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 an implantable loop recorder is another type of pre-symptom MLR, it is implanted 
subcutaneously in a patients upper left chest and may remain implanted for many months. An ILR is used 
when syncope is thought to be cardiac-related but is too infrequent to be detected by either a HolterTM monitor 
or a traditional pre-symptom MLR. 
 
The following indications are covered nationally unless otherwise indicated: 
1. Computer analysis of EKGs when furnished in a setting and under the circumstances required for 
coverage of other EKG services. 
2. EKG services rendered by an IDTF, including physician review and interpretation. Separate physician 
services are not covered unless he/she is the patients attending or consulting physician. 
3. Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed 
as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance 
at the time the service is performed or immediately thereafter. 
4. Home EKG services with documentation of medical necessity. 
5. Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications 
described below, when performed with equipment meeting the standards described below, subject to the 
limitations and conditions specified below. Coverage is further limited to the amounts payable with 
respect to the physicians service in interpreting the results of such transmissions, including charges for 
rental of the equipment. The device used by the beneficiary is part of a total diagnostic system and is 
not considered DME separately. Covered uses are to: 
a. Detect, characterize, and document symptomatic transient arrhythmias; 
b. Initiate, revise, or discontinue arrhythmic drug therapy; or, 
c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); 
(only if 24-hour coverage is provided, see C.5. below). 
Certain uses other than those specified above may be covered if, in the judgment of the local Medicare 
Administrative Contractor (MAC), such use is medically necessary. 
Additionally, the transmitting devices must meet at least the following criteria: 
a. They must be capable of transmitting EKG Leads, I, II, or III; and,  
 
b. The tracing must be sufficiently comparable to a conventional EKG. 
You can find this information in National Coverage Determination (NCD): Electrocardiographic Services 
(20.15). 
 
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 
osteoporotic VCF when both the following: 
1. Inclusion criteria (all are required): 
a. Acute or subacute osteoporotic vertebral compression fracture (VCF), based on symptom onset, 
and documented by advanced imaging 
b. Symptomatic (one): 
i. Hospitalized with severe pain 
ii. Non-hospitalized with moderate to severe pain despite optimal non-surgical management 
(NSM) (one): 
1. Worsening pain 
2. Stable to improved pain (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 (Both are required) 
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. 
You can find this information in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L38201). 
 
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 $45 copayment for physician/practitioner services/specialist. You can 
find this information on page 111 of the Plan's 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 say that treatment for ower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH) 
treatment will be considered medically reasonable and necessary when performed ONCE in patients with the 
following: 
 
    1. Indications including ALL of the following: 
        a. Age less than or equal to 80 
        b. Prostate volume of 30-150 cc by transrectal ultrasound (TRUS) 
        c. Persistent moderate to severe symptoms despite maximal medical management 
 
including ALL of the following: 
 
           i. International Prostate Symptom Score (IPSS) greater than or equal to 12 
           ii. Maximum urinary flow rate (Qmax) of less than or equal to 15 mL/s4 (voided volume greater than 
125 cc) 
           iii. Failure, contraindication or intolerance to at least three months of conventional medical therapy for 
LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
 
   2. Only treatment using an FDA approved/cleared device will be considered medically reasonable and 
necessary. 
 
Limitations 
 
The following are considered not medically reasonable and necessary: 
 
   1. Body mass index greater than or equal to 42kg/m2 
   2. Known or suspected prostate cancer (based on NCCN Prostate Cancer Early Detection guidelines7) or a 
prostate specific antigen (PSA) >10 ng/mL unless the patient has had a negative prostate biopsy within the last 
6 months. 
   3. Bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum6    4. Active urinary tract or systemic infection 
   5. Treatment for chronic prostatitis 
   6. Diagnosis of urethral stricture, meatal stenosis, or bladder neck contracture 
   7. Damaged external urinary sphincter 
   8. Known allergy to device materials 
   9. Inability to safely stop anticoagulants or antiplatelet agents preoperatively. 
 
Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in 
this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and 
all existing CMS national coverage determinations, and all Medicare payment rules. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Transurethral Waterjet 
Ablation of the Prostate (L38726). 
 
