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 a PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in 
beneficiaries with chronic and severe lymphedema when all of the following three requirements are met: 
1. The beneficiary has a diagnosis of lymphedema as defined above, and 
2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented 
presence of at least one of the following clinical findings: 
o Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
o Papillomatosis cutis lymphostatica, 
o Deformity of elephantiasis, 
o Skin breakdown with persisting lymphorrhea, 
o Detailed measurements over time confirming the persistence of the lymphedema with a history 
evidencing a likely etiology, and 
3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to 
other clinical treatment over the course of a required four-week trial. 
You can find this rule at Local Coverage Determination (LCD) L33829: Pneumatic Compression Devices (eff. 
1/1/20). 
 
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 state that where electric nerve stimulation is employed to treat motor function disorders, no 
reimbursement may be made for the stimulator or for the services related to its implantation since this treatment 
cannot be considered reasonable and necessary. This information is found in National Coverage Determination 
(NCD): Treatment of Motor Function Disorders with Electric Nerve Stimulation (160.2). 
 
 
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 a long-term acute care hospital (LTA CH) is a hospital that has a n average inpatient length of 
stay of greater tha n 25 d ays. You can find this rule in the Social Security Act, Section 1886( d)(1)(B)(iv)(I).   
 
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the 
diagnosis and c ondition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need 
medical care. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100 -08, Me dicare Program Integrity Manual, Chapter 6, Section 6.5.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Pl an 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 must notify the enrollee in writing before a Medicare plan ends coverage of 
skilled nursing facility services. A Notice of Medicare Non-Coverage (NOMNC) must be issued no later than 
two days before the last covered day. The notice must state: 
 
1. The date that coverage of services ends, 
2. The date that the enrollee must begin to pay for the services, and 
3. A description of the enrollee's right to a fast-track appeal and other appeal procedures. 
The Medicare plan must continue to cover services until two days after valid notice is delivered. You can find 
this rule at 42 CFR Section 422.624. 
 
The rules say that notification of changes for an enrollee who is incapable of receiving or incompetent to 
receive the notice must be made to a representative of the enrollee. You can find these rules in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 30, Section 260.3.8. 
 
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 services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that this coverage policy provides the following information: 
 defines tests required to register for a unique identifier 
 defines tests required to submit a complete technical assessment (TA) for coverage determination 
 defines the payment rules applied to covered tests that are not reported with specific codes from a code 
set recognized in 45 CFR 162.1002 (a)(5), and termed HIPAA compliant code sets throughout the 
remainder of this LCD 
 lists specific covered tests that have completed the registration and TA process and meets 
Medicares reasonable and necessary criteria for coverage. 
You can find this rule in Local Coverage Determination (LCD) MolDX: Molecular Diagnostic Tests (MDT) 
L36807. 
 
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 items that do not contribute meaningfully to the treatment of an illness or injury or the 
functioning of a malformed body member are not covered. Charges for special items requested by the patient 
such as radio, television, telephone, and air conditioner, and beauty and barber services are excluded from 
coverage. You can find this rule at Medicare Benefit Policy Manual Chapter 16 - General Exclusions from 
Coverage - Personal Comfort Items (Rev. 1, 10-01-03) A3-3156, HO-260.6, B3-2318. 
 
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 the Plan covers inpatient care. Covered services include but are not limited to: Semi-private 
room (or a private room if medically necessary), meals including special diets, regular nursing services, costs 
of special care units (such as intensive care or coronary care units), drugs and medications, lab tests, x-rays and 
other radiology services, necessary surgical and medical supplies, use of appliances, such as wheelchairs, 
operating and recovery room costs, physical, occupational, and speech language therapy. Under certain 
conditions, the following types of transplants are covered: corneal, kidney, kidney-pancreatic, heart, liver, lung, 
heart/lung, bone marrow, stem cell, and intestinal/multivisceral. Blood - including storage and administration. 
Coverage begins with the first pint of blood that you need. Physician services. You can find this information on 
pages 4-28 to 4-31 of the Plans 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 durable medical equipment (DME) and related 
supplies. You can find this information on pages 70 and 71 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 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 $50 copayment for laboratory services. You can find this information in 
chapter 4 on page 112 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 standard walker (E0130, E0135, E0141, E0143) and related accessories are covered if all of 
the following criteria (1-3) are met: 
1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADL) in the home. 
 
A mobility limitation is one that: 
 
a. Prevents the beneficiary from accomplishing the MRADL entirely, or 
b. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality 
secondary to the attempts to perform the MRADL, or 
c. Prevents the beneficiary from completing the MRADL within a reasonable time frame; and 
2. The beneficiary is able to safely use the walker; and 
3. The functional mobility deficit can be sufficiently resolved with use of a walker. 
You can find this rule at Local Coverage Determination (LCD) L33791: Walkers (eff. 1/1/20). 
 
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 20% coinsurance for prosthetic devices and related supplies. You can find 
this information in chapter 4 on page 111 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 the claims processing systems contain edits which identify exact duplicate claims and 
suspect duplicate claims. All exact duplicate claims or claim lines are auto-denied or rejected (absent 
appropriate modifiers). Suspect duplicate claims and claim lines are suspended and reviewed by the claims 
administration contractors to make a determination to pay or deny the claim or claim line. You can find this 
information in the Medicare Claims Processing Manual Chapter 1 - General Billing Requirements; 120.1 - 
Overview. 
 
