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 contract suppliers are not required to furnish a specific brand name item or mode of 
delivery to a beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical 
outcome. A physician or treating practitioner (that is a physician assistant, clinical nurse specialist, or nurse 
practitioner) may prescribe, in writing, a particular brand of a competitively bid item or mode of delivery for an 
item if he or she determines that the particular brand or mode of delivery is necessary to avoid an adverse 
medical outcome for the beneficiary. The physician or treating practitioner must document in the beneficiarys 
medical record the reason why the specific brand or mode of delivery is necessary to avoid an adverse medical 
outcome. This documentation should include the following: 
 
1. The product's brand name or mode of delivery 
2. The features that this product or mode of delivery has versus other brand name products or modes of 
delivery; and 
3. An explanation of how these features are necessary to avoid an adverse medical outcome. 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 36, Section 30.4. 
 
The rules say that if a physician or treating practitioner prescribes a particular brand or mode of delivery to 
avoid an adverse medical outcome, the contract supplier must either:  
 
1. Furnish the particular brand or mode of delivery as prescribed by the physician or treating practitioner, 
2. Consult with the physician or treating practitioner to find another appropriate brand of item or mode of 
delivery for the beneficiary and obtain a revised written prescription from the physician or treating practitioner; 
or 
3. Assist the beneficiary in locating a contract supplier that can furnish the particular brand of item or mode of 
delivery prescribed by the physician or treating practitioner. 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 36, Section 30.4.  
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 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 this rule in the Local Coverage Determination (LCD) L33930: 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 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 $250 copayment for each Medicare-covered outpatient hospital facility 
visit. You can find this information on page 73 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 definitive urine drug testing (UDT) is considered reasonable and necessary when the clinical 
information supplied supports the definitive testing as in: 
 
1. Identifies a specific substance or metabolite that is inadequately detected by a presumptive UDT screen; 
2. Definitively identifies specific drugs in a large family of drugs; 
3. Identifies a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, 
meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
4. Identifies drugs when a definitive concentration of a drug is needed to guide management (e.g., 
discontinuation of THC use according to a treatment plan); 
5. Identifies a negative or confirms a positive presumptive UDT result that is inconsistent with a patients self-
report, presentation, medical history, or current prescribed pain medication plan; 
6. Rules out an error as the cause of a presumptive UDT result; 
7. Identifies non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 
8. For use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
 
You can find this rule in the Local Coverage Determination (LCD) - Urine Drug Testing (L35724). 
 
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 coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that the records must document the beneficiarys current functional capabilities and his/her 
expected functional potential, including an explanation for the difference, if that is the case. It is recognized, 
within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by 
functional level classifications. You can find this rule in Local Coverage Determination (LCD): Lower Limb 
Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that a fluid, pneumatic, or electronic/microprocessor knee (L5828, L5848, L5856) is covered for 
beneficiaries whose functional level is 3 or above. You can find this rule in Local Coverage Determination 
(LCD): Lower Limb Prostheses (L33787) - Effective January 1, 2020. 
 
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 rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
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. You can find this information 
on page 54 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 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 payment is not generally allowed for an assistant surgeon when payment for either two 
surgeons (modifier -62) or team surgeons (modifier -66) is appropriate. If carriers receive a bill for an 
assistant surgeon following payment for co-surgeons or team surgeons, they pay for the assistant only if a 
review of the claim verifies medical necessity. You can find this information in the Medicare Claims 
Processing Manual, Chapter 12, Section 40.9. 
 
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 a diagnostic colonoscopy is indicated for the following: 
 
1. Evaluation of an abnormality discovered by a radiology examination wherein the findings of the study are 
consistent with a colonic lesion that is likely to be clinically significant, 
2. An abnormal oncology colorectal screening or stool based DNA test as described in the CMS Colorectal 
Cancer screening Preventive Services requirements, 
3. Evaluation of unexplained gastrointestinal bleeding: 
 
a. Hematochezia that is not from the rectum or a perianal source, 
b. Melena of unknown origin after an upper GI source has been ruled out or when clinical findings indicate that 
a lower GI source may also be present, 
c. Presence of fecal occult blood, or 
d. Unexplained iron deficiency anemia. 
 
