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 TAVR is covered for the treatment of symptomatic aortic valve stenosis when furnished 
according to a Food and Drug Administration (FDA)-approved indication and when all of the following 
conditions are met: 
 
    The procedure is furnished with a complete aortic valve and implantation system that has received FDA 
premarket approval (PMA) for that system's FDA approved indication. 
 
    The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-
disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication 
across medical specialties to offer optimal patient-centered care. The heart team includes the following: 
        Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis 
who have: 
            independently examined the patient face-to-face, evaluated the patients suitability for surgical aortic 
valve replacement (SAVR), TAVR or medical or palliative therapy; 
            documented and made available to the other heart team members the rationale for their clinical 
judgment. 
        Providers from other physician groups as well as advanced patient practitioners, nurses, research 
personnel and administrators. 
 
    The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-
operative technical aspects of TAVR. 
 
    TAVR must be furnished in a hospital with the appropriate infrastructure that includes but is not limited to: 
        On-site heart valve surgery and interventional cardiology programs, 
        Post-procedure intensive care facility with personnel experienced in managing patients who have 
undergone open-heart valve procedures, 
        Appropriate volume requirements per the applicable qualifications below: 
 
There are two sets of qualifications; the first set outlined below is for hospital programs and heart teams 
without previous TAVR experience and the second set is for those with TAVR experience. 
 
Qualifications to begin a TAVR program for hospitals without TAVR experience: 
 The hospital program must have the following: 
 
    = 50 open heart surgeries in the previous year prior to TAVR program initiation, and; 
    = 20 aortic valve related procedures in the 2 years prior to TAVR program initiation, and; 
    = 2 physicians with cardiac surgery privileges, and; 
    = 1 physician with interventional cardiology privileges, and; 
    = 300 percutaneous coronary interventions (PCIs) per year. 
 
You can find this information in the National Coverage Determination (NCD) Transcatheter Aortic Valve 
Replacement (TAVR) 20.32. 
 
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 state that if a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes 
will be considered part of the same panel. A panel constitutes a single procedural service, so 1 code must be 
submitted for the panel. This rule is found in the Medicare NCCI Coding Policy Manual- Chapter 10- CPT 
codes 80000 - 89999, Section F, Number 8. 
 
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 September 1, 1992, all laboratory testing sites (except as provided in 42 Code of 
Federal Regulations (CFR) 493.3(b)) must have either a Clinical Laboratory Improvement Amendments 
(CLIA) certificate of waiver, certificate for provider-performed microscopy procedures, certificate of 
registration, certificate of compliance, or certificate of accreditation to legally perform clinical laboratory 
testing on specimens from individuals in the United States. 
 
Effective with services provided October 1, 1997, any independent laboratory performing tests covered by 
CLIA must submit the CLIA number on the claim. Laboratory claims submitted without the required CLIA 
number are returned as unprocessable. If the CLIA number is submitted on the claim, but is inconsistent with 
the CLIA format, the A/B MAC (B) returns the claim as unprocessable. If more than one CLIA number is 
submitted on the claim, except when a reference laboratory is on the same claim, the A/B MAC (B) returns the 
claim as unprocessable. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 16, Section 70. 
 
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 clinical assessments of beneficiary rehabilitation potential must be based on the following 
classification levels: 
 
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a 
prosthesis does not enhance their quality of life or mobility. 
Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed 
cadence. Typical of the limited and unlimited household ambulator. 
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers 
such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator 
who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise 
activity that demands prosthetic utilization beyond simple locomotion. 
Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting 
high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. 
 
The records must document the beneficiarys current functional capabilities and his/her expected functional 
potential, including an explanation for the difference, if that is the case. It is recognized, within the functional 
classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level 
classifications.  
 
The reason for replacement must be documented by the treating practitioner, either on the order or in the 
medical record, and must fall under one of the following: 
1. A change in the physiological condition of the patient resulting in the need for a replacement. Examples 
include but are not limited to, changes in beneficiary weight, changes in the residual limb, beneficiary 
functional need changes; or, 
2. An irreparable change in the condition of the device, or in a part of the device resulting in the need for a 
replacement; or, 
3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would 
be more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being 
replaced. 
 
You can find this rule in the Local Coverage Determination and Article for Lower Limb Prostheses, L33787 
and 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 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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract 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 in Chapter 3 on pages 30 to 31 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 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 only the 
items and services listed in the dental services benefit category. Surgical extractions (D7230) and deep sedation 
(D9222, D9223) are not covered by the Plan's dental benefits. You can find this information on pages 58-59 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 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 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. 
You can find these rules in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787). 
 
