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 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 an 
annual dental allowance amount of $1,500. You can find this information on page 82 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 state that PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with 
BOTH the following: 
 
1. Inclusion criteria (ALL are required): 
a. Acute (less than 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 imaing (MRI) 
or bone-scan/Single-Photon Emission Computerized Tomography (SPECT)/computed tomography (CT) 
uptake) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score greater 
than or equal to 8)  
ii. Non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) despite optimal non-
surgical management (NSM) (ONE): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still greater than or equal to 5) (with greater than or equal to 2 of 
the following): 
A. Progression of vertebral body height loss 
B. greater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) greater than 17) 
 
c. Continuum of care (BOTH): 
i. All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis education for 
subsequent treatment as indicated.  
ii. 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 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s) 
ii. Osteomyelitis, discitis or active systemic or surgical site infection 
iii. Pregnancy 
 
b. Relative contraindication 
i. Allergy to bone cement or opacification agents 
ii. Uncorrected coagulopathy 
iii. Spinal instability 
iv. Myelopathy from the fracture 
v. Neurologic deficit 
vi. Neural impingement 
vii. Fracture retropulsion/canal compromise 
viii. Greater than three vertebral fractures 
 
Vertebral augmentation and kyphoplasty for vertebral compression fractures 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 this information 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 state that a Professional Component (PC)/Technical Component (TC) indicator value of 3 means that 
the code is a technical component only code. This indicator identifies standalone codes that describe the 
technical component of selected diagnostic tests for which there is an associated code that describes the 
professional component of the diagnostic test only. It also identifies codes that are covered only as diagnostic 
tests and therefore do not have a related professional code. You can find this rule in Medicare Claims 
Processing Manual Chapter 23, Section 50.6. 
 
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 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 Plan 
contract says some covered services may consider prior tooth history and procedures in conjunction with 
frequency limitations. If you wish to discuss detailed information about your plan with your dentist, you can 
find it in the Plan's Dental Medicare quick reference guide. You can find this information on pages 113 and 114 
of the Plan's 2023 Evidence of Coverage (EOC). 
 
The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit 
includes the requested item or service but is limited to 1 per 36 floating months. You can find this information 
on page 179 of the Plan's 2023 Dental Medicare quick reference guide.
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 the Physician Fee Schedule Status Indicator I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30.2.2.

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 does not include 
unspecified periodontal procedure. You can find this information in the 2023 Dental Benefits Chart.
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 meals may be offered as a supplemental benefit to address the following two types of 
circumstances: 
1. Immediately following surgery or an inpatient hospital stay, for a temporary duration - typically a four-
week period - per enrollee per year, provided they are ordered by a physician or practitioner. 
2. For a chronic condition, for a temporary period  typically two weeks  per enrollee per year provided 
they are ordered by a physician or practitioner and are part of a supervised program designed to transition the 
enrollee to lifestyle modifications. 
 
You can find this rule in Medicare Managed Care Manual Chapter 4, Section 30.2. 
 
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 immediately following discharge from a Plan Hospital as an inpatient due to congestive heart 
failure, we cover up to two meals per day in a consecutive four-week period, once per calendar year as follows: 
as part of the discharge process, someone from your care team will initiate a referral valid for 30 days. The 
Plan contract also says that once the referral is approved, the meal delivery vendor will contact you with meal 
options and arrange meal delivery. You can find this information on page 35 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 modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative (NCCI) Policy Manual, Chapter 1, Section E(d). 
 
