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 the pain of active trigger points can begin as an acute single muscle syndrome resulting from 
stress overload or injury to the muscle, or can develop slowly because of chronic or repetitive muscle strain. 
The pain normally refers distal to the specific hypersensitive trigger point. Trigger point injections are used to 
alleviate this pain. After making the diagnosis of myofascial pain syndrome and identifying the trigger point 
responsible for it, a treatment options is an injection of local anesthetic, with or without corticosteroid, into the 
muscle trigger points. You can find this rule in the Local Coverage Determination for Trigger Point Injections, 
L36859 (eff 12/01/19). 
 
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.
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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The Plan contract says that 
out-of-network services are not covered for routine preventive dental. You can find this information on page 67 
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 plans can restrict members to using contract providers except for emergency care (including 
ambulance services), out-of-area urgently needed care, post-stabilization care, and pre-approved care. You can 
find this rule at 42 CFR Section 422.112(a)(9). 
 
The rules say that a Medicare plan must pay for emergency care regardless of whether the care is provided by a 
contract provider or a non-contract provider. Emergency care ends when the patient is stabilized.  
 
Post-stabilization care is care that is administered to maintain, improve, or resolve the enrollee's stabilized 
condition. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is 
obtained from a non-contract provider, approval is required from the plan. However, the requirement for pre-
approval does not apply if: 
 
1. The Plan does not respond to a request for pre-approval within one hour, 
 
2. The Plan cannot be contacted, or 
 
3. The Plan representative and the treating physician cannot reach an agreement concerning the enrollee's care 
and a plan physician is not available for consultation. 
You can find this rule at 42 CFR Section 422.113(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 
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 10 of the Plan's 2019 
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 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 12 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 at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that lumbar epidural injections are generally performed to treat pain arising from spinal nerve 
roots. These procedures may be performed via three distinct techniques, each of which involves introducing a 
needle into the epidural space by a different route of entry. Local anesthesia or minimal conscious sedation 
may be appropriate. Use of moderate sedation and Monitored Anesthesia Care (MAC) is usually unnecessary. 
Documentation must clearly establish the need for such sedation in the specific patient. You can find this rule 
in the Local Coverage Determination for Lumbar Epidural Injections, L34980 (eff 10/01/19). 
 
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.
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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract says that inn 
general, criteria for crowns will be met only for permanent teeth needing multi-surface restorations where other 
restorative materials have a poor prognosis. Permanent molar teeth must have pathologic destruction to the 
tooth by caries or trauma, and should involve four or more surfaces and two or more cusps. Permanent bicuspid 
teeth must have pathologic destruction to the tooth by caries or trauma, and should involve three or more 
surfaces and at least one cusp. Permanent anterior teeth must have pathologic destruction to the tooth by caries 
or trauma, and must involve four or more surfaces and at least 50% of the incisal edge. You can find this 
information on page 39 of the Plan's 2020 dental contract.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41. 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Medicare Managed Care Manual, 
Chapter 4, Section 30.3. 
 
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 that enrollees must pay a $0 co-payment per trip for 48 one-way trips every year to plan 
approved locations. You can find this information in Chapter 4 on page 96 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 state that the CologuardTM test is covered once every three years for Medicare beneficiaries that 
meet certain criteria. This is covered for those between 50 to 85 years of age with an average risk of developing 
colorectal cancer, such as no family history of colorectal cancer. You can find this information in the National 
Coverage Determination (NCD) for Colorectal Cancer Screening Tests (210.3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that codes A4230 (infusion set for external insulin pump, non-needle cannulas type) and A4231 
(infusion set for external insulin pump, needle type) are not valid for claim submission to the DME MAC 
because they are included in code A4224.  
 
The rules also say that Code K0552 describes a syringe-type reservoir that is used with the K0455 pump when 
it is used to administer epoprostenol/treprostinil, or with an E0779 pump used to administer subcutaneous 
immune globulin. The reservoir may be either glass or plastic and includes the needle for drawing up the drug. 
This code does not include the drug for use in the reservoir. Code A4232 is invalid for submission to Medicare 
and should not be used for this purpose. 
 