The rules state that addition codes for endoskeletal knee-shin systems such as L5828 are considered an upgrade 
to the knee-shin system. The beneficiary may qualify for an upgraded knee-shin system based on their assigned 
K-Level modifier (K0-K4). L5845, L5848, L5856 are additional features and/or functions that do not describe 
a complete endoskeletal knee-shin system and must be used in combination with an L-code for a knee-shin 
system. You can find these rules 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 Viscosupplementation therapy for the knee via intra-articular injections of hyaluronic 
preparations will be considered medically reasonable and necessary when ALL of the following conditions are 
met: 
 
1. The patient is symptomatic. Such symptoms may include pain which interferes with the activities of daily 
living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness. 
2. The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space 
narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. 
3. If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, 
laboratory and imaging studies (i.e., the pain and functional disability is not considered likely to be due to a 
diagnosis other than osteoarthritis of the knee). 
4. The patient has failed at least three months of conservative therapy. Conservative therapy is defined as: 
   -Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss, 
physical therapy if indicated); and 
   -If not contraindicated, simple analgesics and (e.g., acetaminophen) or NSAIDS per hyaluronan product 
prescribing information. 
5. The patient has failed to respond to aspiration of the knee when effusion is present and intra-articular 
corticosteroid injection therapy when inflammation is a significant component of the patients symptoms and 
intra-articular corticosteroids are not contraindicated. 
 
You can find this information in Local Coverage Determination (LCD): Hyaluronan Acid Therapies for 
Osteoarthritis of the Knee (L35427). 
 
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 delivery and service are an integral part of oxygen and durable medical equipment (DME) 
suppliers costs of doing business. Such costs are ordinarily assumed to have been taken into account by 
suppliers (along with all other overhead expenses) in setting the prices they charge for covered items and 
services. As such, these costs have already been accounted for in the calculation of the fee schedules. This 
information is found in Medicare Claims Processing Manual, Chapter 20, 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.
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 surgical dressings are covered when a qualifying wound is present. A qualifying wound is 
defined as either of the following: 
 
1. A wound caused by, or treated by, a surgical procedure, or 
2. After debridement of the wound, regardless of the debridement technique 
 
You can find this rule in the Local Coverage Article (LCA) - Surgical Dressings - Policy Article (A54563) - 
Effective May 1, 2021. 
 
The rules say that a gradient compression stocking described by codes A6531 or A6532 or a non-elastic 
gradient compression wrap described by code A6545 is only covered when it is used in the treatment of an 
open venous stasis ulcer that meets the qualifying wound requirements described above. These codes are non-
covered for the following conditions: 
 
-Venous insufficiency without stasis ulcers; 
-Prevention of stasis ulcers; 
-Prevention of the reoccurrence of stasis ulcers that have healed; 
-Treatment of lymphedema in the absence of ulcers. 
 
You can find this rule in the Local Coverage Article (LCA) - Surgical Dressings - Policy Article (A54563 - 
Effective May 1, 2021. 
 
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 codes E2368, E2369, E2370 are for a replacement motor and/or gearbox. These codes are 
not used at the time of initial issue. If the item is a rebuilt component, the UE (used DME) modifier must be 
added to the code. 
 
All types of tires and wheels are included in the code for a power mobility base. Codes E2381, E2382, E2383, 
E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2393, E2394, E2395, E2396 may only 
be used for replacements other than at the time of initial issue. 
 
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.
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 surgical dressings are covered when a qualifying wound is present. A qualifying wound is 
defined as either of the following: 
 
-A wound caused by, or treated by, a surgical procedure; or, 
-After debridement of the wound, regardless of the debridement technique. 
 
You can find this rule in the Local Coverage Article (LCA) - Surgical Dressings - Policy Article (A54563) - 
Effective May 1, 2021. 
 
The rules say that compression burn garments are covered under the Surgical Dressings benefit when they are 
used to reduce hypertrophic scarring and joint contractures following a burn injury. You can find this rule in 
the Local Coverage Article (LCA) - Surgical Dressings - Policy Article (A54563) - Effective May 1, 2021. 
 
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 minimally-invasive surgical (MIS) fusion of the sacroiliac (SI) joint is considered medically 
necessary when the enrollee has a positive response to a cluster of 3 provocative tests (e.g. thigh thrust test, 
compression test, Gaenslens test, distraction test, Patricks sign, posterior provocation test). You can find this 
rule and the full criteria for coverage in Local Coverage Determination - Minimally-invasive Surgical (MIS) 
Fusion of the Sacroiliac (SI) Joint (L36406). 
 
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 the claims processing systems contain edits which identify exact duplicate claims and 
suspect duplicate claims. All exact duplicate claims or claim lines are auto-denied or rejected. Some claims that 
appear to be duplicates are actually claims or claim lines that contain an item or service, or multiple instances 
of an item or service, for which Medicare payment may be made. Correct coding rules applicable to all billers 
of health care claims encourage the appropriate use of condition codes or modifiers to identify claims that may 
appear to be duplicates, but, in fact, are not. You can find this rule in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, 
Section 120.1. 
 
The rules say that the claims processing systems contain edits which identify exact duplicate claims and 
suspect duplicate claims. All exact duplicate claims or claim lines are auto-denied or rejected. Some claims that 
appear to be duplicates are actually claims or claim lines that contain an item or service, or multiple instances 
of an item or service, for which Medicare payment may be made. Correct coding rules applicable to all billers 
of health care claims encourage the appropriate use of condition codes or modifiers to identify claims that may 
appear to be duplicates, but, in fact, are not. You can find this rule in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, 
Section 120.1. 
 
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.