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 It has not been established that a water circulating heat pad with pump (E0217) is 
reasonable and necessary compared to a standard electric heating pad; therefore, if E0217 is provided it will be 
denied as not reasonable and necessary. You can find this rule at Centers for Medicare and Medicaid Services, 
Local Coverage Determination L33784 entitled "Heating Pads and Heat Lamps." 
 
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 the clinician's rationale for the definitive urine drug testing and the tests ordered must be 
documented in the patients medical record. You can find this rule in the Local Coverage Determination (LCD) 
- Controlled Substance Monitoring and Drugs of Abuse Testing (L35006). 
 
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. The Plan has a Point-of-Service (POS) option to cover out-of-
network services. You will need to obtain authorization from the Plan prior to seeking out-of-network care. 
You can find this information on pages 64-66 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 
coverage for a crown (D2751), one per tooth every 84 months, and documentation must comply with the 
clinical criteria. You can find this information in Chapter 4 on pages 63 to 67 of the Plans 2023 Evidence of 
Coverage (EOC) and in the Plan's 2023 Dental Benefit Details.
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 crowns 
or partial crowns once per tooth every 84 months; requires extensive loss of tooth structure due to decay or 
fracture; requires at least 50% remaining bone support. You can find this information on pages 5-10 in the 
Plan's 2023 Dental Benefits Details.
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 makes payment for an assistant at surgery when the procedure is authorized for an assistant and the 
person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or clinical nurse 
specialist (CNS). Medicare uses the payment policy indicators on the Medicare Physician Fee Schedule 
Database (MPFSDB) to determine if assistant at surgery services are reasonable and necessary for a specific 
Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code. The 
rules say that if the MPFSDB contains an assistant at surgery indicator of 2 for the surgical procedure in 
question, assistant at surgery service may be paid. Payment restrictions do not apply to this procedure. You can 
find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 4, Sections 250.9, 250.9.1, and 250.9.3.  
 
The rules state that surgical assistant services provided by a physician should be billed with modifiers -80, -81, 
or -82. The AS modifier is to be used for assistants-at-surgery who are physician assistants, nurse practitioners 
and clinical nurse specialists.  You can find this rule at Centers for Medicare and Medicaid Services, Internet-
Only Publication 100-04, Medicare Claims Processing Manual Chapter 12, Section 20.4.3. 
 
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 thermal destruction of the intraosseous BVN will be considered medically reasonable and 
necessary for the treatment of chronic low back pain in patients who meet all the following criteria: 
1. Chronic lumbar back pain of at least 6 months duration that causes functional deficit measured on a 
pain or disability scale 
2. Documented failure to respond to at least 6 months of non-surgical management 
3. 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 
4. 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. 
You can find this information in 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 state that molecular pathology procedures (Tier 1 and Tier 2) may be eligible for coverage when ALL 
of the following criteria are met: 
 
- Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are 
unavailable or results are clearly equivocal; AND 
- Availability of a clinically valid test, based on published peer reviewed medical literature; AND 
- Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed test) or 
LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) of analytical 
validity and clinical utility; AND 
- Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND 
- For testing panels, including but not limited to, multiple genes or multiple conditions, and in cases where a 
tiered approach/method is clinically available, testing would be covered ONLY for the number of genes or test 
that are reasonable and necessary to obtain necessary information for therapeutic decision making; AND 
- Individual has not previously received genetic testing for the disease/condition. (In general, diagnostic genetic 
testing for a disease should be performed once in a lifetime.) Exceptions include clinical scenarios whereby 
repeat testing of somatically-acquired mutations (for example, pre- and post- therapy) may be required to 
inform appropriate therapeutic decision-making. 
 
MTHFR (5,10-methyenetetrahydrofolate reductase) (e.g. hereditary hypercoaguability), gene analysis, common 
variants(e.g., EG, 677T, 1298C) is not considered to be clinically efficacious; therefore, testing is not medically 
necessary. 
 
