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 state that Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint (SIJ) for the 
treatment of back pain is indicated for the treatment of SIJ pain for patients with low back/buttock pain who 
meet all of the following criteria: 
a) Have undergone and failed a minimum six months of intensive non-operative treatment that must 
include medication optimization, activity modification, and active physical therapy; 
b) Patients report of non-radiating, unilateral pain that is caudal to the lumbar spine (L5 vertebrae), 
localized over the posterior SIJ, and consistent with SIJ pain; 
c) Localized tenderness with palpation of the posterior SIJ in the absence of tenderness of similar severity 
elsewhere (e.g. greater trochanter, lumbar spine, coccyx) and other obvious sources for their pain do not 
exist; 
d) Positive response to the thigh thrust test OR compression test AND 2 of the following additional 
provocative tests: Gaenslens test, Distraction test, Patricks sign; 
e) Absence of generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g. 
fibromyalgia); 
f) Diagnostic imaging studies that include ALL of the following: 
1. Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of 
destructive lesions (e.g., tumor, infection) or inflammatory arthropathy that would not be 
properly addressed by percutaneous SIJ fusion; 
2. Imaging of the ipsilateral hip (plain radiographs) to rule out osteoarthritis; 
3. Imaging of the lumbar spine (CT or MRI) to rule out neural compression or other degenerative 
condition that can be causing low back or buttock pain; 
g) At least 75 percent reduction of pain for the expected duration of the anesthetic used following an 
image-guided, contrast-enhanced SIJ injection on two separate occasions. 
 
You can find this rule in the Local Coverage Determination for Percutaneous minimally invasive 
fusion/stabilization of the sacroiliac joint for the treatment of back pain, L36000.  
 
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. 
 
Certain cardiac event monitors capture electrical activity with a single electrode attached to the skin. Other 
devices may employ multiple electrodes in order to record more complex EKG tracings. Additionally, devices 
may be individually programmed to detect patient-specific factors, electrode malfunction, or other factors. 
Cardiac event monitors can be further categorized as either pre-event or post-event recorders, based on 
their memory capabilities: 
a. Pre-symptom Memory Loop Recorder (MLR) 
Upon detecting symptoms, the wearer presses a button, which activates the recorder to save (i.e., 
memorize) an interval of pre-symptom EKG data along with data during and subsequent to the 
symptomatic event. Self-sensing recorders (also known as event-activated or automatic trigger) do not 
require patient input to capture these data. Single or multiple events may be recorded. The device is 
worn at all times, usually for up to 30 days. 
o Implantable (or Insertable Loop) Recorder (ILR) 
Another type of pre-symptom MLR, it is implanted subcutaneously in a patients upper left chest and 
may remain implanted for many months. An ILR is used when syncope is thought to be cardiac-related, 
but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom MLR. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 20.15. 
 
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 determination of the type of knee 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 single axis, constant friction knee. Other prosthetic knees are considered for coverage 
based upon functional classification. 
 
A high activity knee control frame (L5930) is covered for beneficiaries whose functional level is 4. 
 
A fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, L5726, L5728, 
L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is covered for 
beneficiaries whose functional level is 3 or above. 
 
L5859 (ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, 
POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY 
TYPE MOTOR(S)) is only covered when the beneficiary meets all of the criteria below: 
 
    Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee 
 
    K3 functional level only 
 
    Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps 
function that impairs K-3 level function with the use of a microprocessor-controlled knee alone 
 
    Is able to make use of a product that requires daily charging 
 
    Is able to understand and respond to error alerts and alarms indicating problems with the function of the unit 
 
 
If these coverage criteria for the knee component are not met, L5859 will be denied as not reasonable and 
necessary. 
 
Other knee systems (L5611, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5810, L5811, L5812, 
L5816, L5818) are covered for beneficiaries whose functional level is 1 or above. 
 
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or 
design feature of a given type of knee. This information must be retained in the treating practitioner's or 
prosthetist's files. 
 
You can find this information in the 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.
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 contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. 
  
  When a plan provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered 
by the plan, the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that 
service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 160. 
 
