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 octreotide exerts pharmacologic actions similar to the natural hormone, somatostatin. It is 
an even more potent inhibitor of growth hormone, glucagon, and insulin than somatostatin. By virtue of these 
pharmacological actions, octreotide has been used to treat the symptoms associated with metastatic carcinoid 
tumors (severe diarrhea and flushing) and vasoactive intestinal peptide (VIP) secreting adenomas (profuse 
watery diarrhea). 
 
Octreotide substantially reduces, and in many cases, can normalize growth hormone and/or IGF-1 
(somatomedin C) levels in patients with acromegaly. 
 
        Octreotide acetate for injectable suspension is Food and Drug Administration (FDA) approved for the 
reduction of growth hormone and IGF-1 in patients with acromegaly, for whom medical treatment is 
appropriate, and who have been shown to respond to and can tolerate short-acting subcutaneous octreotide 
acetate. The goal of treatment is to reduce growth hormone and IGF-1 levels to normal. It is also used in 
patients who have had an inadequate response to surgery or in those for whom surgical resection is not an 
option. It is also used in patients who have received radiation and have had an inadequate therapeutic response. 
 
 
    It is FDA approved for the suppression of severe diarrhea and flushing associated with malignant carcinoid 
syndrome in patients in whom initial treatment with short-acting, subcutaneous octreotide acetate has been 
effective and tolerated. 
 
    It is FDA approved for long-term treatment of the profuse watery diarrhea associated with VIP-secreting 
tumors in patients in whom initial treatment with short-acting, subcutaneous octreotide acetate has been shown 
to be effective. 
 
    The approved route of administration of octreotide acetate for injectable suspension is intragluteally, and it 
must be administered under the direct supervision of a physician. 
 
    Octreotide acetate for injectable suspension is covered only when it is used according to FDA guidelines. 
 
    A trial of therapy using the short-acting, subcutaneous form of octreotide acetate is a prerequisite prior to 
administering the long-acting octreotide acetate suspension. However, the short-acting, subcutaneous form of 
octreotide is noncovered by Palmetto Government Benefit Administrators (GBA), because it is self-administrable. 
 
    Octreotide is covered for chemotherapy-induced diarrhea (CID) when oral antidiarrheal medications, such as 
loperamide, have become ineffective. 
 
You can find this information in the Local Coverage Determination (LCD) Octreotide Acetate for Injectable 
Suspension (Sandostatin LAR Depot) L33438. 
 
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 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 an 
occlusal guard hard appliance full arch (D9944) but is limited to one every three years. You can find this 
information on page 4-70 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 in order to be eligible for coverage under Medicare Part B, a drug or biological must be 
administered by a physician or personnel under the physicians supervision. In addition, the charge must be 
included in the physicians bill and the cost of the drug or biological must represent an expense to the 
physician. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.3. 
 
The rules say that it is covered under this benefit when the patient has a diagnosed primary immune deficiency 
disease, it is administered in the home of a patient with a diagnosed primary immune deficiency disease, and 
the physician determines that administration of the derivative in the patients home is medically appropriate. 
The benefit does not include coverage for items or services related to the administration of the derivative. For  
coverage of IVIG under this benefit, it is not necessary for the derivative to be administered through a piece of 
durable medical equipment. You can find this information in the Medicare Benefit Policy Manual Chapter 15  
Covered Medical and Other Health Services; 50.6  Coverage of Intravenous Immune Globulin for Treatment 
of Primary Immune Deficiency Diseases in the Home. 
 
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 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 specific 
dental codes listed in a dental benefits chart. Removal of impacted tooth (D7240) and therapeutic parenteral 
drugs, two or more administrations (D9612) are not covered dental services. You can find this information in 
Chapter 4 on pages 58 to 71 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 intermittent catheterization is covered when basic coverage criteria are met and the 
beneficiary or caregiver can perform the procedure. 
 
For each episode of covered catheterization, Medicare will cover: 
 
     A. One catheter (A4351, A4352) and an individual packet of lubricant (A4332); or 
     B. One sterile intermittent catheter kit (A4353) if additional coverage criteria (see below) are met. 
Intermittent catheterization using a sterile intermittent catheter kit (A4353) is covered when the beneficiary 
requires catheterization and the beneficiary meets one of the following criteria (1-5): 
 
     1. The beneficiary resides in a nursing facility, 
     2. The beneficiary is immunosuppressed, for example (not all-inclusive): 
            a. on a regimen of immunosuppressive drugs post-transplant, 
            b. on cancer chemotherapy, 
            c. has AIDS, 
            d. has a drug-induced state such as chronic oral corticosteroid use. 
      3. The beneficiary has radiologically documented vesico-ureteral reflux while on a program of intermittent 
catheterization, 
      4. The beneficiary is a spinal cord injured female with neurogenic bladder who is pregnant (for duration of 
pregnancy only), 
      5. The beneficiary has had distinct, recurrent urinary tract infections, while on a program of sterile 
intermittent catheterization with A4351/A4352 and sterile lubricant A4332, twice within the 12-month prior to 
the initiation of sterile intermittent catheter kits. 
 