You can find this information in the Local Coverage Article: External Infusion Pumps - Policy Article 
(A52507). 
 
The rules say that a physician shall not unbundle services that are integral to a more comprehensive procedure. 
A physician shall not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code 
describes these services. You can find this rule in the Medicare National Correct Coding Initiative Manual, 
Chapter I. 
 
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 Thermal Medial Branch Radiofrequency Neurotomy (includes RF and microwave 
technologies) is covered: 
- Only when dual MBBs provide greater than or equal to 80% relief of the primary or index pain and 
duration of relief is consistent with the agent employed may facet joint denervation with RF medial 
branch neurotomy be considered.  
- Repeat denervation procedures involving the same joint will only be considered medically necessary if 
the patient experienced greater than or equal to 50% improvement of pain and improvement in patient 
specific Activities of Daily Living (ADLs) documented for at least 6 months. 
A maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular injections, 
facet cyst rupture and RF ablations may be performed per year in the cervical/thoracic spine and five (5) in the 
lumbar spine. Non-thermal RF modalities for facet joint denervation including chemical, low grade thermal 
energy (less than 80 degrees Celsius), as well as pulsed RF are not covered. You can find this rule in the Local 
Coverage Determination for Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency 
Neurotomy, L35996 (eff 11/01/19). 
 
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.
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 say that 7th character 'S', sequela, is for use for complications or conditions that arise as a direct 
result of a condition, such as scar formation after a burn.  The scars are sequelae of the burn.  When using 7th 
character 'S', it is necessary to use both the injury code that precipitated the sequela and the code for the 
sequela itself.  The 'S' is added only to the injury code, not the sequela code.  The 7th character 'S' identifies 
the injury responsible for the sequela.  The specific type of sequela (e.g. scar) is sequenced first, followed by 
the injury code. Coding of sequela generally requires two codes sequenced in the following order: the condition 
or nature of the sequela is sequenced first. The sequela code is sequenced second. You can find this rule in the 
ICD-10-CM Official Guidelines for Coding and Reporting FY 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 state that adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the beneficiary 
requires an arm height that is different from that available using nonadjustable arms and the beneficiary spends 
at least 2 hours per day in the wheelchair. One example (not all-inclusive) of a covered indication for 
swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so 
that a beneficiary can perform a slide transfer to a chair or bed. You can find these rules in Local Coverage 
Determination (LCD) Wheelchair Options/Accessories (L33792). 
 
The rules also state that a power seat elevation feature (E2300) and power standing feature (E2301) are non-
covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device 
described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or 
power standing feature, it will be denied as non-covered. Swingaway, retractable, or removable hardware 
(E1028) is non-covered if the primary indication for its use is to allow the beneficiary to move close to desks or 
other surfaces. If it is ordered for this indication, a GY modifier must be added to the code. You can find these 
rules in Local Coverage Article (LCA) Wheelchair Options/Accessories - Policy Article (A52504). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the 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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. Covered dental services are 
listed on pages 4-74 to 4-78 of the plan's 2020 Evidence of Coverage. Any service not listed is not a covered 
benefit.
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* (< 6 weeks) osteoporotic VCF (T5 - L5) by recent (within 30 days) advanced imaging (bone 
marrow edema on MRI or bone-scan/SPECT/CT uptake) (1-3,10,25) 
       b.  Symptomatic (ONE): 
            i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
= 8) (4-7) 
           ii. Non-hospitalized with moderate to severe pain (NRS or VAS =5) despite optimal non-surgical 
management (NSM) (10)** (ONE): 
                1. Worsening pain 
                2. Stable to improved pain (but NRS or VAS still =5) (with = 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 (2,5,8-10) (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) (L33569). 
 
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 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 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; 
 
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. 
 
You can find this information in the Local Coverage Determination (LCD): Cardiovascular Nuclear Medicine 
(L33960). 
 
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.