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 epidural steroid injection (ESI) will be considered medically reasonable and necessary 
when the following three (3) requirements are met: 
 History, physical examination, and concordant radiological image-based diagnostic testing supporting 
one of the following: 
 Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic 
claudication due to disc herniation, osteophyte or osteophyte complexes, severe 
degenerative disc disease, producing foraminal or central spinal stenosis; OR 
 Post-laminectomy syndrome; OR 
 Acute herpes zoster associated pain 
AND 
 Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality 
of life or function. An objective pain scale or functional assessment must be performed at baseline 
(prior to interventions). The same scale* must be repeated at each follow-up for assessment of response. 
AND 
 Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or 
acute herpes zoster refractory to conservative management where a four (4) week wait is not required. 
The ESIs must be performed under CT or fluoroscopy image guidance with contrast
 
unless the patient has a 
documented contrast allergy or pregnancy where ultrasound guidance without contrast may be considered. 
Injections performed without image guidance or by ultrasound are not considered reasonable and necessary 
except in cases of documented contraindication to contrast media (e.g., allergy, pregnancy). You can find this 
rule in the Local Coverage Determination (LCD) - L39036, Epidural Steroid Injections for Pain Management. 
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 417.414. 
 
The rules say that Medicare may cover medically accepted off-label uses for Food and Drug Administration 
(FDA) approved drugs used in an anti-cancer chemotherapeutic regimen. Medicare maintains a list of 
compendia which define if a use is medically accepted. The off-label use must be supported in one or more of 
these compendia or in published, peer-reviewed medical literature. An off-label use must be supported in one 
or more of the compendia and the use must not be listed as unsupported, not indicated, not recommended, or 
equivalent terms, in any of the compendia. An off-label use may also be determined by the carrier in the state 
to be reasonable and necessary. You can find these rules and the list of the Medicare-recognized compendia in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 15, Section 50.4.5. 
 
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 a spinal orthosis (L0450 - L0651) is covered when it is ordered for one of the following 
indications:  
1. To reduce pain by restricting mobility of the trunk; or  
2. To facilitate healing following an injury to the spine or related soft tissues; or  
3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or  
4. To otherwise support weak spinal muscles and/or a deformed spine.  
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically 
necessary. You can find this rule at Local Coverage Determination (LCD): Spinal Orthoses: TLSO and LSO 
(L33790). 
 
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 laboratory shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 
If no CPT code accurately describes the procedure performed, the laboratory may report CPT code 81479 
(Unlisted molecular pathology procedure) with one unit of service or may report multiple individual CPT codes 
describing the component test results when medically reasonable and necessary. Procedures reported together 
must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician 
who is treating the beneficiary and using the results in the management of the beneficiary's specific medical 
problem. You can find this information in Chapter X: Pathology/Laboratory Services (CPT codes 80000-8999) 
for National Correct Coding Initiative Policy Manual for Medicare Services. 
 
The rules say that modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(d). 
 
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 this is a NON-coverage policy for all platelet rich plasma injections and/or applications as a 
means of managing musculoskeletal injuries and/or joint conditions. You can find this information in 
Medicare's Local Coverage Determination (LCD): Platelet Rich Plasma (L38937). 
 
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 claims or claim lines that have been determined to be exact duplicates of another claim or 
claim line are denied. However, such denials may be appealed. An exact duplicate for physician and other 
supplier claims submitted to a MAC or carrier is a claim or claim line that exactly matches another claim or 
claim line with respect to the following elements: Medicare beneficiary identifier, provider Number, from date 
of service, through date of service, type of service, procedure Code, place of Service, and billed amount. You 
can find this information in the Medicare Claims Processing Manual, Chapter 1 Section 120.2.. 
 
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 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 A bacterial urine culture is a laboratory procedure performed on a urine specimen to 
establish the probable etiology of a presumed urinary tract infection. It is common practice to do a urinalysis 
prior to a urine culture. A urine culture may also be used as part of the evaluation and management of another 
related condition. You can find this rule in National Coverage Determination (NCD) Urine Culture, Bacterial 
190.12. 
 
