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 Facet Joint Interventions generally consist of four types of procedures: Intraarticular (IA) 
Facet Joint Injections, Medial Branch Blocks (MBB), Radiofrequency Ablations (RFA) and Facet cyst 
rupture/aspiration: 
 
Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of 
chronic pain in patients who meet ALL the following criteria: 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. There is no non-facet 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. 
 
You can find these rules in Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management (L35936). 
 
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 to repair means to fix or mend and to put the equipment back in good condition after 
damage or wear. Repairs to equipment which a beneficiary owns are covered when necessary to make the 
equipment serviceable. If the expense for repairs exceeds the estimated expense of purchasing or renting 
another item of equipment for the remaining period of medical need, no payment can be made for the amount 
of the excess. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. 
During the reasonable useful lifetime of five years, Medicare does cover repair up to the cost of replacement 
(but not actual replacement) for medically necessary equipment owned by the beneficiary. You can find this 
information in the Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 15, Section 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 a power operated vehicle (POV) is covered when: 
A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, 
grooming, and bathing in customary locations in the home. A mobility limitation is one that: 
- Prevents the beneficiary from accomplishing an MRADL entirely, or 
- Places the beneficiary at reasonably determined heightened risk of morbidity or mortality 
secondary to the attempts to perform an MRADL; or 
- Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
B. The beneficiarys mobility limitation cannot be sufficiently and safely resolved by the use of an 
appropriately fitted cane or walker. 
 
C. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-
configured manual wheelchair in the home to perform MRADLs during a typical day. 
- Limitations of strength, endurance, range of motion, or coordination, presence of pain, or 
deformity or absence of one or both upper extremities are relevant to the assessment of upper 
extremity function. 
- An optimally-configured manual wheelchair is one with an appropriate wheelbase, device 
weight, seating options, and other appropriate nonpowered accessories. 
 
D. The beneficiary is able to: 
- Safely transfer to and from a POV, and 
- Operate the tiller steering system, and 
- Maintain postural stability and position while operating the POV in the home. 
 
E. The beneficiarys mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) 
are sufficient for safe mobility using a POV in the home. 
 F. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for 
the operation of the POV that is provided. 
 
G. The beneficiarys weight is less than or equal to the weight capacity of the POV that is provided and 
greater than or equal to 95% of the weight capacity of the next lower weight class POV  i.e., a Heavy 
Duty POV is covered for a beneficiary weighing 285  450 pounds; a Very Heavy Duty POV is covered 
for a beneficiary weighing 428  600 pounds. 
 
H. Use of a POV will significantly improve the beneficiarys ability to participate in MRADLs and the 
beneficiary will use it in the home. 
 
I. The beneficiary has not expressed an unwillingness to use a POV in the home. 
 
If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable 
and necessary. You can find this information in Local Coverage Determination (LCD): Power Mobility 
Devices (L33789). 
 
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: 
 
Nationally Covered Indications 
Effective for services performed on or after September 26, 2022, cochlear implantation may be covered for 
treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals 
who demonstrate limited benefit from amplification. Limited benefit from amplification is defined by test 
scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set 
sentence recognition. Patients must meet all of the following criteria. 
 Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from 
appropriate hearing (or vibrotactile) aids; 
 Cognitive ability to use auditory clues and a willingness to undergo an extended program of 
rehabilitation; 
 Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to 
implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous 
system; 
 No contraindications to surgery; and 
 The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling. 
You can find this rule at the Medicare National Coverage Determination (NCD) 50.3: Cochlear Implantation. 
 
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). 
 
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that, for reporting interpretation of a diagnostic test, there is a difference between the 
interpretation and report of an x-ray procedure and a review of the procedure. A professional component 
billing based on a review of the findings of these procedures, without a complete, written report similar to that 
which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the 
service. When carriers receive only one claim for an interpretation, they must presume that the one service 
billed was a service to the individual beneficiary rather than a quality control measure and pay the claim if it 
otherwise meets any applicable reasonable and necessary test. You can find this rule in the Centers for 
Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 13, Section 100.1. 
 
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 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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for
Medicare Services, Chapter I(A).

The rules also say that the definition of the GY modifier is Item or Service Statutorily Excluded or Does Not
Meet the Definition of Any Medicare Benefit. Lines submitted as non-covered and will be denied. You can find
this in the Medicare Claims Processing Manual, Chapter 1, Section 60.4.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit does not include 
D4275 or D4285. You can find this information on pages 141-154 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 certain cardiac event monitors capture electrical activity with a single electrode attached to 
the skin. Other devices may employ multiple electrodes in order to record more complex EKG tracings. 
Additionally, devices may be individually programmed to detect patient-specific factors, electrode malfunction, 
or other factors. Cardiac event monitors can be further categorized as either pre-event or post-event 
recorders, based on their memory capabilities: 
a. Pre-symptom Memory Loop Recorder (MLR) 
Upon detecting symptoms, the wearer presses a button, which activates the recorder to save (i.e., 
memorize) an interval of pre-symptom EKG data along with data during and subsequent to the 
symptomatic event. Self-sensing recorders (also known as event-activated or automatic trigger) 
do not require patient input to capture these data. Single or multiple events may be recorded. 
The device is worn at all times, usually for up to 30 days. 
o Implantable (or Insertable Loop) Recorder (ILR) 
Another type of pre-symptom MLR, it is implanted subcutaneously in a patients upper left 
chest and may remain implanted for many months. An ILR is used when syncope is thought to 
be cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a 
traditional pre-symptom MLR. 
You can find this rule at the Medicare National Coverage Determination (NCD) 20.15: Electrocardiographic 
Services. 
 
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 or services are not covered. You can find this rule at 42 CFR Sections
411.15 and 411.15(o).

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 plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1.  
 
The rules also 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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
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 modifier -GY is used to identify that a service is statutorily excluded from coverage and does 
not meet the definition of any benefit category. Use of this modifier will lead to claim denial. You can find this 
information in an article on the Medicare Administrative Contractor (MAC) Noridians website at 
https://med.noridianmedicare.com/web/jeb/topics/modifiers/gy 
 
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 cover for a lower limb prosthesis and related components is approved if there is sufficient
clinical documentation of functional need for the technologic or design feature of a given prosthetic. This
information must be retained in the treating practitioner's or prosthetist's files. You can find this in the
Medicare 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.

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 Definitive UDT is reasonable and necessary for the following circumstances: 
-Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT screen; 
-Definitively identify specific drugs in a large family of drugs; 
-Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, 
Meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
-Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., discontinuation 
of THC use according to a treatment plan); 
-Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients self- 
report, presentation, medical history, or current prescribed pain medication plan; 
-Rule out an error as the cause of an unexpected presumptive UDT result; 
-Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 
-Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
Definitive UDT may be reasonable and necessary based on patient specific indications, including historical use, 
medication response, and clinical assessment, when accurate results are necessary to make clinical decisions. 
The clinicians rationale for the definitive UDT and the tests ordered must be documented in the patients 
medical record. 
At the current time, physician-directed definitive profile testing is reasonable and necessary when ordered for a 
particular patient based upon historical use and community trends. However, the same physician-defined 
profile is not reasonable and necessary for every patient in a physicians practice. Definitive UDT orders 
should be individualized based on clinical history and risk assessment, and must be documented in the medical 
record. 
 
You can find this rule in the Local Coverage Determination (LCD) for Controlled Substance Monitoring and 
Drugs of Abuse Testing, L36393. 
 
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare & Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules say that the Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no 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. You can find this information in the Centers for 
Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 30.2.2. 
 
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.