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 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).  
 
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 there is a $500 deductible which applies to certain items and services. The Plan 
deductible applies to physician/practitioner serves and outpatient diagnostic tests and therapeutic services. You 
can find this information on pages 4-2 to 4-4 of the Plan's 2022 Evidence of Coverage (EOC).   
 
The Plan contract also says that enrollees must pay a $10 copayment after meeting the deductible for in-
network specialist office visits. You can find this information on pages 4-64 to 4-70 of the Plans 2022 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 procedure code E2311 describes the electronic components that allow the beneficiary to 
control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or 
non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power 
leg elevation, power seat elevation, power standing. 
 
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the 
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting 
hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and 
with complete replacement of the expandable controller. Code K0108 must not be used for any component or 
feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete 
expandable controller is included in the allowance for codes E2377/E2376 plus E2313. You can find this 
information in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). 
 
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 8 to 9 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 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 for Medicare to consider coverage and payment for an item or service, the information 
submitted by the supplier or provider must corroborate the services so we can confirm Medicare coverage has 
been met. You can find this rule in the Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1. 
 
The rules say that when an unlisted service or procedure code is reported, a report describing the service or 
procedure shall be submitted with the claim. Pertinent information includes a definition or description of the 
nature, extent and need for the procedure or service, as well as the provider time, effort, and equipment 
necessary to provide the service. You can find this rule in the Medicare Claims Processing Manual, Chapter 4, 
Section 180.3. 
 
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.
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 
(CMS), Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
The rules state that when a patient is hospitalized for a dental procedure and the dentist's service is covered 
under Part B, the inpatient hospital services furnished are covered under Part A. For example, both the 
professional services of the dentist and the inpatient hospital expenses are covered when the dentist reduces a 
jaw fracture of an inpatient at a participating hospital. In addition, hospital inpatient services, which are 
necessary because of the patient's underlying medical condition and clinical status or the severity of a 
noncovered dental procedure, are covered. 
 
When the hospital services are covered, all ancillary services such as x-rays, administration of anesthesia, use 
of the operating room, etc., are covered. 
 
Regardless of whether the inpatient hospital services are covered, the medical services of physicians furnished 
in connection with noncovered dental services are not covered. The services of an anesthesiologist, radiologist, 
or pathologist whose services are performed in connection with the care, treatment, filling, removal, or 
replacement of teeth or structures directly supporting teeth are not covered. You can find this rule in the CMS, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter, 1, Section 70. 
 
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 an 
annual maximum benefit of $1,000 for non-Medicare covered preventive and comprehensive dental services combined. You are responsible for any amount above the dental coverage limit. You can find this information 
on page 73 to 74 of the Plans 2022 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 Medicare will consider reimbursement for Mohs micrographic surgery (MMS) for the 
following indications and anatomic locations: 
I. Basal Cell Carcinoma (BCC) 
 
A. Recurrent BCC of any size or unexpected positive margin on recent excision (healthy or 
immunocompromised or genetic syndrome(s)) 
i. Aggressive Pathology 
1. Area H, M, and/or L 
ii. Nodular pathology 
1. Area H, M, and/or L 
iii. Superficial pathology 
1. Area H and M only 
2. No coverage for Area L 
 
B. Primary Aggressive 
i. Size less than or equal to 0.5 cm 
1. Area H and M. 
2. Area L may be covered on redetermination 
ii. Size greater than or equal to 0.6 cm 
1. Area H, M, and L 
 
C. Primary Nodular BCC (Healthy patient) 
i. Size less than or equal to 0.5  1 cm  
1. Area H and M only 
2. No coverage for Area L 
ii. Size 1.1  2 cm 
1. Area H and M. 
2. Area L may be covered on redetermination 
iii. Size greater than or equal to 2 1. Area H, M, and L 
 
D. Primary Nodular BCC (Immunocompromised patient) 
i. Size less than or equal to 0.5 cm 
1. Area H and M only 
2. No coverage for Area L. 
ii. Size 0.6  1 cm 
1. Area H and M 
2. Area L may be covered on redetermination 
iii. Size greater than or equal to 2 cm 
1. Area H, M, and L 
 
E. Primary Superficial BCC (Healthy Patient) 
i. Size less than or equal to 0.5 cm 
1. Area H. 
2. Area M may be considered for coverage on redetermination. 
3. No coverage for Area L. 
ii. Size greater than or equal to 0.6 cm 
1. Area H and M. 
2. No coverage for Area L. 
 
