylon device that allows vertical shock reduction between the foot 
and pelvis during ambulation. The vertical shock reducing pylon feature of L5988 is a separate function from 
other products which use a piston/telescoping mechanism such as products described by L5781 or L5782. The 
predicate product is the Total Shock that was manufactured by Century XXII International, Inc. You can find 
this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (LCA) (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 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 
preventive and comprehensive services. A semi-precision attachment  placement (D6192) is excluded from 
this benefit. You can find this information on pages 58 - 59 and 105 - 124 of the Plans 2023 Evidence of 
Coverage (EOC).