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 percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for the following indications: 

1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have 
not responded to non-surgical medical management (e.g. narcotic and/or non- narcotic medication, 
physical therapy modalities) with and without methods of immobility (e.g. rest, bracing). 
- Both PVP and PVA will be considered reasonable and necessary when all of the following 
criteria are met: 
~ Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression 
fracture (VCF) (T1- L5), based on symptom onset, and documented by advanced 
imaging demonstrating bone marrow edema 
~ The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating 
Scale [NRS] or Visual Analog Scale [VAS] pain score of 8 or more) or is non-
hospitalized with moderate to severe pain (NRS or VAS of 5 or more) despite optimal 
non-surgical management (NSM) with one of the following: 
- Worsening Pain or 
- Stable to improved pain (but NRS or VAS of 5 or more) when 2 or more of the 
following are present: 
~ Progression of vertebral body height loss 
~ Greater than 25% vertebral body height reduction 
~ Kyphotic deformity 
~ Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire [RDQ] greater than 17) 
2. Osteolytic vertebral metastasis or myeloma with severe back pain related to a destruction of the 
vertebral body, not involving the major part of the cortical bone. 
 
The exclusion criteria are: 
- Absolute contraindication 
~ Current back pain is not primarily due to the identified acute or subacute VCF(s). ~ Osteomyelitis, discitis or active systemic infection 
~ Pregnancy 
~ Active surgical site infection 
- Relative contraindication 
~ Greater than three vertebral fractures per procedure 
~ Allergy to bone cement or opacification agents 
~ Uncorrected coagulopathy 
~ Spinal instability 
~ Myelopathy from the fracture 
~ Neurologic deficit 
~ Neural impingement 
~ Fracture retropulsion/canal compromise 
 
You can find these rules in Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L35130). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit for supplemental 
dental coverage is limited to $3,000 annually. The contract also says charges for any type of implant and all 
related services, including crowns or the prosthetic device attached to it; precision or semi-precision 
attachments; over-dentures and any endodontic treatment associated with over-dentures; other customized 
attachments are excluded from coverage. You can find this information on pages 74 and 80 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 rate, facility or nonfacility, that a physician service is paid under the Physician Fee Schedule is determined 
by the Place of service (POS) code that is used to identify the setting where the beneficiary received the face-
to-face encounter with the physician, nonphysician practitioner (NPP) or other supplier. In general, the POS 
code reflects the actual place where the beneficiary receives the face-to-face service and determines whether 
the facility or nonfacility payment rate is paid. You can find this in the Centers for Medicare and Medicaid 
Service, Internet-Only Manual, Publication Number 100-04, Medicare Claims Processing Manual, Chapter 12, 
Section 20.4.2. 
 
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 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 
preventive and comprehensive services. Drugs or medicaments dispensed in the office for home use (D9630) 
are excluded from this benefit. You can find this information on pages 75-76 and 82 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 will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for specifically listed dental codes. The contract also says that any services related to implants, 
including implant removal, repair, restoration, or placement are not covered. You can find this information on 
pages 52, 53, and 86 through 88 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 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 2 of 
(D6010, D6013) every calendar year; 1 per tooth every 5 calendar years. This benefit also includes 8 
(extractions, D7140-D7241) every calendar year. The contract also says the Plan lists all covered procedures. 
Any code not listed is not covered. You can find this information on pages 58-60 and 105-124 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. 
 
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 a cervical and vaginal cancer screening. For all women: Pap tests and 
pelvic exams are covered once every 24 months. If you are at high risk of cervical or vaginal cancer or you are 
of childbearing age and have had an abnormal Pap test within the past 3 years: one Pap test every 12 months. 
You can find this information on page 61 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 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 
$1,000 of the annual coverage limit is earned each quarter, with a total of $4,000 annual coverage limit. You 
can find this information on pages 118-126 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 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 $350 copayment for surgery services. You can find this information on 
pages 65 to 66 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that measurement of 25-OH Vitamin D level is indicated for patients with: 
 