4. Clinically significant diarrhea of unexplained origin, after other appropriate workup, 
5. Evaluation of acute colonic ischemia/ischemic bowel disease, 
6. Evaluation of patients with streptococcus bovis endocarditis when a source is determined to likely to be of 
colonic origin (e.g. streptococcus bovis), 
7. Clinical suspicion of inflammatory bowel disease which may be manifested by abdominal pain, fever, 
diarrhea, bloody diarrhea, elevated erythrocyte sedimentation rate or other pertinent findings, 
8. Known chronic inflammatory bowel disease of the colon when a more precise determination of the extent of 
disease will influence clinical management, 
9. Surveillance of selected patients with Crohns colitis, or chronic ulcerative colitis for the purpose of ruling 
out colorectal cancer is considered high risk screening and should follow the requirements set forth in the CMS 
Internet Only Manual 100-04 Chapter 18 Section 60 
10. Surveillance of colonic neoplasia: 
 
a. Evaluation of the entire colon for a cancer with polyps noted on an earlier colonoscopy in accordance with 
the established national guidelines. b. This includes patients with known polyps from a previous colonoscopy or imaging study who have a known 
genetic predisposition for colon cancer. 
 
You can find this rule in the Local Coverage Determination (LCD) - Diagnostic and Therapeutic Colonoscopy 
(L34213). 
 
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 coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
  
  practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that replacement of a prosthesis or prosthetic component is covered if the treating practitioner 
orders a replacement device or part because of any of the following: 
 
1. A change in the physiological condition of the beneficiary; or 
2. Irreparable wear of the device or a part of the device; or 
3. The condition of the device, or part of the device, requires repairs and the cost of such repairs would be more 
than 60% of the cost of a replacement device, or of the part being replaced. 
 
You can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article 
(A52496). 
 
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 rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
The rules say that an axial rotation unit (L5986) is covered for beneficiaries whose functional level is 3 or 
above. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
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 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 and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 30.2.2. 
 
The rules say that when billing multiple units of a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code, providers must enter the actual number of units 
provided on the claim form. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.4. 
 
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 pages 39-43 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 vascular stents are used to enhance primary patency in arteries and veins, usually at the site 
of stenotic or occlusive lesions. Stents also may be used as an adjunct to technically inadequate Percutaneous 
Transluminal Angioplasty (PTA) or in cases where PTA alone will not be expected to provide a durable result. 
Peripheral vascular stenting may be indicated for patients with symptomatic arterial and venous disease 
resulting from an occlusive process. This LCD does not address carotid artery stenting, which is subject to 
National Coverage Determination 20.7. 
 
PTA and stenting of vessels is covered only when all of the following conditions are met: 
 
The patient has undergone prior thorough medical evaluation and management of symptoms. See below under 
specific categories for guidelines on medical evaluation and management recommendations. 
Surgical intervention would otherwise be considered as an alternative treatment for the patient. 
A stent may be placed as a planned adjunct to PTA rather than in response to a suboptimal or failed PTA (so-
called primary stent deployment). Primary stenting is justified for situations where PTA alone is not expected 
to provide a durable result, such as arterial or venous occlusions that carry a high risk for distal embolization or 
rapid recurrence OR occlusive lesions known to be unfavorable for PTA alone such as significantly calcified 
lesions, eccentric lesions, lesions related to external compression (e.g., May-Thurner syndrome and malignant 
compression of the superior vena cava), or ostial renal artery stenosis. 
Coverage for non-coronary vascular stents depends on the use of an FDA-approved stent. Several different 
stents are currently used in the medical community. Each device has specific indications described by the FDA 
for approved market uses. Stent placement is covered by Medicare only when an FDA-approved stent is: 
 
Used for the FDA-approved indications, OR 
Used for the above indications supported by the peer medical literature. 
You can find these rules in Local Coverage Determination (LCD) non-coronary vascular stents (L35998). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 effective for dates of service specified below, the Centers for Medicare & Medicaid Services 
(CMS) has determined that PILD will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E)of the Social Security Act (the Act) through Coverage with Evidence Development (CED) for 
beneficiaries with LSS who are enrolled in an approved clinical study that meets the criteria in section I or II. 
You can find this information in Medicare's National Coverage Determination (NCD): Percutaneous Image-
Guided Lumbar Decompression for 
Lumbar Spinal Stenosis (150.13). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.