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 for services performed on or after January 21, 2020, Medicare will now provide limited 
coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, 
CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, 
such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This 
benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated 
improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may 
be provided by a physician in accordance with state requirements, or by physician assistants, nurse 
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. 
Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, 
physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determinations Manual, Section 30.3.3. 
 
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 offers additional coverage for acupuncture beyond what is covered by Medicare. This benefit 
covers 24 non-Medicare covered acupuncture visits every year. You can find this information on page 60 of the 
Plan's 2023 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 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 ICD-10-CM has two types of excludes notes. Each type of note has a different definition 
for use, but they are all similar in that they indicate that codes excluded from each other are independent of 
each other. 
a. Excludes1 
A type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. An 
Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired 
form of the same condition. An exception to the Excludes1 definition is the circumstance when the two 
conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note 
are related or not, query the provider. For example, code F45.8, Other somatoform disorders, has an Excludes1 
note for "sleep related teeth grinding (G47.63)," because "teeth grinding" is an inclusion term under F45.8. 
Only one of these two codes should be assigned for teeth grinding. However psychogenic dysmenorrhea is also 
an inclusion term under F45.8, and a patient could have both this condition and sleep related teeth grinding. In 
this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 
and G47.63 together. 
b. Excludes2 
A type 2 Excludes note represents Not included here. An excludes2 note indicates that the condition 
excluded is not part of the condition represented by the code, but a patient may have both conditions at the 
same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate. You can find this in the International Classification of Diseases 
(ICD)-10-CM Official Guidelines for Coding and Reporting FY 2023 -- UPDATED April 1, 2023. 
 
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 program reimbursement for HBO therapy will be limited to that which is administered in a 
chamber (including the one man unit) and is limited to the following conditions: 
 
   1.  Acute carbon monoxide intoxication, 
   2. Decompression illness, 
   3. Gas embolism, 
   4. Gas gangrene, 
   5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in 
combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened. 
   6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an 
adjunctive treatment when loss of function, limb, or life is threatened. 
   7. Progressive necrotizing infections (necrotizing fasciitis), 
   8. Acute peripheral arterial insufficiency, 
   9. Preparation and preservation of compromised skin grafts (not for primary management of wounds), 
   10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, 
   11. Osteoradionecrosis as an adjunct to conventional treatment, 
   12. Soft tissue radionecrosis as an adjunct to conventional treatment, 
   13. Cyanide poisoning, 
  14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to 
antibiotics and surgical treatment, 
   15. Diabetic wounds of the lower extremities in patients who meet the following three criteria: 
       a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; 
       b. Patient has a wound classified as Wagner grade III or higher; and 
       c. Patient has failed an adequate course of standard wound therapy. 
 
You can find this information in Medicare's National Coverage Determination (NCD): Hyperbaric Oxygen 
Therapy (20.29) 
 
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 miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a 
specific HCPCS code and are not included in another code should be coded K0108. 
 
The rules say that 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. Code K0108 must not be used for any 
component or feature of an expandable controller at the time of initial issue. The reimbursement for any type of 
complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. However, if 
individual components of the harness are replaced, code K0108 should be used. 
 
The rules say that code K0108 may not be billed for nonstandard dimensions of a power tilt and/or recline 
seating system (E1002, E1003, E1004, E1005, E1006, E1007, E1008). The definition of those codes includes 
any frame width and depth. 
 
The rules say that coding for a power tilt system (E1002), power recline system (E1003, E1004 and E1005), 
and tilt/recline system (E1006, E1007 and E1008) are all-inclusive. Usage of K0108 to bill for additional heavy 
duty or bariatric features is considered unbundling and is not allowed. 
 
The rules say that a power tilt and recline seating system (E1006, E1007, E1008) includes: a solid seat platform 
and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests. 
 
A Column II code is included in the allowance for the corresponding Column I code when provided at the same 
time. When multiple codes are listed in column I, all the codes in column II relate to each code in column I. All 
armrest codes (E0973, K0017, K0018, K0020) and K0019 Arm Pads are listed under Column II, and E1007 
(Power Tilt + Recline) is listed under Column I. 
 
You can find this information 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 the Centers for Medicare & Medicaid Services (CMS) covers percutaneous LAAC for non-
valvular atrial fibrillation (NVAF) through Coverage with Evidence Development (CED) with the following 
conditions: 
a. LAAC devices are covered when the device has received Food and Drug Administration (FDA) 
Premarket Approval (PMA) for that device's FDA-approved indication and meet all of the conditions 
specified below:  

The patient must have: 
- A CHADS2 score  2 (Congestive heart failure, Hypertension, Age > 75, Diabetes, Stroke/transient 
ischemia attack/thromboembolism) or CHA2DS2-VASc score  3 (Congestive heart failure, 
Hypertension, Age  65, Diabetes, Stroke/transient ischemia attack/thromboembolism, Vascular 
disease, Sex category) 
- A formal shared decision making interaction with an independent non-interventional physician using an 
evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. 
Additionally, the shared decision making interaction must be documented in the medical record. 
- A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following 
the conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral 
anticoagulants. The patient (preoperatively and postoperatively) is under the care of a cohesive, 
multidisciplinary team (MDT) of medical professionals. The procedure must be furnished in a hospital 
with an established structural heart disease (SHD) and/or electrophysiology (EP) program. 