-chronic kidney disease stage III or greater 
-cirrhosis 
-hypocalcemia 
-hypercalcemia 
-hypercalciuria 
-hypervitaminosis D 
-parathyroid disorders 
-malabsorption states 
-obstructive jaundice 
-osteomalacia 
-osteoporosis if 
i. T score on DEXA scan <-2.5 or 
ii. History of fragility fractures or 
iii. FRAX > 3% 10-year probability of hip fracture or 20% 10-year probability of other major osteoporotic 
fracture or  
iv. FRAX > 3% (any fracture) with T-score <-1.5 or 
v. Initiating bisphosphanate therapy (Vitamin D level should be determined and managed as necessary 
before bisphosphonate is initiated) 
-osteosclerosis/petrosis 
-rickets 
-vitamin D deficiency on replacement therapy related to a condition listed above; to monitor the efficacy of 
treatment. 
 Testing may not be used for routine or other screening. You can find this information in Local Coverage 
Determination (LCD): Vitamin D Assay Testing (L36692). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes specific 
dental procedures included in a dental benefits chart. A consultation with an endodontist is excluded from 
coverage, services must be performed by a participating general dentist. You can find this information on pages 
58-59 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 state that for blood glucose monitors (codes E0607, E2100, E2101) and related supplies (codes 
A4233, A4234, A4235, A4236, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, 
A4258, A4259) and continuous glucose monitor (CGM) devices (code E2102 or E2103) and supply allowance 
(code A4238 or A4239), the following modifiers must be added to the code(s) on every claim submitted: 
 
- Use modifier KX if the beneficiary is insulin treated; or, 
- Use modifier KS if the beneficiary is non-insulin treated. 
 
The KX modifier must not be used for a beneficiary who is exclusively treated with oral hypoglycemic agents. 
For initial coverage of non-adjunctive CGM devices (code E2103) and the supply allowance (code A4239) the 
CG modifier must be added to the claim line only if all of the CGM coverage criteria (1)-(5) in the Glucose 
Monitors Local Coverage Determination (LCD) are met. For continued coverage of non-adjunctive CGM 
devices (code E2103) and the supply allowance (code A4239) the CG modifier must be added to the claim line 
only if the continued coverage criterion in the Glucose Monitors LCD is met. If any of the coverage criteria are 
not met, the CG modifier must not be used. 
 
The CG modifier must be added to the claim line for an adjunctive CGM (E2102) incorporated into an insulin 
infusion pump and supply allowance (code A4238) only if all of the initial CGM coverage criteria (1)-(5) in the 
Glucose Monitors LCD and the coverage criteria for an insulin infusion pump as outlined in the External 
Infusion Pumps LCD (L33794) are met. For continued coverage of adjunctive CGM devices incorporated into 
an insulin infusion pump (code E2102) and the supply allowance (code A4238), the CG modifier must be 
added to the claim line only if the continued coverage criteria in the Glucose Monitors LCD and the External 
Infusion Pumps LCD are met. If any of the coverage criteria are not met, the CG modifier must not be used. 
 
You can find this information in the Local Coverage Article (LCA): Glucose Monitor (A52464). 
  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. 
 
For Medicare to consider coverage and payment for any item or service the information submitted by the 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). 
 
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 providers must accept, and Plans must pay, the Medicare-allowed rate for services rendered 
by non-contracted providers.  You can this rule at 42 CFR 422.214. 
 
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 you pay 30% coinsurance for outpatient surgery you have an an out-of-network 
ambulatory surgery center.  
 You can find this information on page 72 of your 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 the treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are > than 4 mm in diameter and if the patient 
remains symptomatic after a six-week trial of conservative therapy. 
 
The rules say that the patient is considered symptomatic if any of the following signs and symptoms of 
significantly diseased vessels of the lower extremities are documented in the medical record: 
 
   stasis ulcer of the lower leg 
   significant pain and significant edema that interferes with activities of daily living, 
   bleeding associated with the diseased vessels of the lower extremities, 
   recurrent episodes of superficial phlebitis, 
   stasis dermatitis, or 
   refractory dependent edema. 
  
You can find this information at Local Coverage Determination (LCD):Varicose Veins of the Lower Extremity, 
Treatment of (L33525). 
 
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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT)  L36256 and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) A57527.  
 
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.