F. Primary Superficial BCC (Immunocompromised Patient) 
i. Size less than or equal to 1.0 cm 
1. Area H and M. 
2. No coverage for Area L. 
ii. Size greater than 1.0 cm 
1. Area H and M. 
2. Area L may be covered on redetermination 
 
You can find this information in the Local Coverage Determination (LCD): Mohs Micrographic Surgery 
(L35702). 
 
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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with 
BOTH the following: 
 
1. Inclusion criteria (ALL are required): 
a. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1  
L5) by recent (within 30 days) advanced imaging (bone marrow edema on MRI or bone-scan/Single-Photon 
Emission Computerized Tomography (SPECT)/computed tomography (CT) uptake) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score greater 
than or equal to 8)  
ii. Non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) despite optimal non-
surgical management (NSM) (ONE): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still greater than or equal to 5) (with greater than or equal to 2 of 
the following): 
A. Progression of vertebral body height loss 
B. greater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) greater than 17) 
 
c. Continuum of care (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 (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 or active systemic or surgical site infection 
iii. Pregnancy 
 
b. Relative contraindication 
i. Allergy to bone cement or opacification agents 
ii. Uncorrected coagulopathy 
iii. Spinal instability 
iv. Myelopathy from the fracture 
v. Neurologic deficit 
vi. Neural impingement 
vii. Fracture retropulsion/canal compromise 
viii. Greater than three vertebral fractures 
 
Vertebral augmentation and kyphoplasty for vertebral compression fractures with intractable spinal pain not 
relieved with medical therapy will be covered for osteolytic vertebral metastatic disease or myeloma involving 
a vertebral body. 
 
You can find this information in the Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38737). 
 
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 gradient compression wrap is only covered when it is used as a primary or secondary 
dressing over wounds that meet the statutory requirements for a qualifying wound (surgically created or 
modified, or debrided). 
 
Claims for gradient compression wraps used without a qualifying wound or when used for other non-qualifying 
conditions will be denied as statutorily non-covered, no benefit. 
 
Utilization of a gradient compression wrap (A6545) is limited to one per 6 months per leg. Quantities 
exceeding this amount will be denied as not reasonable and necessary.  
 
You can find this information in the Local Coverage Determination (LCD) for Surgical Dressings (L33831). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 50 one-way trips per year. You can find this information on page 73 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 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 information in the Local Coverage Determination  L38803 
 
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 FDA has approved Viscosupplementation as a device. Medicare is allowing this non-
pharmacologic therapy. This treatment will only be covered for the treatment of pain in osteoarthritis of the 
knee. All other uses will be denied as investigational.  
 
Documentation in the patient's medical record must support the patient failed to respond adequately over a 
three-month period to a past history of treatment with analgesics and conservative nonpharmacological therapy 
(exercise or physical therapy, weight loss if appropriate, use of assistive devices). 
 
This information can be found in Local Coverage Article: Intraarticular Knee Injections of Hyaluronan Billing 
Guidelines (A56157). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that quantitative calcium scoring is not a covered service and will be denied as not medically 
necessary. Calcium scoring reported in isolation is considered a screening service. When performed in 
association with CT angiography, there is neither separate nor additional included reimbursement for the 
calcium scoring. Procedure code 75571 is not a covered service. You can find this information in the Centers 
for Medicare and Medicaid Services, Local Coverage Determination (LCD): Cardiac Computed Tomography 
(CCT) and Coronary Computed Tomography Angiography (CCTA) (L33559) and in the related Local 
Coverage Article (A56737). 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
The rules say that there is sufficient evidence to conclude the use of infrared therapy devices and any related 
accessories is not reasonable and necessary. You can find this information in National Coverage Determination 
(NCD): Infrared Therapy Devices (270.6). 
 
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 47 to 48 of the Plan's 
2022 Evidence of Coverage (EOC).