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 a Group 3 power wheelchair can be covered only for enrollees who have a mobility 
limitation that is due to: 
 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices L33789. 
 
The rules say that a power seating system  tilt only, recline only, or combination tilt and recline  with or 
without power elevating leg rests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: 
The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices 
LCD; and a specialty evaluation that was performed by a licensed/certified medical professional, such as a 
physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience 
in rehabilitation wheelchair evaluations of the beneficiarys seating and positioning needs. The PT, OT, or 
practitioner may have no financial relationship with the supplier; and the wheelchair is provided by a supplier 
that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and 
who has direct, in-person involvement in the wheelchair selection for the beneficiary. The beneficiary is at high 
risk for development of a pressure ulcer and is unable to perform a functional weight shift; or The beneficiary 
utilizes intermittent catheterization for bladder management and is unable to independently transfer from the 
wheelchair to bed; or The power seating system is needed to manage increased tone or spasticity. If these 
criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Local Coverage 
Determination (LCD): Wheelchair Options/Accessories (L33792). 
 
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. 
 
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 therapeutic facet joint procedures are considered medically reasonable and necessary for 
patients who meet all of the following criteria: 
 
1. The patient has had two (2) medically reasonable and necessary diagnostic facet joint 
procedures with each one providing a consistent minimum of 80% relief of primary (index) pain 
(with the duration of relief being consistent with the agent used); and 
2. Subsequent therapeutic facet joint procedures at the same anatomic site result in at least 
consistent 50% pain relief for at least three (3) months from the prior therapeutic procedure or at 
least 50% consistent improvement in the ability to perform previously painful movements and 
ADLs as compared to baseline measurement using the same scale; and 
3. Documentation of why the patient is not a candidate for radiofrequency ablation (such as 
established spinal pseudarthrosis, implanted electrical device) is in the medical record. 
 
You can find this information in Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L34892). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 47 to 54 of the Plan's 
2021 Evidence of Coverage (EOC) and on pages 46 to 53 of the Plan's 2022 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 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 
includes acupuncture services for chronic low back pain provided by a licensed acupuncturist. Coverage is 
subject to the same 20-visit annual limit imposed by Medicare. Additionally, a wellness allowance is provided 
for reimbursement up to $150 per calendar year towards your cost for membership in a qualified health club or 
fitness facility, covered instructional fitness classes, participation in wellness programs such as Matter of 
Balance, Chronic Disease self-management, diabetes workshop, Healthy Eating for Successful Living, Healthy 
IDEAS, Powerful Tools for Caregivers, Arthritis Foundation Exercise, Enhance Wellness, Fit For Your Life, 
AAA Senior Driving, memory fitness activities, acupuncture, and/or covered nutritional counseling sessions 
with a licensed nutritional counselor or registered dietician. You can find this information on pages 70 and  
82-83 of the Plans 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 state that payment for a spinal orthosis is included in the payment to a hospital or SNF if: 
 
  
      The orthosis is provided to a beneficiary prior to an inpatient hospital admission or Part A covered SNF stay; 
and 
 
    The medical necessity for the orthosis begins during the hospital or SNF stay (e.g., after spinal surgery). 
 
A claim should not be submitted to the DME MAC in this situation. 
 
Payment for a spinal orthosis is also included in the payment to a hospital or a Part A covered SNF stay if: 
 
    The orthosis is provided to a beneficiary during an inpatient hospital or Part A covered SNF stay prior to the 
day of discharge; and 
 
    The beneficiary uses the item for medically necessary inpatient treatment or rehabilitation. 
 
A claim must not be submitted to the DME MAC in this situation. 
 
Payment for a spinal orthosis delivered to a beneficiary in a hospital or a Part A covered SNF stay is eligible 
for coverage by the DME MAC if: 
 
    The orthosis is medically necessary for a beneficiary after discharge from a hospital or Part A covered SNF 
stay; and 
 
    The orthosis is provided to the beneficiary within two days prior to discharge to home; and 
 
    The orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the beneficiary 
to take home. 
 
You can find this information in the Local Coverage Article Spinal Orthoses: TLSO and LSO - Policy Article 
A52500. 
 
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 follow-up services are included in the global surgical package. You can find this rule in the 
Center for Medicare Services (CMS) Internet-Only Manual Publication 100-04, Medicare Claims Processing 
Manual, Chapter 12, Section 40.1. 
 
