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 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 some codes may be reported with modifiers 26 and TC to indicate if only the 
professional or technical component of a code is being reported. Eligible codes which are reported with 
modifier 26 include values for physician work, practice expense and malpractice expense. 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 50.6. 
 
The rules say that ICD-10-CM codes that describe symptoms and signs (R00-R99) are acceptable for reporting 
purposes when a related definitive diagnosis has not been confirmed or established by the provider. If these 
codes are reported with a related definitive diagnosis, then the sign or symptom must not be routinely 
associated with that diagnosis, and should be sequenced after the diagnosis code.  
 
For patients receiving diagnostic services during an encounter or visit, sequence first the diagnosis, condition, 
problem or other reason for encounter or visit. For outpatient encounters for diagnostic tests that have been 
interpreted by a physician, and the final report is available at the time of coding, code any confirmed or 
definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional 
diagnoses. 
 
You can find these rules in the Centers for Medicare and Medicaid Services, ICD-10-CM Official Guidelines 
for Coding and Reporting FY 2023, Section I.C.18 and Section IV.k. 
 
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 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 lumbar spinal stenosis 
who are enrolled in an approved clinical study. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations 
(NCD) Manual Section 150.13. 
 
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The rules say that the following criteria needs to be met for medically necessity: 
o Disabling pain or functional disability; or 
o Progressive and substantial bone loss; or 
o Fracture or dislocation of the patella; or 
o Infection; or 
o Periprosthetic fracture or aseptic loosening; or 
o Failure and wear of the prosthetic components; or 
o Dislocation of the knee joint; or 
o Instability of the knee joint 
Local Coverage Determination (LCD): Major Joint Replacement (Hip and Knee) (L33618). 
 
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 also state that beginning January 1, 2017, presumptive drug testing may be reported with CPT codes 
80305-80307. These codes differ based on the level of complexity of the testing methodology. Only one code 
from this code range may be reported per date of service. This infomation is found in the National Correct 
Coding Initiative Coding Policy Manual 2023, Chapter 10. 
 
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 if coverage under a Medicare Advantage (MA) plan begins while the beneficiary is an 
inpatient in a hospital facility, payment for inpatient services until the date of the beneficiary's discharge is 
made by the previous MA organization, or Original Medicare, as appropriate. You can find this information in 
the 42 CFR Section 422.318. 
 
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 items and services furnished outside the United States are excluded from coverage except for 
the following services, and certain services rendered on board a ship: 
- Emergency inpatient hospital services where the emergency occurred: 
~ While the beneficiary was physically present in the United States; or 
~ In Canada while the beneficiary was traveling without reasonable delay and by the most direct 
route between Alaska and another State. 
- Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the 
United States, if the hospital was closer to, or substantially more accessible from, the beneficiary's 
United States residence than the nearest participating United States hospital which was adequately 
equipped to deal with and available to provide treatment of the illness or injury; 
- Physician and ambulance services furnished in connection with a covered foreign hospitalization. 
Program payment may not be made for any other Part B medical and other health services, including 
outpatient services furnished outside the United States; 
- Services rendered on board a ship in a United States port, or within 6 hours of when the ship arrived at, 
or departed from, a United States port, are considered to have been furnished in United States territorial 
waters. Services not furnished in a United States port, or within 6 hours of when the ship arrived at, or 
departed from, a United States port, are considered to have been furnished outside United States 
territorial waters, even if the ship is of United States registry; and 
 
The term "United States" means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the 
Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of services rendered 
on a ship, includes the territorial waters adjoining the land areas of the United States. You can find these rules 
in Medicare Benefit Policy Manual Chapter 16, Section 60. 
 
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 emergency services outside of the United States are covered. You must pay $125 copayment 
for emergency services outside of the United States. You are covered for up to $50,000 every year for emergency or urgently needed services outside of the United States. You can find this information in Chapter 4 
on page 64 of the Plans 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 manual wheelchair bases (K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, 
and K0009) include construction of any type of material, including but not limited to, titanium, carbon, or any 
other lightweight high strength material. Suppliers must not bill HCPCS code K0108 in addition to the base 
wheelchair for construction materials or for a heavy duty package reflecting the type of material used to 
construct the manual wheelchair base. Billing for construction material is considered incorrect coding  
unbundling. You can find these rules in the Local Coverage Article Manual Wheelchair Bases - Policy Article 
A52497. 
 
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 effective for claims with dates of service July 1, 2007, and after, the non-Outpatient 
Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. 
This integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital 
claims, through a single integrated OCE eliminating the need to update two separate OCE software packages 
on a quarterly basis. The integrated OCE does not change the current logic that is applied to outpatient bill 
types that already pass through the OPPS OCE software. It merely expands the software usage to include non-
OPPS hospitals. This new software product will be referred to as the Integrated OCE (I/OCE). The I/OCE 
instructions and specifications are provided via Recurring Update Notifications. They are also posted on the 
Web at the following address 
https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 4, Section 40.1. 
 