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 coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that a flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 
or above. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
The rules say that a fluid, pneumatic, or electronic/microprocessor knee (L5828, L5848, L5856) is covered for 
beneficiaries whose functional level is 3 or above. You can find this rule in Local Coverage Determination 
(LCD): Lower Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that a determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiarys 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: 
 
 
1. The beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
3. The beneficiarys desire to ambulate. 
You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
The rules say that a level 3 ambulator 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. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that many of the diagnostic services, including radiology services, provided by 
physicians/practitioners contain both a technical component (TC) and a professional component (PC). Often, 
the PC and TC of diagnostic services are furnished in different settings. As a general policy, the Place of 
Service (POS) code assigned by the physician/practitioner for the PC of a diagnostic service shall be the setting 
in which the beneficiary received the TC service. If the same physician or other supplier entity does not furnish 
both the TC and PC of the diagnostic service, or if the same physician or other supplier entity furnishes both 
the TC and PC but the professional interpretation was furnished in a different payment locality from where the 
TC was furnished, the professional interpretation of a diagnostic test must be separately billed with modifier -
26 by the interpreting physician. You can find this rule in the Centers for Medicare and Medicaid Services 
(CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 13, Radiology 
Services and Other Diagnostic Procedures, 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.
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 following are examples of wound care items which are non-covered under the surgical 
dressing benefit because they do not meet the statutory definition of a dressing (not all-inclusive): 
 
Skin sealants or barriers (A6250) 
Wound cleansers (A6260) or irrigating solutions 
Solutions used to moisten gauze (e.g., saline) 
Silicone gel sheets (A6025) 
Topical antiseptics 
Topical antibiotics 
Enzymatic debriding agents 
Gauze or other dressings used to cleanse or debride a wound but not left on the wound 
First-aid type adhesive bandage (A6413) 
Any item listed in the latest edition of the Orange Book (e.g., an antibiotic-impregnated dressing which 
requires a prescription 
Gradient compression stockings (A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, 
A6541, A6544, A6549) 
Surgical stockings (A4490, A4495, A4500, A4510) 
Non-elastic binder for an extremity (A4465) 
Small adhesive bandages (e.g., Band-Aid or similar product) are not primarily used for the treatment of wounds 
addressed in the Surgical Dressings policy. 
 
These dressings are noncovered under the surgical dressing benefit. 
 
You can find this information in the Local Coverage Article Surgical Dressings - Policy Article A54563. 
 
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 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. While the Plan offers a Point-of-Service option for coverage of 
out-of-network services, this benefit only applies to dental services. You can find this information on page 37 
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 claims with dates of service on or after July 1, 2013, contractors shall pay Transcatheter 
Aortic Valve Replacement (TAVR) claim lines for 33361, 33362, 33363, 33364, 33365 and 0318T when billed 
with the numeric, 8-digit clinicaltrials.gov identifier number preceded by the two alpha characters CT when 
placed in Field 19 of paper Form CMS-1500, or when entered without the CT prefix in the electronic 837P in 
Loop 2300REF02(REF01=P4). Claim lines billed without an 8-digit clinicaltrials.gov identifier number shall 
be returned as unprocessable. You can find this information in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 
290. 
 
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 Percutaneous Vertebral Augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
percutaneous kyphoplasty (PKP)) is covered in patients with BOTH the following: 
 
1. Inclusion criteria (ALL are required):  
   1. 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 magnetic resonance imaging 
(MRI) or bone-scan/single photon emission computed tomography (SPECT)/computed tomography (CT) 
uptake) 
   2. Symptomatic (ONE): 
      1. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
greater than or equal to 8)4-7 
      2. 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): 
            1. Progression of vertebral body height loss 
            2. Greater than 25% vertebral body height reduction 
            3. Kyphotic deformity 
            4. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
greater than 17) 
 
2. Exclusion criteria (Can have NONE of the following): 
   a. Absolute contraindication: 
      1. Current back pain is not primarily due to the identified acute or subacute VCF(s) 
      2. Osteomyelitis, discitis or active systemic or surgical site infection 
      3. Pregnancy 
   b. Relative contraindication: 
      1. Allergy to bone cement or opacification agents       2. Uncorrected coagulopathy 
      3. Spinal instability 
      4. Myelopathy from the fracture 
      5. Neurologic deficit 
      6. Neural impingement 
      7. Fracture retropulsion/canal compromise 
      8. Greater than 3 vertebral fractures 
 
Vertebral augmentation and kyphoplasty for VCFs 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 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 pontics 
and retainer crowns, up to four units per year, covered only once per tooth per lifetime. In addition, up to two 
implants per year are covered, with only one crown on an implant covered every 5 years. You can find this 
information on pages 128-131 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 state that wireless capsule endoscopy is indicated for investigating suspected small intestinal bleeding 
in persons with objective evidence of recurrent, obscure gastrointestinal (GI) bleeding (e.g., persistent or 
recurrent iron-deficiency anemia and/or persistent or recurrent positive fecal occult blood test (FOBT), or 
visible bleeding) who have had upper and lower GI endoscopies within the past 12 months 
(esophagogastroduodenoscopy (EGD) and colonoscopy) that have failed to identify a bleeding source. You can 
find this information in Local Coverage Determination (LCD): Wireless Capsule Endoscopy (L36427). 
 
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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. 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 10.1.2.  
 
The rules say that orthopedic shoes and other supportive devices for the feet generally are not covered. 
However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is 
included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to 
diabetics. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290(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.