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 say cervical traction devices (E0840, E0849, E0850, E0855 and E0860) are covered only if both of 
the following criteria are met: 
1. The beneficiary has a musculoskeletal or neurologic impairment requiring traction equipment; and 
2. The appropriate use of a home cervical traction device has been demonstrated to the beneficiary and the 
beneficiary tolerated the selected device. 
If criteria 1 and 2 are not met, cervical traction will be denied as not reasonable and necessary. 
Cervical traction devices described by code E0849 or E0855 are covered only when criteria 1 and 2 above and 
either criterion A, B or C below has been met: 
A. The beneficiary has a diagnosis of temporomandibular joint (TMJ) dysfunction; and has received 
treatment for the TMJ condition; or, 
B. The beneficiary has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that 
a chin halter is unable to be utilized; or, 
C. The treating practitioner orders and/or documents the medical necessity for greater than 20 pounds of 
cervical traction in the home setting. 
If the criteria for cervical traction are met but the additional criteria for E0849 or E0855 are not met, they will 
be denied as not reasonable and necessary. 
You can find this rule in the Local Coverage Determination (LCD): Cervical Traction Devices (L33823). 
 
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 treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are at least 4 millimeters (mm) in diameter 
  
  and if the patient remains symptomatic after a six-week trial of conservative therapy. You can find this 
information in 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 invasive procedures, including endovenous ablation therapy, for the treatment of varicose 
veins are considered medically reasonable and necessary when all of the following criteria have been met: 
1. An evaluation of the patient has been performed including a history and physical examination, the 
CEAP clinical classification and the revised Venous Clinical Severity Score (VCSS), and 
2. A duplex scan of the deep and superficial venous systems supports the examination findings, and 
3. A duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers in 
the saphenous, or perforator veins is 500 milliseconds or greater
3
 and absence of deep venous 
obstruction,
 
and 
4. The documentation supports signs and/or symptoms that interfere with activities of daily living and/or 
quality of life, and 
5. The CEAP clinical classification is C1 to C6 with the following criteria: 
a. Treatment of C1 disease (telangiectasia and their feeding reticular veins) is considered 
medically reasonable and necessary for patients with spontaneous and/or traumatic venous 
hemorrhage. 
b. For patients with C2 or C3 disease and VCSS <6, the plan of care shall include documentation 
of a period of conservative therapy (2 to 4 weeks) including graduated compression 20-30 
mmHg or greater, ambulation, elevation, and avoiding prolonged sitting and standing. 
c. For patients who meet any one of the following criteria, the mandatory conservative therapy 
prior to the invasive procedure may be waived. 
- VCSS 6 
- C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, 
and active venous leg ulceration) 
- Hemorrhage 
- Recurrent superficial thrombophlebitis 
You can find this information in Local Coverage Determination (LCD): Treatment of Chronic Venous 
Insufficiency of the Lower Extremities (L38720). 
 
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 therapeutic facet joint procedures are considered medically reasonable and necessary for 
patients who have had two (2) medically reasonable and necessary diagnostic facet joint procedures with each 
one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of relief being 
consistent with the agent used). You can find this information in Local Coverage Determination (LCD): Facet 
Joint Interventions for Pain Management (L34892). 
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 STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV 
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. See 
the OPPS Webpage at http://www.cms.hhs.gov/HospitalOutpatientPPS/for identification of STV-packaged 
codes. You can find this rule in the Medicare Claims Processing Manual Chapter 4 - Part B Hospital, Section 
10.4, C, 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 417.414. 
 
The rules say that cryosurgery of the prostate gland, also known as cryosurgical ablation of the prostate 
(CSAP), destroys prostate tissue by applying extremely cold temperatures in order to reduce the size of the 
  
  prostate gland. It is safe and effective, as well as medically necessary and appropriate, as primary treatment for 
patients with clinically localized prostate cancer, Stages T1-T3. You can find this information in National 
Coverage Determination (NCD): Cryosurgery of Prostate (230.9). 
 
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 determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiarys potential functional abilities. Potential functional ability is based on the reasonable 
expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to: 
1. The beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other 
medical problems; and 
3. The beneficiarys desire to ambulate. 
Clinical assessments of beneficiary rehabilitation potential must be based on classification levels. Level 3 is 
described as a beneficiary who has the ability or potential for ambulation with variable cadence. Typical of the 
community ambulator who has the ability to traverse most environmental barriers and may have vocational, 
therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. 
 