The rules also say that Medicare plans must make reasonable and diligent efforts to gather and forward 
information to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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. 
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 the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L35936). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Limitations for CCTA include: 
 
    The test is never covered for screening, i.e., in the absence of signs, symptoms or disease.  
    The test will be considered not medically necessary if the anticipated results are not expected to provide 
new, additional information to that already previously obtained from other tests (such as stress myocardial 
perfusion images or cardiac ultrasound). New or additional information should facilitate the management 
decision, not merely add a new layer of testing.  
    The test will be considered not medically necessary if pretest evaluation indicates that the patient would 
require invasive cardiac angiography for further diagnosis or for therapeutic intervention.  
    The test may be denied, on post-pay review, as not medically necessary when used for cardiac evaluation if 
there were pre-test knowledge of sufficiently extensive calcification of the suspect coronary segment that 
would diminish the interpretive value. (e.g., angina decubitus, unstable angina, Prinzmetal angina, etc.)  
    Coverage is limited to devices that process thin, high-resolution slices (1mm or less). The multi-detector 
scanners must have at least 64 slices per rotation capability.  
    The administration of beta blockers and the monitoring of the patient during MDCT/CCTA by a physician 
experienced in the use of cardiovascular drugs is included as part of the test and is not a separately payable 
service.  
    All studies must be ordered by the physician/qualified non-physician practitioner treating the 
    patient and who will use the results of the test in the management of the patient.  
    The test must be performed under the direct supervision of a physician, similar to the stress myocardial 
perfusion imaging.  
    This LCD does not address electron beam tomography (EBT) technology or Ultrafast CT for coronary artery 
examination. There is no extension of coverage of EBT based on this policy.  
    Quantitative calcium scoring is not a covered service and will be denied as not medically necessary. Calcium 
scoring reported in isolation is considered a screening service. When performed in association with CT 
angiography, there is neither separate nor additional included reimbursement for the calcium scoring. 
    Atrial fibrillation or atrial flutter alone is not an indication; atrial fibrillation or atrial flutter with planned 
ablation therapy is allowed. 
 
You can find this information in the Local Coverage Determination (LCD) Coronary Computed Tomography 
Angiography (CCTA) L35121. 
 
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 provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say that, generally, items and services provided outside of the United States (US) are not covered. 
The only exceptions are emergency hospital services when the emergency occurred within the US, 
emergency/non-emergency hospital services when the foreign hospital is substantially closer or more 
accessible than the US hospital, or services provided on a ship docked at a US port or within US Territorial 
waters. You can find this information in the Medicare Benefit Policy Manual, Chapter 16, Section 60. 
 
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 it provides coverage for emergency care provided worldwide. It is noted that the enrollee is 
responsible for paying for services up front. A request for reimbursement must be filed. You can find this on 
pages 65-66 of the Plan's 2021 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. 
 
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 Plan also provides a point of service benefit. This benefit provides some coverage for 
services rendered by out-of-network providers. The annual limit for these services is $5,000. Costs in excess of 
this amount are the responsibility of the member. You can find more information on page 37 of the Plans 2021 
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 that according to Medicare guidelines, therapeutic facet joint nerve blocks are covered when all 
of the following are met: 
 
- 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 
- Subsequent therapeutic facet joint procedures at the same anatomic site result 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 
- Documentation of why the patient is not a candidate for radiofrequency ablation (such as established spinal 
pseudarthrosis, implanted electrical device) is in the medical record. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Interventions 
for Pain Management (L33930). 
 
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 an epidural steroid injection (ESI) will be considered medically reasonable and necessary 
when the following three (3) requirements are met: History, physical examination, and concordant radiological 
image-based diagnostic testing supporting one of the following: 
-Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to disc 
herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis; OR -Post-laminectomy syndrome; OR -Acute herpes zoster associated pain. You can 
find this rule in the Local Coverage Determination (LCD) - L39036, Epidural Steroid Injections for Pain 
Management. 
 
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 Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3. 
 
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 health 
plan contract says covered drugs include: Drugs that usually aren't self-administered by the patient and are 
injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. 
You can find this information in Chapter 4 on page 4-28 of the plan's 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 that cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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 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.
15
 
o Difficulty walking or functional impairment in activities of daily living.
15,16
 
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. You can find this in Local Coverage Determination (LCD) Cosmetic and 
Reconstructive Surgery L35090. 
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.