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 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 (NCCI) Policy 
Manual for Medicare Services, Chapter I(A). 
 
The rules say that the National Correct Coding Initiative (NCCI) was developed to prevent inappropriate 
payment of services that should not be reported together. NCCI edits are organized in a Column I/Column 2 
table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of an edit 
pair, only the Column 1 code is payable. For edits with a modifier indicator of 0, the Column 2 code cannot be 
paid regardless of whether a modifier is used. You can find this rule in the NCCI Manual, Chapter I(O). 
 
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 are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL of 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; AND 
2. Pain that has been present for a minimum of 3 months with documented failure to respond to 
noninvasive conservative care management (as tolerated); AND 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused 
by facet joint synovial cyst); AND 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain 
the source of the patients pain, including but not limited to fracture, tumor, infection, or 
significant deformity. 
 
Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who 
meet ALL of the following criteria: 
1. 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 
2. 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 
activities of daily living as compared to baseline measurement using the same scale; AND 
3. 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 rule in the Local Coverage Determination for 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 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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 pages 10 to 11.
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 power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered. You can find this rule in the Local Coverage Article for 
Wheelchair Options/Accessories - Policy Article, A52504. 
 
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 pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). 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 110.1(D). 
 
The rules say that it is expected that the beneficiary's medical records will reflect the need for the care 
provided. The beneficiary's medical records include the treating practitioner's office records, hospital records, 
nursing home records, home health agency records, records from other healthcare professionals and test 
reports. This documentation must be available upon request. You can find this information in the Local 
Coverage Determination (LCD) for Power Mobility Devices (L33789). 
 
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 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 for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
The rules state that all skilled nursing facility (SNF) Part A inpatient services are paid under a prospective 
payment system (PPS). This involves payment based on a Health Insurance Prospective Payment System 
(HIPPS) rate code. Under the new Patient-Driven Payment Model (PDPM), which is effective for services 
provided on or after 10/1/2019, the HIPPS code is structured differently, as a result of there being five case-mix 
adjusted rate components under the revised model. The first position represents the Physical and Occupational 
Therapy case-mix group. The second position represents the Speech-Language Pathology (SLP) case-mix 
group. The third character represents the nursing case-mix group. The fourth character represents the Non-
Therapy Ancillary (NTA) case- mix group. The fifth character represents the assessment indicator code. You 
can find this information in the Centers for Medicare and Medicaid Service (CMS), Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Sections 10, 30, and 120. 
 
The rules also say that active diagnoses are intended to code diseases that have a direct relationship to the 
residents current functional status, cognitive status, mood or behavior status, medical treatments, nursing 
monitoring, or risk of death. One of the important functions of the Minimum Data Set (MDS) assessment is to 
generate an updated, accurate picture of the residents current health status. You can find this rule in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 
Manual, Chapter 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.
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. 
 
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 the Plan covers a grocery benefit. Members must be diagnosed with both of the 
following conditions to be eligible to receive the grocery benefit from a Plan-specified vendor: diabetes, 
depression or depressive disorders. You can find this information on page 107 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 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 copayment for medical eye exams under the Vision care benefit 
category. You can find this information on page 110 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 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 3-3 to 3-6 of the Plan's 
2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a 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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 30 in 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 therapeutic facet joint procedures are considered medically reasonable and necessary for 
patients who meet ALL of the following criteria: 
  
1. 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 
2. 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
11
; AND 
3. 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. 
 
Frequency limitation: For each covered spinal region no more than four (4) therapeutic facet joint injection 
(IA) sessions will be reimbursed per rolling 12 months. 
 
You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L34892). 
 
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 
semi-precision attachments. You can find this information on pages 62-65 of the Plans 2023 Evidence of 
Coverage (EOC) and in the Plan's schedule of benefits.
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 claims or claim lines that have been determined to be exact duplicates of another claim or 
claim line are denied. However, such denials may be appealed. An exact duplicate for physician and other 
supplier claims is a claim that exactly matches another claim or claim line with respect to, among other items, 
provider number, date of service, procedure code, place of services, and billed amount. You can find this rule 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 1, Section 120.2. 
 
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 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 the requested items or services, but only when they are received from an in-network provider. You 
can find this information on pages 31-31, and 78 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 spinal cord stimulators (SCS) may be covered for the relief of chronic intractable pain under 
the following circumstances: 
 
1. To treat chronic pain caused by lumbosacral arachnoiditis that has not responded to medical management 
including physical therapy.  
2. To treat intractable pain caused by nerve root injuries, post-surgical or post-traumatic including that of post-
laminectomy syndrome (failed back syndrome). 
3. To treat intractable pain caused by complex regional pain syndrome I & II. 
4. To treat intractable pain caused by phantom limb syndrome that has not responded to medical management.  
5. To treat intractable pain caused by end-stage peripheral vascular disease, when the patient cannot undergo 
revascularization or when revascularization has failed to relieve painful symptoms and the pain has not 
responded to medical management. 
6. To treat intractable pain caused by post-herpetic neuralgia. 
7. To treat intractable pain caused by cauda equina injury. 
8. To treat intractable pain caused by incomplete spinal cord injury. 
9. To treat intractable pain caused by plexopathy. 
 
You can find this information in the Local Coverage Determination (LCD): Spinal Cord Stimulation for 
Chronic Pain (L36035). 
  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.