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 use of the appropriate HCPCS code assures that accurate processing can be accomplished 
resulting in a proper claim determination and reimbursement. The HCPCS is a standardized set of codes used 
for billing items and services to all payers, including Medicare and Medicaid. The HCPCS is divided into two 
principal subsystems, referred to as level I and level II. Since 2003, authority has been delegated to CMS to 
maintain and distribute HCPCS Level II codes.  The DME MACs and the Pricing, Data Analysis, and Coding 
(PDAC) contractor are responsible for assigning individual DMEPOS products to HCPCS code categories for 
billing Medicare. When a product has been formally reviewed by the DME MACs or PDAC, the manufacturer 
is provided with a letter informing them of the correct coding to be used for Medicare billing purposes. Not 
every HCPCS code has a product classification list; but reviewed products are added to the listings for each 
code as coding determinations are completed.  For Medicare claim purposes, this product classification listing 
is accepted as evidence of correct coding. You can find this information on the PDAC website in a DME MAC 
Joint Publication found at https://www.dmepdac.com/palmetto/PDAC.nsf/DID/J54ATVITZH 
 
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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with BOTH the following:

    1. Inclusion criteria (ALL are required):
       a. Acute* (less than 6 weeks) osteoporotic VCF (T5 - L5) by recent (within 30 days) advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake)
        b. Symptomatic (ONE):
            i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score greater than or equal to 8) 
          ii. Non-hospitalized with moderate to severe pain (NRS or VAS  greater than or equal to 5) despite optimal non-surgical management (NSM) (10)** (ONE):
                1. Worsening pain
                2. Stable to improved pain (but NRS or VAS still greater than or equal to 5) (with greater than or equal to 2 of the following):
                    A. Progression of vertebral body height loss
                    B. Greater than 25% vertebral body height reduction
                    C. Kyphotic deformity
                    D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) greater than 17
        c. Multidisciplinary team consensus (2) (ALL are required)
           i. Referring physician (e.g., rheumatologist, endocrinologist)
           ii. Treating physician (i.e., performing the PVA)
            iii. Radiologist
           iv. Neurologist

    2 .Exclusion criteria (Can have NONE of the following):
        a. Absolute contraindication
            1. Current back pain is not primarily due to the identified acute VCF(s).
            2. Osteomyelitis, discitis or active systemic infection
           3. Pregnancy
           4. Greater than three vertebral fractures
       b. Relative contraindication
            1. Allergy to bone cement or opacification agents
            2. Coagulopathy
            3. Spinal instability
            4. Myelopathy from the fracture
           5. Neurologic deficit
            6. Neural impingement
            7. Fracture retropulsion/canal compromise
*at least an acute component (e.g., acute on chronic)

**consider including pedicle periosteal infiltration 7.

You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous Vertebral  Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L34228).

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 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 $270 copayment for surgery or other services you receive in an 
outpatient hospital facility. You can find this information on pages 4-48 and 4-49 of the Plan's 2020 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 must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(A). 
 
The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. You can find 
this in the Medicare National Coverage Determinations Manual, Chapter 1, Section 280.6. 
 
The rules say that a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints 
(L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury 
to or a surgical procedure on the knee(s). 
  
The rules also say that knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a 
beneficiary who is ambulatory and has knee instability due to a condition specified in the ICD-10 Codes that 
Support Medical Necessity Group 4 Codes section. Knee instability must be documented by examination of the 
beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer 
test). Claims will be denied as not reasonable and necessary when the beneficiary does not meet the above 
criteria for coverage. You can find this rule at Local Coverage Determination (LCD): Knee Orthoses (L33318). 
 
The rules state that replacement refers to the provision of an identical or nearly identical item. Equipment 
which the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. 
Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot 
be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful 
lifetime of the equipment, which may be no less than five years. Replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover 
repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by 
the beneficiary. You can find this information in the Medicare Benefit Policy Manual, Chapter 15, Section 
110.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 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 4 of the 2020 Evidence 
of Coverage.  
 