You can find this information in Local Coverage Determination (LCD): Molecular Pathology Procedures 
(L35000). 
 If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the global surgery package of procedures with a global period of 10 or 90 days includes all 
additional medical or surgical services required of the surgeon during the postoperative period of the surgery 
because of complications which do not require additional trips to the operating room, follow-up visits during 
the postoperative period of the surgery that are related to recovery from the surgery, among other related 
services. In order to report an unrelated evaluation and management (EM) service by same physician during a 
postoperative period, modifier -24 must be used. Services submitted with the -24 modifier must be sufficiently 
documented to establish that the visit was unrelated to the surgery. Not included in the global surgery payment 
are clearly distinct surgical procedures during the postoperative period which are not re-operations or treatment 
for complications. These services should be billed with modifier -79. 
 
When treatment for complications requires a return trip to the operating room, physicians must bill the Current 
Procedural Terminology (CPT) code that describes the procedure(s) performed during the return trip. In 
addition to the CPT code, physicians use CPT modifier -78 for these return trips (return to the operating 
room for a related procedure during a post-operative period).  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 40.1 and 40.2. 
 
The rules say that an operating room (OR) is defined as a place of service specifically equipped and staffed for 
the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and 
an endoscopy suite. It does not include a patients room, a minor treatment room, a recovery room, or an 
intensive care unit (unless the patients condition was so critical there would be insufficient time for 
transportation to the OR). You can find this information at https://www.novitas-
solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144546 
 
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 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.
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 minimally-invasive surgical (MIS) fusion of the sacroiliac (SI) joint is considered medically 
necessary when all of the following criteria are met: 
1. Have moderate to severe pain with functional impairment and pain persists despite a minimum six 
months of intensive nonoperative treatment that must include medication optimization, activity 
modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip 
including a home exercise program 
2. Patients report of typically unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized 
over the posterior SIJ, and consistent with SIJ pain 
3. A thorough physical examination demonstrating localized tenderness with palpation over the sacral 
sulcus in the absence of tenderness of similar severity elsewhere and that other obvious sources for their 
pain do not exist 
4. Positive response to a cluster of 3 provocative tests 
5. Absence of generalized pain behavior (e.g. somatoform disorder) or generalized pain disorders (e.g. 
fibromyalgia) 
6. Diagnostic imaging studies that include all of the following: 
a. Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of 
destructive lesions (e.g. tumor, infection), fracture, traumatic SIJ instability, or inflammatory 
arthropathy that would not be properly addressed by percutaneous SIJ fusion 
b. Imaging of the pelvis (AP plain radiograph) to rule out concomitant hip pathology 
c. Imaging of the lumbar spine (CT or MRI) to rule out neural compression or other degenerative 
condition that can be causing low back or buttock pain 
7. At least 75 percent reduction of pain for the expected duration of two anesthetics (on separate visits 
each with a different duration of action), and the ability to perform previously painful maneuvers, 
following an image-guided, contrast-enhanced intra-articular SIJ injection. 
8. A trial of at least one therapeutic intra-articular SIJ injection (i.e. corticosteroid injection) 
You can find this information in Local Coverage Determination (LCD): Minimally-invasive Surgical (MIS) 
Fusion of the Sacroiliac (SI) Joint (L36406). 
 
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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 10. 
 
The rules also say that certain conditions have both an underlying etiology and multiple body system 
manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention 
that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 
Wherever such a combination exists, there is a use additional code note at the etiology code, and a code 
first note at the manifestation code. These instructional notes indicate the proper sequencing order of the 
codes, etiology followed by manifestation. In most cases the manifestation codes will have in the code title, in 
diseases classified elsewhere. Codes with this title are a component of the etiology/ manifestation convention. 
The code title indicates that it is a manifestation code. 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. 
 
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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients 
with both the following: 
1. Inclusion criteria (all are required): 
a. Acute (less than 6 weeks) or subacute (6 to 12 weeks) osteoporotic vertebral compression 
fracture (VCF) (T1  L5), based on symptom onset, and documented by advanced imaging 
(bone marrow edema on MRI or bone-scan/SPECT/CT uptake) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain 
ii. Non-hospitalized with moderate to severe pain despite optimal non-surgical management 
(NSM) (ONE): 
1. Worsening pain 
2. Stable to improved pain (with at least 2 of the following): 
A. Progression of vertebral body height loss 
B. At least 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning >17 
You can find this information in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L33569). 
 
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 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 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, 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, only 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). 
 
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.