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 an addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988) is an 
additional feature and/or function that does not describe a complete prosthetic foot and may be used in 
combination with L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979, L5980, L5981, and L5987. The 
use of additional feature L-codes may also depend on the assigned K-Level modifier (K0-K4) as referenced in 
the LCD. You can find this information in the Local Coverage Article: Lower Limb Prostheses  Policy Article 
(A52496). 
 
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. 
 
K2 - Lower extremity prosthesis functional Level 2 - Has the ability or potential for ambulation with the ability 
to traverse low level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited 
community ambulator. 
 
You can find this information in the Local Coverage Determination (LCD) for Lower Limb Prostheses 
(L33787). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that one to two levels, either unilateral or bilateral, are allowed per session per spine region. The 
need for a three or four-level procedure bilaterally may be considered under unique circumstances and with 
sufficient documentation of medical necessity on appeal. A session is a time period, which includes all 
procedures (i.e., medial branch block (MBB), intraarticular injections (IA), facet cyst ruptures, and RFA 
ablations that are performed during the same day. You can find this information in Local coverage 
Determination (LCD): Facet Joint Interventions for Pain Management (L35936). 
 
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 typically, psychological testing will require from four (4) to six (6) hours to perform, 
including administration, scoring and interpretation. Supporting documentation in the medical record must be 
present to justify greater than 8 hours per patient per evaluation. You can find this information in the Local 
Coverage Determination (LCD) for Psychiatry and Psychology Services (L33632). 
 
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 
coverage for items/services stated in the Plans contract. Prosthetics are limited to one per arch every five 
years. You can find this information on page 73 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 a Pneumatic Compression Device (PCD) that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a 
preventative service or function are excluded from coverage under the Medicare Durable Medical Equipment 
(DME) benefit. You can find this information in the Local Coverage Article: Pneumatic Compression Devices 
- Policy Article (A52488) and in the Local Coverage Determination (LCD): Pneumatic Compression Devices 
(L33829). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
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 patient status code 06 should be reported in all cases where the home health agency (HHA) 
is aware that the period of care will be paid a partial period payment adjustment. These are cases in which  
the agency is aware that the beneficiary has transferred to another HHA within the 30-day period, or the agency 
is aware that the beneficiary was discharged with the goals of the original plan of care met and has been 
readmitted within the period. Situations may occur in which the HHA is unaware at the time of billing the 
discharge that these circumstances exist. In these situations, Medicare claims processing systems will adjust the 
discharge claim automatically to reflect the partial period payment adjustment, changing the patient status code 
on the paid claims record to 06. You can find this information in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, 
Section 40.2. 
 
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 repeat epidural steroid injections (ESIs) when the first injection directly and significantly 
provided improvement of the condition being treated may be considered medically reasonable and necessary 
when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement 
in function measured from baseline using same scale for at least three months. If a patient fails to respond well 
to the initial ESI, a repeat ESI after 14 days can be performed, using a different approach, level and/or 
medication if appropriate, with the rationale and medical necessity for the second ESI documented in the 
medical record. You can find this information in Local Coverage Determination (LCD): Epidural Steroid 
Injections for Pain Management (L39036). 
 
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 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 a Medicare plan may restrict enrollees to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the plan must 
arrange for specialty care outside of the plan provider network when network providers are unavailable or 
inadequate to meet an enrollees medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community-based 
services. You can find this rule at 42 CFR Section 422.112. 
 
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 pages 38 to 39 of the Plan's 
2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that repeat Hyaluronan treatments are considered medically necessary for patients being treated 
for osteoarthritis of the knee, who meet both of the following criteria: 
 
1. Significant improvement in knee pain and known improvement in functional capacity resulted from the 
previous series of injections which has been documented in the record; and 
2. At least six (6) months have elapsed since the last injection in the series. 
3. The patient has failed at least three months of conservative therapy.  
 
This information is found in Local Coverage Article Billing and Coding Billing and Coding: Intraarticular 
Knee Injections of Hyaluronan (A56157) and Local Coverage Determination (LCD): Viscosupplementation 
Therapy For Knee (L33767). 
 
