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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with 
both the following: 
 
   1, Inclusion criteria (ALL are required): 
       a, Acute* (< 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 
&#8805; 8) 
           ii. Non-hospitalized with moderate to severe pain (NRS or VAS &#8805;5) despite optimal non-surgical 
management (NSM) (10)** (ONE): 
               1. Worsening pain 
               2. Stable to improved pain (but NRS or VAS still &#8805;5) (with &#8805; 2 of the following): 
                   A. Progression of vertebral body height loss 
                   B. > 25% vertebral body height reduction 
                   C. Kyphotic deformity 
                   D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
>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 
 
You can find this rule in the Local Coverage Determination (LCD) for Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L38213). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs/in-network. 
You can find this information on pages 78-80 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 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 $40 copayment for outpatient rehabilitation services/in-network. You can find this information on page 82 of the Plan's 2019 Evidence of Coverage (EOC) and page 86 of the Plan's 2020 EOC. The Plan contract says that enrollees must pay a $300 copayment for outpatient surgery/in-network/outpatient hospital. You can find this information on page 83 of the Plan's 2019 EOC and on page 87 of the Plan's 2020 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 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 SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances, 
Organization/Coverage Determinations, and Appeals Grievance Manual, Section 50.12.1. 
 
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. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
restorative foundation for an indirect restoration (D2949) and is limited to one procedure per tooth every five 
plan years. You can find this information on page 4-61 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 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 $325 copayment for outpatient facilities and surgical centers/outpatient 
surgery outpatient hospital. You can find this information on pages 4-49 to 4-51 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 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 $400 copayment for each visit to an in-network outpatient hospital 
facility for Medicare-covered services. You can find this information on pages 82-84 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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that 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 SSA, Section 1862(a)(12) and 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 Plan 
contract says that covered non-routine dental care services are limited to surgery of the jaw or related 
structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation 
treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. You 
can find this information on page 84 of the Plan's 2019 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $75 copayment for same day outpatient surgery in a freestanding 
ambulatory surgical center or outpatient hospital. Unless the provided has written an order to admit you as an 
inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient hospital 
services. Even if you stay in the hospital overnight, you might still be considered an ?outpatient.? If you are not 
sure if you are an outpatient, you should ask the hospital staff. You can find this information on pages 92 to 94 
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 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. Physicians must report services 
correctly. This manual discusses general coding principles in Chapter I and principles more relevant to other 
specific groups of HCPCS/CPT codes in the other chapters. There are certain types of improper coding that 
physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes 
the services performed. Physicians must avoid upcoding. AHCPCS/CPT code may be reported only if all 
services described by that code have been performed." You can find this guidance in the Medicare Program 
Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Action, Section 3.3.2.1-
Documents on Which to Base a Determination and National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter 1-General Correct Coding Policies, Section A-Introduction, page I-7 and I-8. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

Please note, the Local Coverage Determinations and Article (LCD/LCA L37649, A57425, and A55624) are not 
binding in this case. These rules do not have jurisdiction where the services were provided.  
 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that 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 rule 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 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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that enrollees must pay a $20 copayment for each Medicare-covered specialist visit. You can find
this information on pages 85 to 86 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 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 SSA, Section 1862(a)(12) and 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 Plan 
contract includes a list of covered supplemental dental services. Treatment of complications is not included on 
this list and is not a covered supplemental benefit. You can find this information on pages 96 to 98 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 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 health 
plan contract says eye refractions are a covered service during a routine eye exam performed by a network 
supplemental Routine Vision Care Provider. You can find this information in Chapter 4 on page 84 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. 
 
The rules say that proper coding is necessary on Medicare claims because the codes are generally used to 
determine coverage and payment amounts. CMS accepts only HIPPA approved ICD-9-CM or ICD-10-
CM/ICD-10-PCS codes, depending on the date of service. Use the diagnosis code that describes the patient?s 
diagnosis, symptom, complaint, condition or problem. Assign the code to the highest level of specificity. The 
"highest degree of specificity" refers to assigning the most precise code that most fully explains the narrative 
description of the symptom or diagnosis. You can find these rules in the Medicare Claims Processing Manual 
Chapter 23, Sections 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 to report a Guardant360 service, please submit the following claim information: 
&#61623; Enter 1 unit of service (UOS) 
&#61623; Enter the appropriate DEX Z-Code identifier adjacent to the Current Procedural Terminology (CPT) 
code 81479 in the comment/narrative field for the following Part B claim field/types: 
o Loop 2400 or SV101-7 for the 5010A1 837P 
o Item 19 for paper claim 
&#61623; Enter the appropriate DEX Z-Code identifier adjacent to the CPT code 81479 in the comment/narrative 
field for the following Part A claim field/types: 
o Line SV202-7 for 837I electronic claim 
o Block 80 for the UB04 claim form 
&#61623; Select the appropriate ICD-10-CM code 
 
You can find this rule in Local Coverage Article (LCA) Billing and Coding: MolDX: Guardant360 Plasma-
Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) (A57425). 
 
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 KX, GA, AND GZ MODIFIERS: 
 
Suppliers must add a KX modifier to a hospital bed code only if all of the criteria in the ?Coverage Indications, 
Limitations and/or Medical Necessity? section of the related LCD have been met. 
 
The KX modifier should also be added for an accessory when the applicable accessory criteria are met. If the 
requirements for the KX modifier are not met, the KX modifier must not be used. 
 
If all of the coverage criteria have not been met, the GA or GZ modifier must be added to a claim line for a 
hospital bed and accessories. When there is an expectation of a medical necessity denial, suppliers must enter 
the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice 
(ABN) or the GZ modifier if they have not obtained a valid ABN. 
 
Claim lines billed without a KX, GA or GZ modifier will be rejected as missing information. 
 
UPGRADE MODIFIERS: 
 
When a hospital bed upgrade is provided, the GA, GK, GL and/or GZ modifiers must be used to indicate the 
upgrade. Fully electric hospital beds must always be billed with these modifiers. 
 
You can find this information in Medicare's Local Coverage Article: Hospital Beds And Accessories - Policy 
Article (A52508). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.