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 a second diagnostic facet procedure is considered medically necessary to confirm validity 
of the initial diagnostic facet procedure when administered at the same level. The second diagnostic procedure 
may only be performed a minimum of 2 weeks after the initial diagnostic procedure. Clinical circumstances 
that necessitate an exception to the 2-week duration may be considered on an individual basis and must be 
clearly documented in the medical record. 
 
A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in 
patients who meet ALL the following criteria: 
 
1) the patient meets the criteria for the first diagnostic procedure; and 
2) 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 information in the Local Coverage Determination (LCD) L38765: Facet Joint Interventions 
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 the Centers for Medicare and Medicaid Services (CMS) has established units of service edits
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims
submitted where the units of service exceed the MUE value for that HCPCS/CPT code will be denied.

Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code
on separate lines of the claim. 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(V).

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 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 $270 copayment per day, per provider, for Medicare-covered diagnostic 
radiology services. You can find this information on page 90 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 does not include 
guided tissue regeneration, add tooth to existing partial denture, or bone replacement grafts. You can find this 
information on pages 76-83 and 88-91 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 that percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) 
is covered in patients with BOTH of the following: 
 
1. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF)  
(T1 L5), based on symptom onset, and documented by advanced imaging demonstrating bone marrow edema 
on magnetic resonance imaging (MRI) or bone-scan/single-photon emission computerized tomography 
(SPECT)/CT uptake, and 
 
2. The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or Visual 
Analog Scale [VAS] pain score 8 or more) or is non-hospitalized with moderate to severe pain (NRS or VAS 5 
or more) despite optimal non-surgical management (NSM) with one of the following: 
 
a. Worsening pain, or 
b. Stable to improved pain (but NRS or VAS 5 or more) when two or more of the following are present: 
 
-Progression of vertebral body height loss 
-More than 25% vertebral body height reduction 
-Kyphotic deformity 
-Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] more than 17) 
 
The rules say that the exclusion criteria for the requested procedure is: 
 
a. Absolute contraindication 
  
1. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
2. Osteomyelitis, discitis or active systemic or surgical site infection 
3. Pregnancy  
 
 b. Relative contraindication 
 
1. Greater than three vertebral fractures per procedure 
2. Allergy to bone cement or opacification agents 
3. Uncorrected coagulopathy 
4. Spinal instability 
5. Myelopathy from the fracture 
6. Neurologic deficit 
7. Neural impingement 
8. Fracture retropulsion/canal compromise 
 
You can find this information at 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 state that for the for the first diagnostic facet joint procedure to be considered medically reasonable 
and necessary, the patient must meet the criteria outlined under indications for facet joint interventions: 
 
1) the patient meets the criteria for the first diagnostic procedure; and 
2) 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 information in the Local Coverage Determination: L38801: Facet Joint Interventions 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 state that the treatments for symptomatic varicose tributaries are either compressive sclerotherapy or 
microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are greater than 4 millimeters in diameter and 
if the patient remains symptomatic after a six-week trial of conservative therapy. 
 
The components of the conservative therapy include, but are not limited to: 
- weight reduction, 
- a daily exercise plan, 
- periodic leg elevation, and 
- the use of graduated compression stockings 
 
The conservative therapy must be documented in the medical record. Inability to tolerate compressive bandages 
or stockings and the reason for such intolerance must be documented in the medical record. 
 
The patient is considered symptomatic if any of the following signs and symptoms of significantly diseased 
vessels of the lower extremities are documented in the medical record: 
- stasis ulcer of the lower leg, 
- significant pain and significant edema that interferes with activities of daily living, 
- bleeding associated with the diseased vessels of the lower extremities, 
- recurrent episodes of superficial phlebitis, 
- stasis dermatitis, or 
- refractory dependent edema. 
 
You can find this information in the Local Coverage Determination (LCD): Varicose Veins of the Lower 
Extremity, Treatment of (L33575). 
 
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 state that when completing the 1500 claim form, providers must enter the correct Place of Service
(POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. You
can find this rule at Medicare Claims Processing Manual Ch. 26 Section 10.6.

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 Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 25 of the Plan's 2023 
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 endovenous stents may be placed for patients with severely symptomatic venous obstructions 
due to any of the following: 
 
1. Iliac vein compression syndrome also known as May-Thurner or Cockett syndrome 
2. Iliocaval obstruction 
3. Iliofemoral obstruction for patients with venous leg ulceration(s) not relieved by conservative therapies 
and compression. Progression of symptoms may lead to Phlegmasia Cerulea Dolens (PCD), acute inferior vena 
cava (IVC) thrombosis, and rapid thrombus extension despite anticoagulation as well as anatomically extensive 
DVT affecting the common femoral and/or iliac vein, or post-thrombotic stenosis with ankle edema of venous 
origin (i.e., minimum CEAP score 3). 
4. Superior or Inferior Vena Caval Thrombosis including Superior Vena Cava syndrome 
5. Post-thrombotic syndrome (PTS). 
6. As an adjunct to catheter-directed thrombolysis for acute femoroiliocaval deep vein thrombosis when 
post thrombolysis imaging identifies symptomatic residual stenosis 
7. Post radiation venous stenosis 
8. Symptomatic post-traumatic venous stenosis including those resulting from central venous catheters or 
transvenous device (e.g., pacemakers, defibrillators,) pacemaker leads or a history of abdominal and/or pelvic 
surgery. 
9. Salvage of thrombosed or stenotic symptomatic or limited function arteriovenous dialysis access 
fistulae or grafts with compromised venous outflow, failed angioplasty rapid restenosis, or vessel perforation. 
This may include treatment of trapping a life threatening thrombus, an aneurysm or pseudoaneurysm that 
threatens the viability of the AV fistula or graft, or the treatment of a hemodialysis vascular access rupture that 
cannot be controlled through balloon tamponade. 
10. Thrombotic obstruction of major hepatic veins (Budd-Chiari syndrome.) 
11. Transvenous decompression of portosystemic shunts 
12. Post-operative stenosis or venous narrowing due to repair of congenital cardiac disease, e.g. sinus 
venosus Atrial Septal Defect (ASD), discordant atrioventricular connection status post Mustard or Senning 
repair of Transposition of the Great Arteries (TGA). 
13. Pulmonary vein stenosis resulting from congenital malformation, extrinsic compression, sequelae of radiofrequency ablation (RFA), lung transplantation, or status post repair of Total Anomalous Pulmonary Vein 
Return (TAPVR).  
 
You can find this information in the Local Coverage Determination (LCD): Endovenous Stenting (L38231). 
 
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 the treatments for symptomatic varicose tributaries are either compressive sclerotherapy or 
microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are greater than 4 mm in diameter and if the 
patient remains symptomatic after a six-week trial of conservative therapy. You can find this information in the 
Local Coverage Determination (LCD) L33575: Varicose Veins of the Lower Extremity, Treatment. 
 
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 includes 
coverage for the periodontal maintenance (D4910), but only when they are received from an in-network 
provider. You can find this information on pages 67-68 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 facet joint injections are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet all of 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; AND* 
2) Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive 
conservative care management (as tolerated); AND 
3) Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst); AND 
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 this information in the Local Coverage Determination (LCD) L34892: Facet Joint Interventions 
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 Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 90 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 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 repeat epidural steroid injection (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. ESIs are limited to a maximum of 4 sessions per spinal region in a rolling 12-month period. 
You can find this information in Local Coverage Determination (LCD): Epidural Steroid Injections for Pain 
Management (L39015). 
 
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.