The procedure must be performed by an interventional cardiologist(s), electrophysiologist(s), or cardiovascular 
surgeon (s) that meet the following criteria: 

- Has received training prescribed by the manufacturer on the safe and effective use of the device prior to 
performing LAAC; and, - Has performed  25 interventional cardiac procedures that involve transeptal puncture through an intact 
septum; and, 
- Continues to perform  25 interventional cardiac procedures that involve transeptal puncture through an 
intact septum, of which at least 12 are LAAC, over a 2-year period. 
You can find this rule in the Center for Medicare Services (CMS) Internet-Only Manual, Publication 100-03, 
Medicare National Coverage Determination (NCD) Manual, Section 20.34. 
 
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 pneumatic compression device (PCD) coded as E0675 to treat peripheral arterial disease 
(PAD) is not eligible for reimbursement. There is insufficient evidence to demonstrate that reimbursement is 
justified. 
 
You can find this information in the Local Coverage Determination (LCD): Pneumatic Compression Devices 
(L33829). 
 
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 only those items and services specifically listed in your Plan contract. Core buildup, including any 
pins when required is not listed as covered. You can find this information on pages 87-90 of the Plans 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 Medicare will automatically deny claim line(s) items submitted with a GZ modifier. You can 
find this rule in the Center for Medicare Services (CMS) Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 20.9.1. 
 
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. 
 
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 $15 copayment for each specialist office visit. You can find this 
information on pages 35-39 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 to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 240.2(E).

To qualify for home oxygen, the patient must meet one of the following blood gas levels:

1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;

2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;

3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;

4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.

For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. You can find this rule in the Centers for Medicare and Medicaid Services, Publication 100-03, Internet Only Manual, Medicare National Coverage Determinations Manual, Section 240.2(D)(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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) 
procedures will be considered medically reasonable and necessary for the following indications: 

Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have not 
responded to non-surgical medical management (e.g., narcotic and/or non- narcotic medication, physical 
therapy modalities) with and without methods of immobility (e.g., rest, bracing). 

- Both PVP and PVA will be considered reasonable and necessary when ALL of the following 
criteria are met: 
o Acute (<6 wks) or subacute (6-12 wks) osteoporotic VCF (T1- L5), based on symptom 
onset, and documented by advanced imaging demonstrating bone marrow edema on 
MRI or bone-scan/SPECT/CT uptake and 
o The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating 
Scale [NRS] or Visual Analog Scale [VAS] pain score  8) or is non-hospitalized with 
moderate to severe pain (NRS or VAS 5) despite optimal non-surgical management 
(NSM)8
 with one of the following: 
 Worsening Pain or 
 Stable to improved pain (but NRS or VAS 5) when 2 or more of the following 
are present: 
o Progression of vertebral body height loss 
o > 25% vertebral body height reduction 
o Kyphotic deformity 
o Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire [RDQ] >17) 

You can find this rule at Local Coverage Determination (LCD) L34976: Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (eff. 7/11/21). 
 
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 non-heated (E0561) or heated (E0562) humidifier is covered when ordered by the treating 
practitioner for use with a covered PAP (E0470 or E0601) device. You can find this rule at Local Coverage 
Determination (LCD) L33718: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep 
Apnea (eff. 9/27.21). 
 
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 both PVP and PVA will be considered reasonable and necessary for osteoporotic conditions 
when ALL of the following criteria are met: 

- Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1 - L5) based on symptom onset, and 
documented by recent (within 30 days) advanced imaging (bone marrow edema on MRI or bone-
scan/SPECT/CT uptake)
1-3, 10,25,27
 and 
- The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or 
visual Analog Scale [VAS] pain score  8)
4-7
 or is non-hospitalized with moderate to severe pain (NRS 
or VAS  5) despite optimal non-surgical management (NSM)8
 with one of the following: 
o Worsening pain or 
o Stable to improved pain (but NRS or VAS  5) when 2 or more of the following are present:  
 Progression of vertebral body height loss 
 >25% vertebral body height reduction 
 Kyphotic deformity 
 Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire 
(RDQ) > 17) 
 Steroid-induced fractures 
 Reinforcement or stabilization of vertebral body prior to surgery 

You can find this rule at Local Coverage Determination (LCD) L38213: Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (eff. 91/22). 
 
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.