The Plan contract says that outpatient mental health services may require prior authorization. You can see this 
on page 78 of the 2020 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 at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that cardiovascular nuclear imaging is indicated for the following:-Assessment of the functional and prognostic importance of angina;-Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused by drugs, bundle branch block, or left ventricular hypertrophy;-Assessment of congenital anomalies of coronary arteries;-Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years;-Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed heart failure or left ventricular systolic dysfunction;-Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization / coronary angiography are not planned;-Evaluation of myocardial perfusion and/or function before and after coronary artery bypass surgery or other re-perfusion procedures;-Quantification and surveillance of myocardial infarction and prognostication in patients with infarction;-Assessment of congenital anomalies of coronary arteries;-Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery and/or perioperative management-Evaluation of ventricular function in patients with non-ischemic myocardial disease;-Evaluation of patients in whom an accurate measure of the ejection fraction is needed to make a determination of whether to implant a defibrillator or biventricular pacemaker;-Evaluation of a patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., adriamycin).You can find this rule in Local Coverage Determination (LCD):Cardiovascular Nuclear Medicine (L33560) -Effective October 1, 2019.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers 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 $300 copayment for outpatient hospital services. The contract also says 
that enrollees pay a $90 copayment for emergency room visits. You can find this information on pages 54 and 
44 of the Plan's 2020 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 therapeutic continuous glucose monitors (CGMs_ and related supplies are covered by 
Medicare when all of the following coverage criteria (1-6) are met: 
1.      The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses); and, 
2.      The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and, 
3.      The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump; and, 
4.      The beneficiarys insulin treatment regimen requires frequent adjustment by the beneficiary on the basis 
of BGM or CGM testing results; and, 
5.      Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the 
beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and, 
6.      Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
  
If any of coverage criteria (1-6) are not met, the CGM and related supply allowance will be denied as not 
reasonable and necessary. You can find this rule in the Local Coverage Determination for Glucose Monitors, 
L33822 (eff 01/01/20). 
 
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 $295 copayment for outpatient surgery provided in an outpatient 
hospital facility. You can find this information in Chapter 4 on page 84 of the Plan's 2020 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 must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(A). 
 
The rules state that when completing the 1500 claim form, providers must enter the correct Place of Service 
(POS) code in section 24B.  Invalid or incorrect POS codes will be denied and returned to the provider.  You 
can find this rule at Medicare Claims Processing Manual Ch. 26 10.6. 
 
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. 
 
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 
covers vision services for an annual routine eye exam to determine changes in your vision and/or the need for 
eyeglasses or contact lenses when provided by a preferred provider. You can find this information on pages 79-
80 of the Plan's 2020 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.Medicare rules state that a total electric hospital bed is not covered. The height adjustment feature is a convenience feature. You can find this rule in the DME MAC Local Coverage Determination L33820, Hospital Beds and Accessories (effective October 1, 2015).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers 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 standard electric heating pad (E0210) is covered to relieve certain types of pain, decrease 
joint and soft tissue stiffness, relax muscles, or reduce inflammation. It has not been established that a moist 
electric heating pad (E0215) or water circulating heat pad with pump (E0217) is reasonable and necessary 
compared to a standard electric heating pad (E0210); therefore, if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary. You can find this information in the Local Coverage Determination 
(LCD): Heating Pads and Heat Lamps (L33784). 
 
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 $35 copayment for specialist services. You can find this information in 
Chapter 4 on pages 88 - 89 of the Plan's 2020 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 A group 2 support surface is covered if the beneficiary meets at least one of the following 
three Criteria (1, 2 or 3): 
1. The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis which have failed to 
improve over the past month, during which time the beneficiary has been on a comprehensive ulcer 
treatment program including each of the following:  
a. Use of an appropriate group1 support surface, and 
b. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and 
c. Appropriate turning and positioning, and 
d. Appropriate wound care, and 
e. Appropriate management of moisture/incontinence, and 
f. Nutritional assessment and intervention consistent with the overall plan of care 
2. The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis, 
3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within 
the past 60 days, and has been on a group 2 or 3 support surface immediately prior to discharge from a 
hospital or nursing facility within the past 30 days 
When the stated coverage criteria for a group 2 mattress or bed are not met, a claim will be denied as not 
reasonable and necessary. You can find this rule in the Local Coverage Determination for Pressure Reducing 
Support Surfaces, L33642 (eff 01/01/20). 
 
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.