The rules say that a fluid, pneumatic, or electronic/microprocessor knee (L5828, L5848) is covered for 
beneficiaries whose functional level is 3 or above. The rules say that a flex-walk system or equal (L5981) is 
covered for beneficiaries whose functional level is 3 or above. You can find this information in the 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 say that a pneumatic compression device (PCD) coded as E0650 or E0651 is covered for both 
primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when all of the 
following three requirements are met: 
1. The beneficiary has a diagnosis of lymphedema as defined above, and 
2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented 
presence of at least one of the following clinical findings:  
A. Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
B. Papillomatosis cutis lymphostatica, 
C. Deformity of elephantiasis, 
D. Skin breakdown with persisting lymphorrhea, 
E. Detailed measurements over time confirming the persistence of the lymphedema with a history 
evidencing a likely etiology, and 
3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to 
other clinical treatment over the course of a required four-week trial. (See below for trial guidelines.) 
A PCD coded as E0650 or E0651 used to treat lymphedema that does not meet all of the requirements above is 
not eligible for reimbursement. Claims will be denied as not reasonable and necessary. A PCD coded as E0650 
or E0651 used to treat edema from causes other than lymphedema is not eligible for reimbursement. Claims 
will be denied as not reasonable and necessary. You can find the rules in Local Coverage Determination (LCD) 
Pneumatic Compression Devices L33829. 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 all diagnostic services (including non-patient laboratory tests) provided to a Medicare 
beneficiary by a hospital (or an entity wholly owned or wholly operated by the hospital) on the date of the 
beneficiary's inpatient admission or during the 3 calendar days (or, in the case of a non-subsection (d) hospital, 
1 calendar day) immediately preceding the date of admission are required to be included on the Part A bill for 
the inpatient stay. You can find this rule in the Centers for Medicare and Medicaid Services, Internet-Only 
Manual, Publication 100-104, Chapter 4, Section 10.12. 
 
For outpatient services furnished on or after June 25, 2010, the technical portion of all nondiagnostic services, 
other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly 
owned or wholly operated by the hospital) on the date of a beneficiary's inpatient admission are deemed related 
to the admission and thus, must be included on the bill for the inpatient stay. Also, the technical portion of 
outpatient nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by 
the hospital (or an entity wholly owned or wholly operated by the hospital) on the first, second, and the third 
calendar days (1 calendar day for a nonsubsection (d) hospital) immediately preceding the date of admission 
are deemed related to the admission and, therefore, must be billed with the inpatient stay, unless the 
nondiagnostic services are unrelated to the inpatient hospital claim (that is, the preadmission nondiagnostic 
services are clinically distinct or independent from the reason for the beneficiary's inpatient admission). In such 
cases, the unrelated outpatient hospital nondiagnostic services are covered by Medicare Part B, and the hospital 
or wholly owned or wholly operated physician practice shall include the technical portion of the services in 
their billing. PACMBPRA did not change the requirement that the technical portion of all diagnostic services 
provided by the hospital (or entity wholly owned or wholly operated by the hospital) occurring on the date of 
an inpatient admission, or during the 3 calendar days (or 1 calendar day) immediately preceding the date of an 
inpatient admission must be billed with the inpatient admission. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet-Only Manual, Publication 100-104, Chapter 12, Section 90.7. 
  
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 state that take-home supply of methadone billed as code G2078 cannot be billed more than 3 times in 
1 month (in addition to the weekly bundled payment code). You can find this rule in the Medicare Payment for 
Opioid Treatment Program located at https://www.cms.gov/medicare/payment/opioid-treatment-
program/billing-payment. 
 
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 48 one-way trips each year. You can find this information on pages 90 to 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 Medicare pays for outpatient rehabilitation therapy services only when they are provided by 
those trained specifically in physical therapy, occupational therapy or speech-language pathology. This means 
that the services of massage therapists may not be billed as covered therapy services. You can find these rules 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare 
Benefit Policy Manual, Chapter 15, Section 230.5. 
 
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. The Plan 
contract also says that the Plan covers clinic-based therapeutic massage services including assessment and 
therapeutic massage services for treatment of myofascial conditions and injuries and musculoskeletal pain 
syndromes provided by a licensed provider of therapeutic massage services. You are covered for up to 6 visits 
per year. You can find this information on page 103 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $35 copayment for physician/practitioner services, including doctors 
office visits.  You can find this information on page(s) 67 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 also state that psoriasis is a chronic skin disease, for which several conventional methods of treatment 
have been recognized as covered. These include topical application of steroids or other drugs; ultraviolet light 
(actinotherapy); and coal tar alone or in combination with ultraviolet B light (Goeckerman treatment). 
 
A newer treatment for psoriasis uses a psoralen derivative drug in combination with ultraviolet A light, known 
as PUVA. PUVA therapy is covered for treatment of intractable, disabling psoriasis, but only after the psoriasis 
has not responded to more conventional treatment. The Medicare Administrative Contractor should document 
this before paying for PUVA therapy. 
  
In addition, reimbursement for PUVA therapy should be limited to amounts paid for other types of 
photochemotherapy; ordinarily, payment should not be allowed for more than 30 days of treatment, unless 
improvement is documented. 
 
You can find these rules in the National Coverage Determination (NCD): Treatment of Psoriasis 250.1. 
 
 
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.