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 a Group 2 Multiple Power Option PWC (K0842) is covered if all of the coverage criteria for 
a PWC are met and if: 
        A. Criterion 1 or 2 is met; and 
        B. Criteria 3 and 4 are met. 
            1. The beneficiary meets coverage criteria for a power tilt and recline seating system (see Wheelchair 
Options and Accessories policy) and the system is being used on the wheelchair. 
            2. The beneficiary uses a ventilator which is mounted on the wheelchair. 
            3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical 
professional, such as a physical therapist (PT) or occupational therapist (OT), or practitioner who has specific 
training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for 
the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or practitioner 
may have no financial relationship with the supplier. 
            4. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and Assistive 
Technology Society of North America (RESNA)-certified Assistive Technology Professional (ATP) who 
specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the 
beneficiary. 
 
If the power wheelchair base is not covered, then related accessories will be denied. 
 
You can find this information in the Local Coverage Determination (LCD) for 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 epidural steroid injection (ESI) will be considered medically reasonable and necessary when 
the following three (3) requirements are met: 
1. History, physical examination, and concordant radiological image-based diagnostic testing and 
supporting one of the following: 
a. Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to 
central disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, 
producing foraminal or central spinal stenosis; or 
b. Post-laminectomy syndrome 
c. Acute herpes zoster associated pain 
 
2. Radiculopathy, Radicular pain and/or neurogenic claudication is severe enough to greatly impact 
quality of life or function. An objective pain scale or functional assessment must be performed at 
baseline (prior to interventions). The same scale* must be repeated at each follow-up for assessment of 
response. 
 
3. Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute 
herpes zoster refractory to conservative management where a four (4) week wait is not required. 
 
You can find this information in Local Coverage Determination (LCD): Epidural Steroid Injections for Pain 
Management (L38994). 
 
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 Coverage Indications, Limitations, and/or Medical Necessity 
 
Provisions in this LCD and related coding article only address Vertebral Augmentation for Osteoporotic 
Vertebral Compression Fracture (VCF). Coverage will remain available for medically necessary procedures for 
other conditions not included in this LCD. 
 
PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with BOTH the 
following: 
 
    1. Inclusion criteria (ALL are required): 
        a. Acute (greater than 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5), based on symptom 
onset, and documented by advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake)  
        b. Symptomatic (ONE): 
            i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
equals 8) (4-7) 
            Non-hospitalized with moderate to severe pain (NRS or VAS equals5) despite optimal non-surgical 
management (NSM) (10) (ONE): 
                1. Worsening pain 
               2. Stable to improved pain (but NRS or VAS still =5) (with = 2 of the following): 
                    A. Progression of vertebral body height loss 
                    B. 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, active systemic or surgical site infection 
            iii. Pregnancy 
        b. Relative contraindication 
            I. Greater than three vertebral fractures per procedure 
            II. Allergy to bone cement or opacification agents 
            III. Uncorrected coagulopathy 
           IV. Spinal instability 
            V. Myelopathy from the fracture 
           VI.  Neurologic deficit 
           VII. Neural impingement 
            Fracture retropulsion/canal compromise 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L33569). 
 
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 state that all End Stage Renal Disease (ESRD) claims with dates of service on or after July 1, 2010, 
must indicate the applicable Kt/V reading for the dialysis patient. The reading result and the date of the reading 
must be reported on the claim using the following claim codes: 
 
Value Code D5 - Result of last Kt/V reading. For in-center hemodialysis patients this is the last reading taken 
during the billing period. For peritoneal dialysis patients and home hemodialysis this may be before the current 
billing period but should be within 4 months of the claim date of service. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Claims Processing Manual, Chapter 8, Section 50.9. 
 
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 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. 
 
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 beneficiarys 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. 
 
You can find this rule in the Local Coverage Determination (LCD) for 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 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 a Medicare plan may restrict enrollees 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 outside of the plan provider network, but at in-
network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollees 
medical needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community based 
services. You can find this rule at 42 CFR Section 422.112. 
 