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 state that effective for claims with dates of service on or after January 21, 2020, MACs will recognize 
and pay for acupuncture for chronic lower back pain services reported with CPT codes 97810, 97811, 97813, 
97814, 20560, and 20561. This information is found in National Coverage Determination: Acupuncture for 
Chronic Low Back Pain (cLBP) (NCD 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.
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 payment is made for only one wheelchair at a time. Backup chairs are denied as not 
reasonable and necessary. You can find this rule in Local Coverage Determination (LCD) Manual Wheelchair 
Bases L33788. 
 
The rules state that payment may be made for repair, maintenance, and replacement of medically required 
DME, including equipment which had been in use before the user enrolled in Part B of the program.  However, 
do not pay for repair, maintenance, or replacement of equipment in the frequent and substantial servicing or 
oxygen equipment payment categories.  In addition, payments for repair and maintenance may not include 
payment for parts and labor covered under a manufacturers or suppliers warranty. You can find this 
information in the Medicare Benefit Policy Chapter 15, 110.2 
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 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 26 to 27 of the Plan's 
2022 Member Handbook. 
 
The contract also says you may need a referral to use a specialist or someone that is not your primary care 
physician (PCP). A referral means that your network PCP must give you approval before you can use the other 
provider. If you do not get a referral, the Plan may not cover the service. If you are using a specialist for your 
care, you may need to return to your PCP for a referral for additional services. You can find this information on 
page 30 of the Plan's 2022 Member Handbook.
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 47-50 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 if a laboratory procedure produces multiple reportable test results, only a single HCPCS/CPT 
code shall be reported for the procedure. If there is no HCPCS/CPT code that describes the procedure, the 
laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service. You can find 
this information in the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative 
Coding Policy Manual for Medicare Services; Chapter X. 
 
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 procedure code 99153 has a PC/TC Indicator of 3. You can find this information in the 2022 
National Physician Fee Schedule Relative Value File. 
 
The rules say that the work (or professional) component of physicians services refers to the resources used in 
furnishing the service that reflect physician time and intensity. The technical component (or practice expense 
[PE]) refers to the portion of resources involved in furnishing services (such as equipment costs, office rent, 
and wages of personnel). As part of the CY 2017 Final Rule, CPT code 99153 was established as a PE-only 
code meaning there is no work component RVU associated with that service. The CY 2017 Final Rule 
established CPT codes 99151, 99152 and 99155-99157 as representative of the work component for moderate 
sedation services. This is further reflected in the 2019 National Physician Fee Schedule Relative Value File 
October Release with CPT code 99153 assigned a PC/TC indicator of 3 and a work RVU of 0.00. You can find 
this information in the Medicare Claims Processing Manual Chapter 26 - Completing and Processing Form 
CMS-1500 Data Set, 10.5 - Place of Service Codes (POS) and Definitions, Medicare Claims Processing 
Manual Chapter 23 - Fee Schedule Administration and Coding Requirements, 50.6 - Physician Fee Schedule 
Payment Policy Indicator File Record Layout and CY 2017 Final Rule. 
 
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 more than 2 test (diagnostic) sockets (L5618, L5620, L5622, L5624, L5626, L5628) for an 
individual prosthesis are not reasonable and necessary unless there is documentation in the medical record 
  
  which justifies the need. Exception: A test socket is not reasonable and necessary for an immediate prosthesis 
(L5400, L5410, L5420, L5430, L5450, L5460). 
 
No more than two of the same socket inserts (L5654, L5655, L5656, L5658, L5661, L5665, L5673, L5679, 
L5681, L5683) are allowed per individual prosthesis at the same time. 
 
Socket replacements are considered reasonable and necessary if there is adequate documentation of functional 
and/or physiological need. It is recognized that there are situations where the explanation includes but is not 
limited to: changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to 
excessive beneficiary weight or prosthetic demands of very active amputees. 
 
You can find this information in the Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
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 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. 
 
The rules also say that there is no Medicare benefit for screening CV risk assessment testing for asymptomatic 
(without signs or symptoms of disease) patients. Screening asymptomatic patients for cardiovascular risk is 
statutorily excluded by Medicare. You can find this information in Local Coverage Determination (LCD): 
MolDX: Biomarkers in Cardiovascular Risk Assessment (L36358). 
 
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.