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 an expandable controller is capable of accommodating one or more of the following 
additional functions: 
- Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin 
control, head control, etc.) 
- Non-proportional input devices (e.g., sip and puff, head array, etc.) 
- Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating 
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) 
 
An expandable controller may also be able to operate one or more of the following: 
- A separate display (i.e., for alternate control devices) 
- Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control) 
- An attendant control 
 
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the 
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting 
hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and 
with complete replacement of the expandable controller. 
 
Codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more 
of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional 
interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, 
power seat elevation, power standing. It includes a function selection switch which allows the beneficiary to 
select the motor that is being controlled and an indicator feature to visually show which function has been 
selected. When the wheelchair drive function has been selected, the indicator feature may also show the 
direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate 
display box or may be integrated into the wheelchair interface. 
 You can find this information in the Local Coverage Article: 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 state that code L5999 must not be used for any features or functions of a socket. This information is 
found in Local Coverage Article: Lower Limb Prostheses - Policy Article (A52496). 
 
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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered as long as all of 
the criteria are met and none of the contraindications are present. You can find this information in 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 codes E2310 and E2311 describe the electronic components that allow the beneficiary to 
control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or 
non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power 
leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the 
beneficiary to select the motor that is being controlled and an indicator feature to visually show which function 
has been selected. When the wheelchair drive function has been selected, the indicator feature may also show 
the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate 
display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for 
fixed mounting hardware for the control box and for the display box (if present). You can find this information 
in the Local Coverage Article (LCA): Wheelchair Options/Accessories (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. 
 
L5781 describes a complete device that is an addition to a lower limb prosthesis. The primary function of the 
vacuum pump is to suspend the prosthetic limb. Additionally, products coded L5781 provide residual limb 
volume management and moisture evacuation. The pump mechanism evacuates air and accumulated moisture 
between the limb and socket walls. The pump mechanism can be actuated by either external power and/or 
mechanical system(s). You can find this information in the Local Coverage Article (LCA): Lower Limb 
Prostheses A52496. 
 
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 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 respiratory pathogen panel test is a single service with a single unit of service (UOS=1). A 
respiratory pathogen panel test must not be unbundled and billed as individual components regardless of the 
fact that the panel reports multiple individual pathogens and/or targets. You can find thsi information in the 
Centers for Medicare and Medicaid Services, Local Coverage Article (LCA): Billing and Coding: Respiratory 
Pathogen Panel Testing (A58577). 
 
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. 
This procedure involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and 
dilate the vessel by inflating the balloon. The objective of percutaneous transluminal angioplasty (PTA) is to 
improve the blood flow through the diseased segment of a vessel so that vessel patency is increased and 
embolization is decreased. With the development and use of balloon angioplasty for treatment of 
atherosclerotic and other vascular stenoses, PTA (with and without the placement of a stent) is a widely used 
technique for dilating lesions of peripheral, renal, and coronary arteries. 
Indications and Limitations of Coverage 
The PTA is covered when used under the following conditions: 
1. Treatment of Atherosclerotic Obstructive Lesions 
In the lower extremities, i.e., the iliac, femoral, and popliteal arteries, or in the upper extremities, i.e., the 
innominate, subclavian, axillary, and brachial arteries. The upper extremities do not include head or neck 
vessels. 
Of a single coronary artery for patients for whom the likely alternative treatment is coronary bypass surgery 
and who exhibit the following characteristics: 
 Angina refractory to optimal medical management; 
 Objective evidence of myocardial ischemia; and 
 Lesions amenable to angioplasty. 
Of the renal arteries for patients in whom there is an inadequate response to a thorough medical management 
of symptoms and for whom surgery is the likely alternative. PTA for this group of patients is an alternative to 
surgery, not simply an addition to medical management. 
Of arteriovenous dialysis fistulas and grafts when performed through either a venous or arterial approach. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determination (NCD) - Percutaneous Transluminal Angioplasty (PTA) 
(20.7) - Effective January 1, 2013.  
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. 
FDA-approved hypoglossal nerve neurostimulation is considered medically reasonable and necessary for the 
treatment of moderate to severe obstructive sleep apnea when all of the following criteria are met: 
1. Beneficiary is 22 years of age or older; and 
2. Body mass index (BMI) is less than 35 kg/m2; and 
3. A polysomnography (PSG) is performed within 24 months of first consultation for HGNS implant; and 
4. Beneficiary has predominantly obstructive events (defined as central and mixed apneas less than 25% 
of the total AHI); and 
5. AHI is 15 to 65 events per hour; and 
6. Beneficiary has documentation that demonstrates CPAP failure (defined as AHI greater than 15 despite 
CPAP usage) or CPAP intolerance (defined as less than 4 hours per night, 5 nights per week or the 
CPAP has been returned) including shared decision making that the patient was intolerant of CPAP 
despite consultation with a sleep expert; and 
7. Absence of complete concentric collapse at the soft palate level as seen on a drug-induced sleep 
endoscopy (DISE) procedure; and 
8. No other anatomical findings that would compromise performance of device (e.g., tonsil size 3 or 4 per 
standardized tonsillar hypertrophy grading scale). 
You can find this information in the Local Coverage Determination (LCD): Hypoglossal Nerve Stimulation for 
the Treatment of Obstructive Sleep Apnea (L38398). 
 