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 Plans 2023 
Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that L5781 describes a complete device that is an addition to a lower limb prosthesis. The 
primary function of the vacuum pump is to suspend the prosthetic limb. Additionally, products coded L5781 
provide residual limb volume management and moisture evacuation. The pump mechanism evacuates air and 
accumulated moisture between the limb and socket walls. The pump mechanism can be actuated by either 
external power and/or mechanical system(s). You can find this rule in the Local Coverage Article (LCA) - 
Lower Limb Prosthesis - Policy Article (A52496). 
 
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 definitive drug testing is indicated when: 
 
1. The results of the screen are presumptively positive. 
2. Results of the screen are negative, and this negative finding is inconsistent with the patient's medical history. 
3. This test may also be used, when the coverage criteria of the policy are met AND there is no presumptive 
test available, locally and/or commercially, as may be the case for certain synthetic or semi-synthetic opioids. 
 
You can find this rule in the Local Coverage Determination (LCD) - Drug Testing (L34645). 
 
The rules say that drugs, or drug classes for which testing is performed, should reflect only those likely to be 
present, based on the patient's medical history, current clinical presentation, and illicit drugs that are in 
common use. Drugs for which specimens are being tested must be indicated by the referring provider in a 
written order. You can find this rule in the Local Coverage Determination (LCD) - Drug Testing (L34645). 
 
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 therapeutic embolization is covered when done for hemorrhage, and for other conditions 
amenable to treatment by the procedure, when reasonable and necessary for the individual patient. Renal 
embolization for the treatment of renal adenocarcinoma continues to be covered as one type of therapeutic 
embolization, to: 
 Reduce tumor vascularity preoperatively; 
 Reduce tumor bulk in inoperable cases; or 
 Palliate specific symptoms. 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 20.28. 
 
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). 
 
A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are 
not primarily medical in nature. If a wheelchair has an electrical connection device described by code 
E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing 
feature, it will be denied as non-covered. You can find this information in the Local Coverage Article 
Wheelchair Options/Accessories - Policy Article (A52504). 
 
A Column II code is included in the allowance for the corresponding Column I code when provided at the same 
time. When multiple codes are listed in column I, all the codes in column II relate to each code in column I." 
E0995, Replacement Calf Pads, is listed under Column II, and K0861 (Power Wheelchair Base Groups 3, 4, 
and 5 (K0848-K0891)) is listed under Column I. Therefore, payment of E0995, Replacement Calf Pads, is 
included in the requested K0861 code for the group 3 power wheelchair. You can find this information in the 
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 Medically Unlikely Edits (MUEs) for HCPCS codes with an MAI of 3 are per day edits 
based on clinical benchmarks. MUEs assigned an MAI of 3 are based on criteria (e.g., nature of service, 
prescribing information) combined with data such that it would be possible but medically highly unlikely that 
higher values would represent correctly reported medically necessary services. If contractors have evidence 
(e.g., medical review) that UOS in excess of the MUE value were actually provided, were correctly coded and 
were medically necessary, the contractor may bypass the MUE for a HCPCS code with an MAI of 3 during 
claim processing, reopening, or redetermination, or in response to effectuation instructions from a 
reconsideration or higher-level appeal. 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(V). 
 
The rules say that when billing multiple units of a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code, providers must enter the actual number of units 
provided on the claim form. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.4. 
 
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 plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules state that home health episode payments must be based upon the site at which the beneficiary is 
served. For certain dates of service when required by law, payments may be further adjusted if the site is in a 
rural area or rural county. To ensure these payment adjustments are applied accurately, the home health agency 
(HHA) must report value code 85 to report the Federal Information Processing Standards (FIPS) state and 
county code of where the services were received. You can find this in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 
40.2. 
 
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 a patient lift is covered if transfer between bed and a chair, wheelchair, or commode is 
required and, without the use of a lift, the beneficiary would be bed confined. A patient lift described by E0635 
is covered if the basic coverage criteria are met. If the coverage criteria are not met, the lift will be denied as 
not reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD) - Patient Lifts 
(L33799). 
 
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.