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 an add-on code is a HCPCS/CPT code that describes a service that, with one exception is 
always performed in conjunction with another primary service. An add-on code with one exception is eligible 
for payment only if it is reported with an appropriate primary procedure performed by the same practitioner. 
An add-on code with one exception is never eligible for payment if it is the only procedure reported by a 
practitioner. Add-on codes may be identified in three ways: 1. The code is listed in this CR or subsequent ones 
as a Type I, Type II, or Type III add-on code. 2. On the Medicare Physician Fee Schedule Database an add-on 
code generally has a global surgery period of "ZZZ". 3. In the CPT Manual an add-on code is designated by the 
symbol "+". The code descriptor of an add-on code generally includes phrases such as "each additional" or 
"(List separately in addition to primary procedure)." CMS has divided the add-on codes into three groups to 
distinguish the payment policy for each group. 2. Type II - A Type II add-on code does not have a specific list 
of primary procedure codes. The CR lists the Type II add-on codes without any primary procedure codes. 
Claims processing contractors are encouraged to develop their own lists of primary procedure codes for this 
type of add-on codes. Like the Type I add-on codes, a Type II add-on code is eligible for payment if an 
acceptable primary procedure code as determined by the claims processing contractor is also eligible for 
payment to the same practitioner for the same patient on the same date of service. You can find this 
information in the Final Complete File of Add-on Code Edits for January 01, 2020, for Medicare, Type I CPT 
Manual, HCPCS Manual, and/or CMS Policy defines all acceptable primary codes: For Add-on code  76937; 
appropriate Primary Codes  Contractor Defined Primary Code(s). 
 
The rules say that HCPCS 76937, Global Days  ZZZ. You can find this information in the 2022 National 
Physician Fee Schedule Relative Value File Release. 
 
The rules say that this field provides the postoperative time frames that apply to payment for each surgical 
procedure or another indicator that describes the applicability of the global concept to the service. ZZZ = Code 
related to another service and is always included in the global period of the other service. (Note: Physician work is associated with intra-service time and in some instances the post service time.). You can find this 
information in the Medicare Claims Processing Manual, Chapter 23  Fee Schedule Administration and Coding 
Requirements, 50.6 -Physician Fee Schedule Payment Policy Indicator File Record Layout: Field # & Item  
16 Global Surgery. 
 
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 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 DME benefit. A PCD coded as 
E0675 to treat peripheral arterial disease is not eligible for reimbursement. There is insufficient evidence to 
demonstrate that reimbursement is justified. Claims for E0675 will be denied as not reasonable and necessary. 
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). 
 
Medicare rules say that the facility or hospital must furnish all necessary covered services to the beneficiary 
either directly or under arrangements made between the facility hospital and outside providers. Applicable 
payments are payment in full for all facility or hospital services, as defined in 42 CFR 409.10. Centers for 
Medicare & Medicaid Services (CMS) does not pay any provider or supplier other than the facility or hospital 
for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to 
the beneficiary either directly or under arrangements (as defined in 42 CFR 409.32). You can see this in 42 
CFR 412.50. 
 
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 cardiovascular stress testing would not be considered Reasonable and Necessary when the 
incremental information obtained from a repeat test or from the addition of an echocardiogram to an electrical 
stress test is of no clinical relevance or when a stress test is performed too frequently. 
 
You can find these rules in the Local Coverage Determination (LCD) for Cardiovascular Stress Testing, 
Including Exercise and/or Pharmacological Stress and Stress Echocardiography (L34324). 
 
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 Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL the following criteria: 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant 
deformity. 
 
Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who 
meet ALL of the following criteria: 
a. The patient has had two (2) medically reasonable and necessary diagnostic facet joint 
procedures with each one providing a consistent minimum of 80% relief of primary (index) pain 
(with the duration of relief being consistent with the agent used) AND 
b. Subsequent therapeutic facet joint procedures at the same anatomic site results in at least 
consistent 50% pain relief for at least three (3) months from the prior therapeutic procedure or at 
least 50% consistent improvement in the ability to perform previously painful movements and 
ADLs as compared to baseline measurement using the same scale; AND 
c. Documentation of why the patient is not a candidate for radiofrequency ablation (such as 
established spinal pseudarthrosis, implanted electrical device) 
 
Therapeutic intraarticular facet injections are not covered unless there is documentation on why RFA cannot be 
performed. Individual consideration may be considered under unique circumstances and with sufficient 
documentation of medical necessity on appeal. You can find this rule in the Local Coverage Determination for 
Facet Joint Interventions for Pain Management, L38765. 
 
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 only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b). 
 
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 services include: Manual manipulation of the spine to correct subluxation (when one 
or more of the bones of your spine move out of position). Excluded from Medicare coverage is any service 
other than manual manipulation for the treatment of subluxation. You can find this information in Chapter 4 on 
pages 4-13 to 4-14 of the Plan's 2022 Evidence of Coverage.