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 physical therapy, occupational therapy , and speech therapy services are covered only when 
they are medically reasonable and necessary. Therapy services are considered reasonable and necessary when: 
  
   
1. The services are specific and effective treatment for the patient's condition, 
 
2. The services require the skills or direct supervision of a therapist,  
 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. 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 220.2. 
 
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 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 specific dental procedure codes listed. Gingival irrigation  per quadrant (D4921) is not listed as 
covered. You can find this information in Chapter 4 on pages 4-58 to 4-69 of the Plans 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 state that abdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the 
abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally, 
chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, and the above symptoms 
have been present for at least three months and are refractory to usual standard medical therapy, such surgery 
may be considered reconstructive. Preoperative photographs may be required to support justification and 
should be supplied upon request. 
 
You can find this information in the Local Coverage Determination (LCD) Plastic Surgery L37020. 
 
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 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 the 
requested oral evaluation - new or established patient (D0150) but is limited to one procedure every three plan 
years. This benefit includes only those items and services specifically listed in your Plan contract. Cone beam 
CT capture and interpretation with field of view of both jaws; with or without cranium (D0367) is not covered 
under the Plans dental benefits. You can find this information on pages 4-83 to 4-98 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 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 one pontic and one retainer crown every five calendar years. You can find this information on 
pages 71-74 of the Plan's 2023 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 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 a determination of the type of foot for the prosthesis will be made by the treating practitioner 
and/or the prosthetist based upon the functional needs of the beneficiary. Basic lower extremity prostheses 
include a SACH foot. Other prosthetic feet are considered for coverage based upon functional classification. A 
microprocessor-controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with 
multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system 
with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above.  You can 
find this information in Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
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 all line items for the same beneficiary, same NPI, and same date of service shall be subject to NCCI procedure-to-procedure (PTP) edits. If the CCMI of a PTP edit is "0", the column two code is not eligible for payment even if an NCCI-associated modifier is appropriately appended to one of the codes. If the CCMI of a PTP edit is "1", the edit may be by passed and the column two code of the edit may be eligible for payment if an NCCI-associated modifier is appropriately appended to one of the codes. If the two codes of a code pair edit have the same NCCI-associated anatomic modifiers, the edit should not be bypassed unless an additional NCCI-associated modifier is appended to one of the codes indicating the reason to bypass the edit. You can find this information in Medicare Claims Processing Manual Chapter 23, Section 20.9.1.1.
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 $195 copayment for surgical services provided at an outpatient hospital. 
You can find this information on page 93 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 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 state that when completing the 1500 claim form, providers must enter the correct Place of Service (POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. You can find this rule at Medicare Claims Processing Manual Ch. 26 Section 10.6
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that the following revenue codes are used for reporting vaccines and administration of the vaccines for all providers except rural health clinics (RHCs) and federal qualified health centers (FQHCs). Revenue Code 0636 for pharmacy, drugs requiring detailed coding. Revenue Code 0771 for preventive care services, vaccine administration. Independent and provider based RHCs and FQHCs follow Section 10.2.2.2 below when billing for influenza virus, pneumococcal, hepatitis B, and COVID-19 vaccines. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 10.2.2.
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).
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 coverage for CPT code 64450 is limited to the diagnosis codes listed. Any diagnosis code 
billed that is not listed means code 64450 would be not covered. 
You can find this rule in the Local Coverage Article Billing and Coding: Peripheral Nerve Blocks, A57452. 
 
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 that a cardiac computed tomography (CCT) scan may be covered for these indications: 
 
a. Patient presenting with chest pain syndrome. 
b. To facilitate the management decision of a patient with an equivocal stress test. 
c. When the recurrence of symptoms in patients with known coronary artery disease may be related to 
progression/exacerbation of underlying disease. 
d. When patients with prior bypass surgery or intracoronary artery stent placement present with chest pain or 
dyspnea. 
e. Suspected congenital anomalies of the coronary circulation. 
f. The assessment of coronary or pulmonary venous anatomy. 
g. The patient undergoing non-coronary artery cardiac surgery. 
h. The test may be medically necessary in patients presenting to the emergency room with complaints 
consistent with cardiac ischemia, but without diagnostic electrocardiography (ECG) or enzymes. 
i. The test may be considered medically necessary in patients status post revascularization procedures who 
present with recurrent symptoms not clearly identifiable as ischemic. 
 
You can find this information in the Local Coverage Determination (LCD) L33559: Cardiac Computed 
Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA). 
 
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 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. 
 
A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in 
patients who meet all the following criteria: 
- The patient meets the criteria for the first diagnostic procedure; and 
- After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 
80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) 
 
You can find this information in Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L38803). 
 
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 fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or 
more of the following criteria (1-4) are met: 
  
  1. The beneficiary has a medical condition which requires positioning of the body in ways not feasible 
with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the 
use of a hospital bed, or 
2. The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to 
alleviate pain, or 
3. The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due 
to congestive heart failure, chronic pulmonary disease, or problems with aspiration, or 
4. The beneficiary requires traction equipment, which can only be attached to a hospital bed. 
A variable height hospital bed (E0255, E0256, E0292, and E0293) is covered if the beneficiary meets one of 
the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to 
permit transfers to chair, wheelchair or standing position You can find this rule at Local Coverage 
Determination (LCD) L33820: Hospital Beds and Accessories (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 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). 
 
Routine foot care is considered medically necessary when the beneficiary has mycotic nails (a fungal infection 
of the nails) and the presence of a qualifying systemic illness causing a peripheral neuropathy (damage to the 
nerves in your body). You can find this information in the Local Coverage Determination (LCD) L33636, 
Routine Foot Care and Debridement of Nail. 
 
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 facet Joint Interventions generally consist of four types of procedures: Intraarticular (IA) 
Facet Joint Injections, Medial Branch Blocks (MBB), Radiofrequency Ablations (RFA) and Facet cyst 
rupture/aspiration. 
 
Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of 
chronic pain in patients who meet ALL of the following criteria: 
 
        Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale11; AND* 
        Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive 
conservative care management (as tolerated); AND 
        Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst); AND 
        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. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Interventions 
for Pain Management (L34892). 
 
The rules say that a Medicare plan may restrict members 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 a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 in Chapter 3 on page 38 of the 
Plan's 2023 Evidence of Coverage.