A beneficiary would be considered to have a urinary tract infection if they have a urine culture with greater 
than 10,000 colony forming units of a urinary pathogen AND concurrent presence of one or more of the 
following signs, symptoms or laboratory findings: 
 
* Fever (oral temperature greater than 38o C [100.4o F]) * Systemic leukocytosis 
* Change in urinary urgency, frequency, or incontinence 
* Appearance of new or increase in autonomic dysreflexia (sweating, bradycardia, blood pressure elevation) 
* Physical signs of prostatitis, epididymitis, orchitis 
* Increased muscle spasms 
* Pyuria (greater than 5 white blood cells [WBCs] per high-powered field) 
 
Usual Maximum Quantity of Supplies: 
 
Code                    Number per Month 
 
A4332                         200 
 
A4351                         200 
 
A4352                         200 
 
A4353                         200 
 
You can find this rule in the Local Coverage Determination (LCD) Urological Supplies L33803. 
 
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 417.414. 
 
The rules say that, in order to receive covered post hospital SNF services, the beneficiary must have a 
medically necessary inpatient hospital stay for at least three consecutive calendar days, not counting the day of 
discharge. You can find this rule at 42 Code of Federal Regulations (CFR) Section 409.30. 
 
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 determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiarys potential functional abilities. Potential functional ability is based on the reasonable 
expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to: 
 
1. The beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
3. The beneficiarys desire to ambulate. 
You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
The rules say that a level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical 
of the community ambulator who has the ability to traverse most environmental barriers and may have 
vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. You 
can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
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.  
 
 
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 specific 
dental procedure codes included in a dental benefits chart. Removal of impacted tooth partially bony (D7230) 
and therapeutic parenteral drugs, two or more administrations (D9612) are not listed as covered dental benefits. 
You can find this information on pages 4-58 to 4-70 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 an "order" is a communication from the treating physician/practitioner requesting that a 
diagnostic test be performed for a beneficiary. While a physician order is not required to be signed, the 
physician must clearly document, in the medical record, his or her intent that the test be performed. You can 
find this information in the Medicare Benefit Policy Manual, Chapter 15, Section 80.6. 
 
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 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 in Chapter 4 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 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 that an "order" is a communication from the treating physician/practitioner requesting that a 
diagnostic test be performed for a beneficiary. While a physician order is not required to be signed, the 
physician must clearly document, in the medical record, his or her intent that the test be performed. You can 
find this information in the Medicare Benefit Policy Manual, Chapter 15, Section 80.6. 
 
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 payment for inpatient psychiatric hospital services is to be made only for active treatment. 
For services to be designated as active treatment they must: 
 
1. be provided under an individualized treatment or diagnostic plan; 
2. reasonably be expected to improve the patients condition, or for the purpose of diagnosis; and 
3. be supervised and evaluated by a physician.   
 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 2, Sections 30.2.2 and 30.2.2.1. 
 
The rules say that Medicare will not pay any expenses for items or services which are not medically necessary 
and reasonable for the diagnosis or treatment of illness or injury. This exclusion extends to claims for services 
which are provided in inappropriate settings. You can find this rule in the Social Security Act, Section 
1862(a)(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 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 a list of 
all covered services/codes. If a service/code is not listed, it is not a covered benefit. You can find this 
information on pages 70-71 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 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 that Medicare provided the CS modifier for the gulf oil spill in 2010, but recently repurposed the 
CS modifier for COVID-19 purposes. Now, for services provided on March 18, 2020, and through the end of 
the Public Health Emergency (PHE), the CS modifier should be used on applicable claim lines to show the 
service is subject to the cost-sharing waiver for COVID-19 testing-related services. Dont charge Medicare 
patients any co-insurance and deductible amounts for those services. You can find this information in the 
Centers for Medicare and Medicaid Services, Medicare Learning Network (MLN) Matters: Medicare Fee for 
Service (FFS) Response to the PHE on COVID-19. 
 
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.