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 effective January 18, 2017, the Centers for Medicare & Medicaid Services (CMS) covers 
leadless pacemakers through Coverage with Evidence Development (CED). CMS covers leadless pacemakers 
  
  when procedures are performed in Food and Drug Administration (FDA) approved studies. CMS also covers, 
in prospective longitudinal studies, leadless pacemakers that are used in accordance with the FDA approved 
label for devices that have either: 
 an associated ongoing FDA approved post-approval study; or 
 completed an FDA post-approval study. 
Each study must be approved by CMS and as a fully described, written part of its protocol, must address the 
following research questions: 
 What are the peri-procedural and post-procedural complications of leadless pacemakers? 
 What are the long term outcomes of leadless pacemakers? 
 What are the effects of patient characteristics (age, gender, comorbidities) on the use and health effects 
of leadless pacemakers? 
You can find this rule at the Medicare National Coverage Determination (NCD) 20.8.4: Leadless Pacemakers. 
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). 
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 core 
buildup (D2950) but is limited to once every 60 floating months. This benefit also includes endodontic therapy, 
premolar tooth (excluding final restoration) (D3320) for tooth number 20, but may require prior authorization. 
You can find this information on pages 52, 95-97 of the Plan's 2023 Evidence of Coverage (EOC), and on page 
279 of the Plans 2023 Medicare Quick Reference Guide.
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 a TENS is covered for the treatment of beneficiaries with chronic, intractable pain or acute 
post-operative pain when one of the following coverage criteria, I or II, are met. 
I. Acute Post-operative Pain 
 
TENS is covered for acute post-operative pain. Coverage is limited to 30 days (one month's rental) from 
the day of surgery. Payment will be made only as a rental. 
 
A TENS unit will be denied as not reasonable and necessary for acute pain (less than three months 
duration) other than for post-operative pain. 
II. Chronic Pain Other than Low Back Pain 
 
TENS is covered for chronic, intractable pain other than chronic low back pain when all of the 
following criteria must be met: 
 The presumed etiology of the pain must be a type that is accepted as responding to TENS 
therapy. Examples of conditions for which TENS therapy is not considered to be reasonable and 
necessary are (not all-inclusive): 
o headache 
o visceral abdominal pain 
o pelvic pain 
o temporomandibular joint (TMJ) pain 
 The pain must have been present for at least three months. 
 Other appropriate treatment modalities must have been tried and failed.  
TENS therapy for chronic pain that does not meet these criteria will be denied as not reasonable and 
necessary. 
TENS therapy for Chronic Low Back Pain (CLBP) will be denied as not reasonable and necessary.  
General Requirements for chronic pain (II) 
When used for the treatment of chronic, intractable pain described in section II, the TENS unit must be used by 
the beneficiary on a trial basis for a minimum of one month (30 days), but not to exceed two months. The trial 
period will be paid as a rental. The trial period must be monitored by the treating practitioner to determine the 
effectiveness of the TENS unit in modulating the pain. For coverage of a purchase, the treating practitioner 
must determine that the beneficiary is likely to derive significant therapeutic benefit from continuous use of the 
unit over a long period of time. 
A 4-lead TENS unit may be used with either 2 leads or 4 leads, depending on the characteristics of the 
beneficiary's pain. If it is ordered for use with 4 leads, the medical record must document why 2 leads are 
insufficient to meet the beneficiarys needs. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L33802: Transcutaneous 
Electrical Nerve Stimulators (TENS). 
 
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 and cover any medically necessary covered benefit outside of the plan provider network, but at in-
network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollees 
medical needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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.
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 inserts and other shoe modifications (L3485) are covered if they are on a shoe that is an 
integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. 
Shoes and related modifications, inserts, heel/sole replacements or shoe transfers billed without a KX modifier 
will be denied as noncovered because coverage is statutorily excluded. Shoes which are incorporated into a 
brace must be billed by the same supplier billing for the brace. Shoes which are billed separately (i.e., not as 
part of a brace) will be denied as noncovered. A KX modifier must not be used in this situation. You can find 
this rule in the Local Coverage Article for Orthopedic Footwear, A52481. 
 
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 certain 
specified dental procedure codes. Procedure codes D7140, D5110, and D5120 are not among those covered by 
the Plan. You can find this information in the Plans 2023 Dental Schedule of Benefits.