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 for all beneficiaries receiving Home Health services in 2021 whose services will continue in 
2022, the Home Health Agency (HHA) shall submit an Notice of Admission (NOA) with a one-time, artificial 
'admission' date corresponding to the "From" date of the first period of continuing care in 2022. For example, if 
a period of care begins in 2021 and ends on January 10, 2022, the HHA submits an NOA with an admission 
date of January 11, 2022, and then submits a claim when the 30-day period of care is over. The HHA should 
submit the January 11, 2022, admission date on all subsequent claims until the beneficiary is discharged and 
another NOA is required. This is to ensure the claim is matched to the correct NOA and the correct receipt date 
is used for payment. This information is found in the Medicare Claims Processing Manual, Chapter 10, Section 
10.1.10.3. 
 
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. 
 
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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
A cardiovascular disease screening (blood) test is defined as a lipid panel consisting of a total cholesterol, high-
density lipoprotein (HDL) cholesterol and triglyceride. The test is performed after a 12-hour fasting period. 
You can find this information in 42 CFR Section 410.17. 
 
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 thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) 
nerves are considered medically reasonable and necessary for patients who meet ALL the following criteria: 
a. Initial thermal RFA: 
i. 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) 
AND 
ii. Repeat thermal facet joint RFA at the same anatomic site is considered medically 
reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six (6) months 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; 
Frequency Limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be 
reimbursed per rolling 12 months. 
You can find this rule in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L35936). 
 
For dates of service on or after 01/01/2020, CPT code 64625 - Radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) should be used to report 
radiofrequency ablation whether performed using traditional or cooled radiofrequency (<80 degrees Celsius). 
Radiofrequency ablation for denervation whether performed using traditional, cooled, or pulsed radiofrequency 
is considered investigational and therefore, not medically necessary. You can find this rule in the Local 
Coverage Article (LCA): Billing and Coding: Pain Management A52863. 
 
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 three fluorodeoxyglucose (FDG) PET scans are nationally covered when used to guide 
subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy. 
Coverage of more than three FDG PET scans to guide subsequent management of anti-tumor treatment strategy 
after completion of initial anti-cancer therapy shall be determined by the local Medicare Administrative 
Contractors. You can find this information in the National Coverage Determination (NCD) for Positron 
Emission Tomography (FDG) for Oncologic Conditions (220.6.17). 
 
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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. 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 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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 60 one-way trips for routine transportation every year. Each one-way trip must not exceed 75 
miles of driving distance. You can find this information on page 4-83 of the Plans 2022 Evidence of Coverage 
(EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that 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:
o 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
o Post-laminectomy syndrome; or
o Acute herpes zoster associated pain
and
- Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality of life or function. An objective pain scale or functional assessment must be performed at baseline (prior to interventions). The same scale must be repeated at each follow-up for assessment of response.
and
- Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes zoster refractory to conservative management where a four (4) week wait is not required.
You can find this information in Local Coverage Determination (LCD): Epidural Steroid Injections for Pain Management (L39036).

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. 
 
A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot 
with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot 
system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. 
You can find this information in the Local Coverage Determination (LCD): Lower Limb Prostheses (L33787). 
 
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 Plan contract says that the Plan covers items and services in accordance with Medicare rules.