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 program coverage for hyperbaric oxygen (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 these rules in 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. 
 
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 second confirmatory diagnostic facet joint procedure is considered medically reasonable 
and necessary in patients who meet ALL the following criteria: 
i. The patient meets the criteria for the first diagnostic procedure; AND 
ii. After the first diagnostic facet joint procedure, there must be a consistent positive 
response of at least 80% relief of primary (index) pain (with the duration of relief being 
consistent with the agent used)  
You can find this rule in Local Coverage Determination (LCD) Facet Joint Interventions for Pain Management 
L38803. 
 
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 studies do not demonstrate any advantage of intrapulmonary percussive ventilation (IPV) 
over that achieved with good pulmonary care in the hospital environment and there are no studies in the home 
setting. There are no data to support the effectiveness of the device. Therefore, IPV in the home setting is not 
covered. You can find this rule in the National Coverage Determination (NCD) - Intrapulmonary Percussive 
Ventilator (IPV) (240.5). 
 
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 
doctors 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 32 one-way trips per calendar year. You can find this information on page 83 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 state that a test panel is a single test with multiple components and is characterized by a single unit of 
service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact that 
the test reports multiple individual pathogens and/or targets. If additional organisms are not included in a panel, 
testing for those organisms separately may be reasonable and necessary when ordered in addition to the panel 
and supported by documentation in the medical record. You can find this information in You can find this 
information in the Centers for Medicare and Medicaid Services, Local Coverage Article (LCA): Billing and 
Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing 
(A58761). 
 
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 
doctors 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 up to 36 one-way trips, combined in and out-of-network, each year (limited to ground transportation 
only). Each one-way trip must not exceed 50 miles of driving distance. A trip is one-way transportation; a 
round trip is two trips. You are responsible for any costs over the trip limit. You can find this information on 
pages 120-121 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 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 $100 deductible for covered services. You can find this information on 
page 4-2 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 state that the Medicare approved amount for global surgery procedures includes payment for the 
following services related to the surgery when furnished by the physician who performs the surgery. 
 
- Preoperative Visits  
- Intra-operative Services  
- Complications Following Surgery  
- Postoperative Visits  
- Postsurgical Pain Management  
- Supplies  
- Miscellaneous Services 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.1. 
 
The rules say that Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be 
used on claims for evaluation and management (E/M) services, and only when these services are provided by 
the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another 
procedure or other service. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claim Processing Manual Chapter 12, Section 30.6.6. 
 
The rules say that modifier "-24" reports an unrelated evaluation and management service by same physician 
during a postoperative period. The physician may need to indicate that an evaluation and management service 
was performed during the postoperative period of an unrelated procedure. This circumstance is reported by 
adding the modifier "-24" to the appropriate level of evaluation and management service.  
 
Services submitted with the "-24" modifier must be sufficiently documented to establish that the visit was 
unrelated to the surgery. A diagnosis code that clearly indicates that the reason for the encounter was unrelated 
to the surgery is acceptable documentation.  
 You can find this rule in the Centers for Medicare and Medicaid Services, Publication 100-04, Medicare 
Claims Processing Manual Chapter 12, Section 40.2. 
 
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 thermal destruction of the intraosseous BVN will be considered medically reasonable and 
necessary for the treatment of cLBP in patients who meet ALL the following criteria:1,2,5,9,10,11,12,13 
 
    Chronic lumbar back pain of =6 months duration that causes functional deficit measured on a pain or 
disability scale*, AND 
    Documented failure to respond to =6 months of non-surgical management**, AND 
    Absence of non-vertebrogenic pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant deformity, 
AND 
    Evidence of Type 1 or Type 2 Modic changes on MRI, such as inflammation, edema, vertebral endplate 
changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent marrow, 
hypotensive signals (Type 1 Modic change), and changes to the vertebral body marrow including replacement 
of normal bone marrow by fat, and hypertensive signals (Type 2 Modic change), in 1 or more vertebrae from 
L3-S1. 
 
* Pain assessment and a disability scale must be obtained at baseline to be used for functional assessment. 
 
** Non-surgical management may include but is not limited to: 
 
    Avoidance of activities that aggravate pain; 
    Trial of Chiropractic manipulation; 
    Trial of Physical Therapy; 
    Cognitive support and recovery reassurance; 
    Injection therapy  epidural and/or facet; 
    Spine biomechanics education; 
    Specific lumbar exercise program; 
    Home use of heat/cold modalities; 
    Low impact aerobic exercise as tolerated; 
    Pharmacotherapy (e.g., non-narcotic analgesics, NSAIDs, muscle relaxants, neuroleptics, and narcotics). 
 
Patients must have undergone careful screening, evaluation, and diagnosis by a multidisciplinary team prior to 
thermal destruction of the intraosseous BVN (such screening must include psychological, as well as, physical 
evaluation). Documentation of the history and careful screening must be available in the patient chart if requested. 
 
You can find this information in the Local Coverage Determination (LCD) Thermal Destruction of the 
Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain L39420. 
 
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 knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints 
(L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury 
to or a surgical procedure on the knee(s). Refer to the diagnoses listed in the Groups 2 or 4 ICD-10 Codes in 
the LCD-related Policy Article. 
 
Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is 
ambulatory and has knee instability due to a condition specified in the Group 4 ICD-10 Codes in the LCD-
related Policy Article. For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, 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). 
 
Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and 
necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied 
if only pain or a subjective description of joint instability is documented. You can find this rule in 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 
doctors 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 up to 24 one-way routine trips per year for non-emergency, medical-related purposes such as doctor 
visits; appointments for dental, vision, hearing, and behavioral health services; and visits to pharmacies to pick 
up prescription drugs within a 50 mile limit. The destination must always be pre-approved. You can find this 
information on pages A1-54 to A1-55 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 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). 
 
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 there is a $500 deductible which applies to certain items and services. The Plan contract says 
that until enrollees have paid the deductible amount, they must pay the full cost for most covered services. The 
Plan deductible applies to in and out-of-network outpatient surgery services. You can find this information on 
pages 4-2 to 4-4 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. 
 
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 states they cover one pair of standard lenses and frames every two years. You can find this information 
on page 4-56 of the Plan's 2022 Evidence of Coverage.