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 percutaneous vertebral augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
percutaneous kyphoplasty (PKP)) is covered in patients with BOTH the following: 
 
1. Inclusion criteria (ALL are required):  
 
Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1  L5) by 
recent (within 30 days) advanced imaging (bone marrow edema on magnetic resonance imaging (MRI) or 
bone-scan/single photon emission computed tomography (SPECT)/computed tomography (CT) uptake) 
Symptomatic (ONE): 
Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score = 8) 
Non-hospitalized with moderate-to-severe pain (NRS or VAS =5) despite optimal non-surgical management 
(NSM)* (ONE): 
Worsening pain 
Stable-to-improved pain (but NRS or VAS still =5) (with = 2 of the following): 
Progression of vertebral body height loss 
> 25% vertebral body height reduction 
Kyphotic deformity 
Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) >17) 
*Consider including pedicle periosteal infiltration 
 
c. Continuum of care (BOTH): 
 
All patients presenting with VCF should be referred for evaluation of bone mineral density (BMD) and 
osteoporosis education for subsequent treatment as indicated. 
All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program. 
2. Exclusion criteria (Can have NONE of the following): a. Absolute contraindication: 
 
Current back pain is not primarily due to the identified acute or subacute VCF(s) 
Osteomyelitis, discitis or active systemic or surgical site infection 
Pregnancy 
b. Relative contraindication: 
 
Allergy to bone cement or opacification agents 
Uncorrected coagulopathy 
Spinal instability 
Myelopathy from the fracture 
Neurologic deficit 
Neural impingement 
Fracture retropulsion/canal compromise 
Greater than 3 vertebral fractures 
Vertebral augmentation and kyphoplasty for VCFs with intractable spinal pain not relieved with medical 
therapy will be covered for osteolytic vertebral metastatic disease or myeloma involving a vertebral body. 
 
You can find these rules in the Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) L38737. 
 
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 pneumatic compression device (PCD) that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. Therefore, claims for 
E0676 will be statutorily denied as no Medicare benefit. You can find this rule at  
 
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
The rules say that an abdominal lipectomy/panniculectomy is considered medically reasonable and necessary 
when the pannus or panniculus hangs below the level of the symphysis pubis causing one or more of the 
following conditions: 
o Chronic intertrigo that consistently remains refractory to appropriate medical therapy 
(e.g., topical antifungals, corticosteroids, antibiotics) over a period of three months. 
o Difficulty walking or functional impairment in activities of daily living. 
If the procedure is being performed following significant weight loss, in addition to meeting the criteria noted 
above, there should be evidence that the patient has maintained a stable weight for at least six months. For 
patients whose weight loss is the result of bariatric surgery, abdominal lipectomy/panniculectomy should not be 
performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the 
most recent six months. 
Local Coverage Determination (LCD); Cosmetic and Reconstructive Surgery (L38914). 
 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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  
 
The rules say that a panniculectomy will be considered medically necessary when: 
 
 The pannus or panniculus hangs below the level of the pubis, and the medical records document that the 
panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin 
irritation, infection or chafing that consistently recurs or remains refractory to appropriate medical 
therapy (e.g. topical antifungals, corticosteroids, antibiotics) over a period of 3 months.12 
 
 When surgery is performed to alleviate such complicating factors as inability to walk normally due 
            to pannus size, chronic pain, ulceration created by the abdominal skin fold, or intertrigal 
           dermatitis, such surgery is considered reconstructive. Preoperative photographs may be required 
           to support justification and should be supplied upon request.12 
 
 This procedure may also be medically necessary for the patient that has had a significant weight- 
            loss following the treatment of morbid obesity, in addition to meeting the criteria noted above, 
            there should be evidence that the individual has maintained a stable weight for at least 6 months. 
 
If the weight loss is the result of bariatric surgery, abdominoplasty/panniculectomy should not be performed 
until at least 18 months after bariatric surgery and only when weight has been stable for at least the most recent 
6 months and infection and inflammation has continued for the most recent 3 months. Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L39051). 
 