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 B: Payment for covered services are always bundled into payment for other services not 
specified. There will be no RVUs or payment amounts for these codes and no separate payment is ever made. 
When these services are covered, payment for them is subsumed by the payment for the services to which they 
are incident (an example is a telephone call from a hospital nurse regarding care of a patient). You can find this 
information www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-
Value-Files.html to download the Relative Value File (PPRRVU xlsx) spreadsheet that corresponds to the 
calendar year of the date-of-service. 
 
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 health plans, physicians, hospitals, and other health care providers must comply with the 
Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding 
Guidelines. You can find this rule in the Medicare Claims Processing Manual, Chapter 23, Section 10. 
 
The rules also say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on 
the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes 
for both the left and right side. If the side is not identified in the medical record, assign the code for the 
unspecified side. You can find this information in the ICD-10-CM Official Guidelines for Coding and 
Reporting, Section I, Conventions, general coding guidelines and chapter specific guidelines. 
 
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 repeat ESI when the first injection directly and significantly provided improvement of the 
condition being treated may be considered medically reasonable and necessary when the medical record 
documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from 
baseline using SAME scale* for at least three months.
  
If a patient fails to respond well to the initial ESI, a 
repeat ESI after 14 days can be performed using a different approach, level and/or medication, if appropriate, 
with the rationale and medical necessity for the second ESI documented in the medical record. You can find 
this rule in the Local Coverage Determination (LCD) - L36920, Epidural Steroid Injections for Pain 
Management. 
 
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 Physicians report the appropriate modifier to denote whether the service meets the  
requirements for payment at the personally performed rate, medically directed rate, or  
medically supervised rate. 
AA - Anesthesia Services performed personally by the anesthesiologist 
AD - Medical Supervision by a physician; more than 4 concurrent anesthesia procedures 
G8 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical 
procedures 
G9 - Monitored anesthesia care for patient who has a history of severe cardio- pulmonary condition 
QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals 
QS - Monitored anesthesia care service 
NOTE: The QS modifier can be used by a physician or a qualified nonphysician anesthetist and is for 
informational purposes. Providers must report actual anesthesia time and one of the payment modifiers on the 
claim.  
QY - Medical direction of one qualified nonphysician anesthetist by an anesthesiologist 
GC - These services have been performed by a resident under the direction of a teaching physician. 
NOTE: The GC modifier is reported by the teaching physician to indicate he/she rendered the services in 
compliance with the teaching physician requirements in 100 of this chapter. One of the payment modifiers 
must be used in conjunction with the GC modifier. The A/B MAC must determine payment for anesthesia in 
accordance with these instructions. They must be able to determine the uniform base unit that is assigned to the 
anesthesia code and apply the appropriate reduction where the anesthesia procedure meets the requirements for  payment at the medically directed rate. They must also be able to determine the number of anesthesia time units 
from actual anesthesia time reported on the claim. The A/B MAC must multiply allowable units by the 
anesthesia-specific conversion factor used to determine fee schedule payment for the payment area. You can 
find this information in the Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician 
Practitioners; 50 - Payment for Anesthesiology Services; I. Anesthesia Claims Modifiers. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare does not pay for gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. 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 Plan 
contract also says that the Plan will provide up to $200 reimbursement each year for qualified health-related 
wellness activities or services including participation in instructional fitness classes, participation in 
instructional physical activities, gym  membership fees, registration or participation fees for road races or 
walking challenges, participation in weight loss programs or visits to licensed nutritional counselor or 
registered dietician for nutritional counseling services. You can find this information on page 27 of the Plan's 
2010 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 all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patients medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patients 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
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 hearing aids under a supplemental benefit, including those from out-of-
network providers. This benefit pays up to $2000 for hearing aids every 3 years. You can find this on pages 4-
26 and 4-27 of the Plan's 2021 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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 the Plan covers certain vision services as a supplemental (extra) benefit..Eye refractions are 
covered during a routine exam when performed by a contracted routine vision care provider. You can find this 
information on pages 101 to 104 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 state that some International Classification of Diseases, 10th Revision, Clinical Modification (ICD-
10-CM) codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no 
bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If 
the side is not identified in the medical record, assign the code for the unspecified side. You can find this 
information in the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) 
Official Guidelines for Coding and Reporting, Section I.B.13. 
 
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.