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/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 effective for claims with dates of service July 1, 2007 and after, the non-Outpatient 
Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. 
This integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital 
claims, through a single integrated OCE eliminating the need to update two separate OCE software packages 
on a quarterly basis. You can find this rule in the Centers for Medicare and Medicaid Services, Integrated OCE 
(IOCE) CMS Specifications V23.2 Effective July 1, 2022, Section 40.1. 
 
The rules say that the integrated OCE does not change the current logic that is applied to outpatient bill types 
that already pass through the OPPS OCE software. It merely expands the software usage to include non-OPPS 
hospitals. This new software product will be referred to as the Integrated OCE (I/OCE). The following bill 
types are subject to OPPS: All outpatient hospital Part B bills (bill types 12X, 13X with condition code 41 14X 
and 13X without condition code 41) with the exception of bills from hospitals in Maryland, Indian Health 
Service, CAHs, hospitals located in Saipan, American Samoa, the Virgin Islands and Guam; and hospitals that 
provide Part B only services to their inpatients. Effective 4/1/06 the 14X type of bill is for nonpatient 
laboratory specimens and is no longer applicable for partial hospitalization billing. You can find this rule in the 
Centers for Medicare and Medicaid Services, Integrated OCE (IOCE) CMS Specifications V23.2 Effective July 
1, 2022, Section 120.1. 
 
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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
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. 
 
The rules say that telecommunications technology (other than audio-only telephone calls) can include: remote 
patient monitoring, defined as the collection of physiologic data (for example, ECG, blood pressure, glucose 
monitoring) digitally stored and/or transmitted by the patient or caregiver or both to the home health agency; 
teletypewriter (TTY) technology; and 2-way audio-video telecommunications technology that allows for real-
time interaction between the patient and clinician. Telecommunications technology can be ordered as part of a 
home health plan of care, but such services cannot be reported as a visit without the provision of another skilled 
service. If telecommunications technologies are used by the home health agency, the costs of any equipment, 
set-up, and service related to the technology are allowable only as administrative costs. Visits to a beneficiary's 
home for the sole purpose of supplying, connecting, or training the patient on the technology, without the 
provision of a skilled service, are not separately billable. However, HHAs may include the costs of 
telecommunications technology as an allowable administrative cost (that is, operating expense), if the 
technology is used by the HHA to augment the care planning process. You can find this rule in the CMS, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual Chapter 7, Section 80.10. 
 
The rules say that this service has to be administered by a Registered Nurse for these procedure codes. You can 
find this information in the Local Coverage Article: Billing and Coding: Independent Diagnostic Testing 
Facilities (IDTF) (A58559). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 105 of the Plans 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that glaucoma surgical aqueous drainage devices will be considered medically reasonable and 
necessary when approved by the FDA and used within accordance of the FDA-approved/cleared indications. 
 
    A single insertion per eye of an anterior segment aqueous drainage device(s), without extraocular reservoir, 
via internal approach into the trabecular meshwork or with creation of intraocular reservoir into the supraciliary 
space is considered medically reasonable and necessary in conjunction with cataract surgery for the treatment 
of adults with mild or moderate open-angle glaucoma and a cataract when the individual is currently being 
treated with an ocular hypotensive medication. 
    A single insertion per eye of an aqueous drainage device(s) without extraocular reservoir, via internal 
approach into the subconjunctival space is considered medically reasonable and necessary as a standalone 
treatment for refractory glaucoma, defined as prior failure of filtering/cilioablative procedure and/or 
uncontrolled IOP (progressive damage and/or mean diurnal medicated IOP greater than or equal to 20 mmHg) 
on maximally tolerated medical therapy (i.e., greater than or equal to 4 classes of topical IOP-lowering 
medications, or fewer in the case of tolerability or efficacy issues). 
 
You can find this information in the Local Coverage Determination (LCD) Micro-Invasive Glaucoma Surgery 
(MIGS) L38223. 
 
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 pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
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 Plan 
contract also says that we cover all medically necessary DME covered by Original Medicare. You can find this 
information on page 77 of the Plan's 2022 Evidence of Coverage.