The rules state that effective January 1, 2015, (v16.0), the submission of a device-intensive procedure also 
requires that a device be submitted on the same claim/day. If any device-intensive procedure is submitted 
without a code for a device on the same claim with the same date of service, the claim is returned to the 
provider (edit 92). Center for Medicare and Medicaid Services Integrated Outpatient Code Editor CMS 
Specifications V24.0 Effective January 1, 2023, Section 5.6 Device Intensive Procedure Editing and 
Processing. 
 
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 a Durable Medical Equipment (DME) supplier must, among other things, meet the 
following conditions to be eligible to receive payment for a Medicare-covered item: (i) the supplier has 
submitted a complete Form CMS-855S (including all supporting documentation) to the applicable contractor); 
and (ii) the item was furnished on or after the date the contractor issued to the supplier a DME supplier number 
conveying Medicare billing privileges. You can find this information in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 
10.4.1.4.1. 
 
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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
The rules say that providers performing validity testing on urine specimens utilized for drug testing should not 
separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, 
creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not 
separately billed. You can find this information in the National Correct Coding Initiative (NCCI) Policy 
Manual, Chapter X, page X-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 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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The rules say that PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients 
with BOTH the following: 
1. Inclusion criteria (ALL are required): 
a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5), based on symptom 
onset, and documented by advanced imaging (bone marrow edema on MRI or bone-
scan/SPECT/CT uptake) (1-3,10,25,27) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score  8) (4-7) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS 5) despite optimal non-
surgical management (NSM) (10) (ONE): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still 5) (with  2 of the following): 
A. Progression of vertebral body height loss 
B. > 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) >17 c. Continuum of care (10) (Both)  
i. All patients presenting with VCF should be referred for evaluation of BMD and 
osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program. 
2. Exclusion criteria (2,5,8-10) (Can have NONE of the following):   
a. Absolute contraindication 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
ii. Osteomyelitis, discitis, active systemic or surgical site infection 
iii. Pregnancy 
b. Relative contraindication 
i. Greater than three vertebral fractures per procedure 
ii. Allergy to bone cement or opacification agents 
iii. Uncorrected coagulopathy 
iv. Spinal instability 
v. Myelopathy from the fracture 
vi. Neurologic deficit 
vii. Neural impingement 
viii. Fracture retropulsion/canal compromise 
Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation (PVA) for Vertebral 
Compression Fracture (VCF) (L33569). 
 
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) that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. Items that are used for a 
preventative service or function are excluded from coverage under the Medicare Durable Medical Equipment 
(DME) benefit. You can find this information in the Local Coverage Article: Pneumatic Compression Devices 
- Policy Article (A52488) and in the 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 say that CT scans are covered if there is literature to support its use for the patients condition and the 
scan is reasonable and necessary for the patient. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations 
Manual, Section 220.1(A). 
 
The rules say that general frequency guidance on the use of advanced imaging modalities are: 
 
1. It is recommended that, when possible, the ordering physician should select a single imaging modality if that 
modality is most likely to provide the most accurate information for providing the most optimal patient care. 
 
2. If the initially selected advanced imaging test does not provide sufficient information for clinical decision-
making, then it is appropriate to select a second imaging modality if, in the opinion of the physician, this will 
likely provide clinically useful information in patient management. In general, multiple such studies should be 
employed successively, when needed, and should only be performed together when both are reasonably 
expected to provide information independently important to patient management. 
 
3. There are multiple reasons for the longitudinal (e.g., excluding baseline assessment, staging/re-staging) use 
of advanced imaging modalities (e.g., CT, MRI, and PET), such as: 
 
 Surveillance, whereby the patient is assumed to have either no known disease, or stable or clinically 
insignificant disease: It is not unreasonable to expect such surveillance to occur every 6-12 months for 
an overall duration (e.g., five years) which is consistent with the tumor biology of that neoplasm. 
 
 Suspected recurrence/progression (as detailed above), whereby frequency guidance is not applicable to 
more of a timeline approach to management. 
 
 Evaluating response to treatment, when a change in therapy is contemplated: In general, imaging should 
be no more often than after 2 cycles of chemotherapy and/or 6-8 weeks since the prior imaging 
evaluation.  
 Finally, there are other applications of advanced imaging, including, but not restricted to, image-
directed biopsy and radiation therapy treatment planning, where frequency guidance is not applicable. 
 
4. Finally, there are other applications of advanced imaging, including, but not restricted to, image-directed 
biopsy and radiation therapy treatment planning, where frequency guidance is not applicable. 
 
You can find this rule in the Local Coverage Determination (LCD) L35391: Multiple Imaging in Oncology. 
 
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.