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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) 
procedures will be considered medically reasonable and necessary for 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). It will be considered reasonable and necessary when ALL of the 
following criteria are met: 
 
1. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1 
L5), based on symptom onset, and documented by advanced imaging demonstrating bone marrow edema on 
magnetic resonance imaging (MRI) or bone-scan/single-photon emission computerized tomography 
(SPECT)/CT uptake, and 
2. The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or Visual 
Analog Scale [VAS] pain score 8 or more) or is non-hospitalized with moderate to severe pain (NRS or VAS 5 
or more) despite optimal non-surgical management (NSM) with one of the following: 
 
a. Worsening pain, or 
b. Stable to improved pain (but NRS or VAS 5 or more) when two or more of the following are present: 
 
-Progression of vertebral body height loss 
-More than 25% vertebral body height reduction 
-Kyphotic deformity 
-Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] more than 17) 
 
You can find this rule in the Local Coverage Determination (LCD) - Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L34976). 
 
The rules say that the exclusion criteria for the requested procedure is: 
 
a. Absolute contraindication   
1. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
2. Osteomyelitis, discitis or active systemic infection 
3. Pregnancy 
4. Active surgical site infection 
 
b. Relative contraindication 
 
1. Allergy to bone cement or opacification agents 
2. Coagulopathy 
3. Spinal instability 
4. Myelopathy from the fracture 
5. Neurologic deficit 
6. Neural impingement 
7. Fracture retropulsion/canal compromise 
8. Greater than three vertebral fractures 
 
You can find this rule in the Local Coverage Determination (LCD) - Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L34976). 
 
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 32-35 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 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 
those items and services specifically listed in your Plan contract. Interim implant abutment placement (D6051), 
custom fabricated abutment  includes placement (D6057), implant supported crown - porcelain fused to high 
noble alloys (D6066) and interim implant crown (D6085) are not covered under the Plans dental benefits. You 
can find this information on pages 63 and 103-109 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 both percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA) 
will be considered reasonable and necessary for osteoporotic conditions when ALL of the following criteria are 
met:  
Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic Vertebral Compression Fracture (T5-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); AND  
The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or Visual 
Analog Scale [VAS] pain score greater than 8) OR is non-hospitalized with moderate to severe pain (NRS or 
VAS greater than 5) despite optimal non-surgical management (NSM) with one of the following:  
1) worsening pain,  
2) stable to improved pain (but NRS or VAS greater than 5) when two or mor of the following are present:  
a) progression of vertebral body height loss,  
b) Greater than 25 percent vertebral body height reduction,  
c) kyphotic deformity,  
d) severe impact of vertebral compression fracture on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) greater than 17),  
e) steroid-induced fractures,  
f) reinforcement or stabilization of vertebral body prior to surgery. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38213). 
 
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 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 if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the lab shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT code accurately describes the procedure performed, the lab may report CPT code 81479 with one unit of service. If a single procedure is performed, on one HCPCS/CPT code with one unit of service may be reported for the procedure. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Manual. Chapter X(f).

The rules state that if an independent lab bills for services the place where the sample was taken is reported as the Place of Service (POS). an independent laboratory taking a sample in it laboratory shows "81" as place of service. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.6.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract say 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 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 pages 32 to 43 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 coverage of NMES to treat muscle atrophy is limited to the treatment of disuse atrophy 
where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-
neurological reasons for disuse atrophy. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet-Only Manual, Publication 100-03, National Coverage Determination (NCD) for 
Neuromuscular Electrical Stimulation (NMES) (160.12). 
 
The rules say that Pneumatic Compression Device (PCD) related accessories are eligible for reimbursement 
only when the appropriate, related based PCD meets the applicable coverage criteria for that type of PCD. If 
the based PCD is not covered, related accessories are not eligible for reimbursement. You can find this 
information in the Local Coverage Determination (LCD) for 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 a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1852) is covered if the beneficiary has had recent injury to or a surgical procedure 
on the knee(s). Knee orthoses are also covered for a beneficiary who is ambulatory and has knee instability. 
You can find this rule in the Local Coverage Determination (LCD) - Knee Orthoses (L33318). 
 
The rules say that knee instability must be documented by examination of the beneficiary and objective 
description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). You can find this rule 
in the Local Coverage Determination (LCD) - Knee Orthoses (L33318). 
 
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 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 
doctor's 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 a total of 24 one-way non-emergency ground transportation trips within our service area every year. This benefit is available to help you obtain medically necessary care and services. Trips are limited to 75 miles, one-way, unless pre-approved by the plan. Call at least 72 hours in advance to schedule routine trips, or anytime for urgent trips. Certain locations may be excluded. For more information about plan-approved locations, please call Member Services. You can find this information on page 102 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 Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. You can find this rule at 42 CFR Section 422.111(a) and (b). 
 
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 oche systems- Accu-Chek Aviva Plus, Accu-Chek Smartview, Accu-Chek Compact Plus, and others; OR Trividia systems- TrueMetrix and TrueTrack. You can find this information on page 52 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 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 providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not separately billed. You can find this information in the National Correct Coding Initiative (NCCI) Policy Manual, Chapter X, page X-7
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 to qualify for portable oxygen, the patient must meet the criteria for home oxygen. Patients who are mobile in the home and would benefit from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by itself, or to use in addition to a stationary oxygen system. 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 (B). The rules say that oxygen is coverable when medically necessary for patients with acute or chronic conditions, short- or long- term, when the patient exhibits hypoxemia. Patients exhibiting hypoxemia are defined using the clinical criteria below. 1. Arterial PO2 (partial pressure of oxygen) at or below 55 mm Hg or arterial O2 (oxygen) 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 patients 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 who do not exhibit hypoxemia according to the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not have a non-covered indication. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Sections 240.2.
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.
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 
mandibular partial denture when meeting certain criteria. You can find this information in Chapter 4 on page 
68 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 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, 3.3.2.1. 
 
For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the 
beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills 
without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be 
denied as not reasonable and necessary. You can find this information in the Local Coverage Determination 
(LCD) for Transcutaneous Electrical Nerve Stimulators (TENS) (L33802). 
 
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.