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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, 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(s) 28-29 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 determinations may be made on coverage of other uses of implanted infusion pumps if the 
MAC medical staff verifies that: 
 
  
      The drug is reasonable and necessary for the treatment of the individual patient; 
    It is medically necessary that the drug be administered by an implanted infusion pump; and, 
    The Food and Drug Administration-approved labeling for the pump must specify that the drug being 
administered and the purpose for which it is administered is an indicated use for the pump. 
 
You can find this information in the National Coverage Determination (NCD) Infusion Pumps 280.14. 
 
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 the thermal radiofrequency destruction of the cervical, thoracic, or lumbar paravertebral facet 
joint (median branch) nerves are considered medically reasonable and necessary after the patient has had at 
least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent 
minimum of 80% sustained relief of primary (index) pain (with the duration of relief being consistent with the 
agent used). You can find this rule 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 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. 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). 
 
The rules say that CMS does not pay any provider or supplier other than the facility or hospital for services 
furnished to the beneficiary while an inpatient. The facility or hospital must furnish all necessary covered 
services to the beneficiary either directly or under arrangements made between the facility and hospital and 
outside providers. You can find this information in 42 CFR 409.10.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that vascular stents are used to enhance primary patency in arteries and veins, usually at the site 
of stenotic or occlusive lesions. Stents also may be used as an adjunct to technically inadequate Percutaneous 
Transluminal Angioplasty (PTA) or in cases where PTA alone will not be expected to provide a durable result. 
Peripheral vascular stenting may be indicated for patients with symptomatic arterial and venous disease 
resulting from an occlusive process. This LCD does not address carotid artery stenting, which is subject to 
National Coverage Determination 20.7. 
 
PTA and stenting of vessels is covered only when all of the following conditions are met: 
 
    The patient has undergone prior thorough medical evaluation and management of symptoms. See below 
under specific categories for guidelines on medical evaluation and management recommendations. 
    Surgical intervention would otherwise be considered as an alternative treatment for the patient. 
    A stent may be placed as a planned adjunct to PTA rather than in response to a suboptimal or failed PTA (so-
called primary stent deployment). Primary stenting is justified for situations where PTA alone is not expected 
to provide a durable result, such as arterial or venous occlusions that carry a high risk for distal embolization or 
rapid recurrence OR occlusive lesions known to be unfavorable for PTA alone such as significantly calcified 
lesions, eccentric lesions, lesions related to external compression (e.g., May-Thurner syndrome and malignant 
compression of the superior vena cava), or ostial renal artery stenosis. 
 
Coverage for non-coronary vascular stents depends on the use of an FDA-approved stent. Several different 
stents are currently used in the medical community. Each device has specific indications described by the FDA 
for approved market uses. Stent placement is covered by Medicare only when an FDA-approved stent is: 
 
    Used for the FDA-approved indications, OR 
    Used for the above indications supported by the peer medical literature. 
 
You can find this information in the Local Coverage Determination (LCD) Non-Coronary Vascular Stents 
L35998. 
 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 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 outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information on pages 101 to 102 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 it is not reasonable and necessary for a physician to perform presumptive point-of-care 
testing and order presumptive testing from a reference laboratory. In other words, Medicare will only pay for 
one presumptive test result per patient per date of service regardless of the number of billing providers. You 
can find this in the Local Coverage Determination (LCD): Urine Drug Testing (L36037). 
 
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 Health Maintenance Organizations (HMOs) may offer a Point of Service (POS) option as a 
mandatory or optional supplemental benefit. The POS benefit provides coverage for some plan-covered 
services outside of the HMOs network. The HMO plan may either require or waive prior authorization rules 
for obtaining POS services. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), 
Internet-Only Manual, Publication 100-16, 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 Plan 
contract also says that some services such as out-of-network physician/practitioner services, including doctor's 
office visits, are covered only if the doctor or other provider gets approval in advance (sometimes called prior 
authorization). You can find this information on pages 58 and 98 to 99 of the Plan's 2022 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 a list of 
covered preventive and comprehensive dental benefits and a list of specific dental procedure codes included in 
a dental benefits chart. Dental code D7961 is not listed and therefore not covered by the Plan's dental benefit. 
You can find this information in Chapter 4 on page 59 and on pages 105 to 125 of the Plans 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 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 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. 
*Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the 
same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for 
functional assessment (if patient qualifies for treatment). 
 
You can find this rule 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.