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 the primary indication of a diagnostic facet joint procedure is to diagnose whether the patient
has facet syndrome. Intraarticular (IA) facet block(s) are considered reasonable and necessary as a diagnostic
test only if medial branch blocks (MMB) cannot be performed due to specific documented anatomic
restrictions or there is an indication to proceed with therapeutic intraarticular injections. These restrictions must
be clearly documented in the medical record and made available upon request.
Diagnostic procedures should be performed with the intent that if successful, radiofrequency ablation (RFA)
procedure would be considered the primary treatment goal at the diagnosed level(s).
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 two-week duration may be considered on an individual basis and must be clearly
documented in the medical record.
For the first diagnostic facet joint procedure:
a. 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.
b. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and
necessary in patients who meet ALL the following criteria:
i. The patient meets the criteria for the first diagnostic procedure; AND
ii. 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)
Frequency limitation: For each covered spinal region no more than four (4) diagnostic joint sessions will be
reimbursed per rolling 12 months, in recognition that the pain generator cannot always be identified with the
initial and confirmatory diagnostic procedure.
You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Interventions
for Pain Management (L38765).
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 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 health plan contract says non-routine dental care (covered services are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician). You can find this information in Chapter 4 on page 57 of the plan's 2021 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 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 a six-
month waiting period for periodontal maintenance. You can find this information on page 122 of the Plan's
2021 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 providers 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 device in the category described by HCPCS code C1734 should always be billed with one of the following Current Procedural Terminology (CPT) codes:
CPT code 27870 (Arthrodesis, ankle, open) which is assigned to APC 5115 for Calendar Year (CY) 2020,
CPT code 28705 (Arthrodesis; pantalar) which is assigned to APC 5116 for Calendar Year (CY) 2020,
CPT code 28715 (Arthrodesis; triple) which is assigned to APC 5115 for Calendar Year (CY) 2020 or,
CPT code 28725 (Arthrodesis; subtalar) which is assigned to APC 5115 for Calendar Year (CY) 2020.
You can find these rules in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Transmittal 4513.
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 auricular peripheral nerve stimulation placement has been billed to Medicare using code
64555. This is incorrect coding. When billing for auricular peripheral nerve stimulation, use the NOC CPT
code 64999 - unlisted procedure, nervous system. The term for the device used for this procedure (e.g.,
NeuroStim/NSS, P-Stim, ANSiStim, E-Pulse, Electro-Acupuncture, NSS-2 Bridge) should be reported. These
devices are listed under the Food and Drug Administration (FDA) approval documents as electro-acupuncture
devices used for stimulation of auricular acupuncture points and as such are non-covered. Acupuncture for
stimulation of auricular points is not a covered Medicare benefit. You can find this information in the Local
Coverage Article: Billing and Coding: Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device)
(A55240).
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 power operated vehicle (POV) is covered when the beneficiary's weight is less than or
equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight
capacity of the next lower weight class POV - i.e., a Heavy Duty POV is covered for a beneficiary weighing
285 - 450 pounds; a Very Heavy Duty POV is covered for a beneficiary weighing 428 - 600 pounds.
You can find this information in the Local Coverage Determination (LCD): Power Mobility Devices (L33789).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that a Pneumatic Compression Device (PCD) coded as E0675 to treat peripheral arterial disease
is not eligible for reimbursement. There is insufficient evidence to demonstrate that reimbursement is justified.
Claims for E0675 will be denied as not reasonable and necessary. You can find this information 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 Medicare will pay for an inpatient rehabilitation facility (IRF) admission when the services
are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary
approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one
therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must
need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program.
This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at
least five days per week. The patient does not need to be expected to achieve complete independence in self-
care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a
rehabilitation physician. The physician must see the patient at least three days per week throughout the stay.
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication
100-02, Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section
412.622.
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 $100 copayment for outpatient surgery. You can find this information
on page 4-52 and 4-53 of the 2021 Evidence of Coverage of the Plan's 2021 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 allows payment for one annual wellness visit (AWV) for enrollees who have not
had an AWV within the past 12 months. You can find this information in the Centers for Medicare and
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter
18, Section 140.
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 reasonable useful lifetime of durable medical equipment is determined through program
instructions. In the absence of program instructions, the Plan may determine the reasonable useful lifetime of
equipment, but in no case can it be less than 5 years. Computation of the useful lifetime is based on when the
equipment is delivered to the beneficiary, not the age of the equipment. Replacement due to wear is not
covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime,
Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary
equipment owned by the beneficiary. You can find this rule at Centers for Medicare and Medicaid Services
(CMS), Internet-Only Manual, Publication 100-02, Medicare Benefit Policy, Chapter 15, Section 110.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that 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 state that a wireless capsule endoscopy is covered under certain conditions:
To help diagnose an obscure site of gastrointestinal (GI) bleeding in those patients who have undergone
upper GI testing and colonoscopy but failed to reveal the source of bleeding.
You can find this information in the Local Coverage Determination (LCD): Wireless Capsule Endoscopy:
(L35089).
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 specialty care outside of the Plan provider network when network providers are unavailable or
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 in Chapter 3 on page 31 of the
plan's 2021 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 state that a determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary's 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: The beneficiary's past history (including prior prosthetic use if applicable); and The beneficiary's current condition including the status of the residual limb and the nature of other medical problems; and The beneficiary's desire to ambulate. Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels: Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility. Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator. Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. Level 3: 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. Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. The records must document the beneficiary's 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. If a prosthesis is denied as not reasonable and necessary, related additions will also be denied as not reasonable and necessary. A fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) 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 state that diagnostic endocardial electrical stimulation (EES), also called programmed electrical
stimulation of the heart, is covered under Medicare when used for patients with severe cardiac arrhythmias.
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual,
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Diagnostic Endocardial
Electrical Stimulation (Pacing), 20.12.
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 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 the services of Physical Therapy Assistants (PTAs) used when providing covered therapy
benefits are included as part of the covered service. These services are billed by the supervising physical
therapist. A physical therapist must supervise PTAs. The services of a PTA shall not be billed as services
incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications
of a therapist. You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only
Manual, Medicare Benefit Policy Manual, Chapter 12, Section 230.1(c).
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 specialty care outside of the Plan provider network when network providers are unavailable or
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 11 of the Plan's 2021
Evidence of Coverage