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 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 only 
those items and services specifically listed in your Plan contract. You can find this information on pages 86-87 
of the Plans 2022 Evidence of Coverage (EOC). 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 
the Plans dental benefits. You can, and page 105 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 state that to be eligible for coverage of a continuous glucose monitor (CGM) and related supplies, the beneficiary must meet all of the following initial coverage criteria (1)-(5):

1. The beneficiary has diabetes mellitus; and, 
2. The beneficiary's treating practitioner has concluded that the beneficiary (or beneficiary's caregiver) has sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
3. The CGM is prescribed in accordance with its Food and Drug Administration (FDA) indications for use; and, 
4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the criteria below: A. The beneficiary is insulin-treated; or,
B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the following:
 - Recurrent (more than one) level 2 hypoglycemic events (glucose less than 54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan; or, 
- A history of one level 3 hypoglycemic event (glucose less than 54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1)-(4) above are met.

You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822).

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 percutaneous vertebroplasty 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: 
o Acute (less than 6 wks) or subacute (6-12 wks) osteoporotic VCF (T1- L5), based on 
symptom onset, and documented by advanced imaging demonstrating bone marrow 
edema on MRI or bone-scan/SPECT/CT uptake and 
o The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating 
Scale [NRS] or Visual Analog Scale [VAS] pain score greater than or equal to 8) or is 
non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) 
despite optimal non-surgical management (NSM) with one of the following:  
 Worsening Pain or 
 Stable to improved pain (but NRS or VAS greater than or equal to 5) when 2 or 
more of the following are present:  
o Progression of vertebral body height loss 
o Greater than 25% vertebral body height reduction 
o Kyphotic deformity 
o Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire [RDQ] greater than 17) 

Limitations 

1. Exclusion criteria  

A. Absolute contraindication  a) Current back pain is not primarily due to the identified acute or subacute VCF(s). 
b) Osteomyelitis, discitis or active systemic infection 
c) Pregnancy 
d) Active surgical site infection 
B. Relative contraindication  
a) Greater than three vertebral fractures per procedure 
b) Allergy to bone cement or opacification agents 
c) Uncorrected coagulopathy 
d) Spinal instability 
e) Myelopathy from the fracture 
f) Neurologic deficit 
g) Neural impingement 
h) Fracture retropulsion/canal compromise 
You can find this rule in the Local Coverage Determination (LCD) for 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 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 $10 copayment for diagnostic tests and procedures. You can find this 
information on pages 114-115 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 examples of problems that might require psychological or neuropsychological testing 
include: 
 
1. Assessment of mental functioning for individuals with suspected or known mental disorders for purposes of 
differential diagnosis or treatment planning. 
2. Assessment of patient strengths and disabilities for use in treatment planning or management when signs or 
symptoms of a mental disorder are present. 
3. Assessment of patient capacity for decision-making when impairment is suspected that would affect patient 
care or management. 
4. Differential diagnosis between psychogenic and neurogenic syndromes (e.g., depression versus dementia). 
5. Detection of neurologic disease based on quantitative assessment of neurocognitive abilities (e.g., mild head 
injury, anoxic injuries, Acquired Immune Deficiency Syndrome [AIDS] dementia). 
6. Delineation of the neurocognitive effects of central nervous system disorders. 
7. Neurocognitive monitoring of recovery or progression of central nervous system disorders. 
 
You can find this rule in the Local Coverage Determination (LCD) - Psychiatric Codes (L35101) - Effective 
July 1, 2020. 
 
The rules say that testing conducted when no mental illness/disability is suspected would be considered 
screening and would not be covered by Medicare. Non-specific behaviors that do not suggest the possibility of 
mental illness or disability are not an acceptable indication for testing. Each test administered must be 
medically necessary. Standardized batteries of tests are only acceptable if each component test is medically 
necessary. You can find this rule in the Local Coverage Determination (LCD) - Psychiatric Codes (L35101) - 
Effective July 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 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 the 
requested periodontal scaling and root planing - 4 or more teeth per quadrant (D4341) but is limited to one 
procedure code every three calendar years, per quadrant. You can find this information on pages 84-87 and 92-
94 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 state that if an independent lab bills for services, the place where the sample was taken is reported as 
the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of 
service. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.6. 
 
The rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other 
supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two 
exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or 
outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You 
can find this information in the MLN Matters article number MM7631, "Revised and Clarified Place of Service 
(POS) Coding Instructions". 
 
The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8).  

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 does not include 
core buildup services or retainer crowns. You can find this information on pages 90-93 and 97-100 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 say that a Medicare plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information in Chapter 3 on page 28 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 polysomnography (PSG) includes sleep staging, which requires items 1 through 3 below. 
Polysomnography is defined to minimally include, but is not limited to, the following: 
 
    A 1-4 lead electroencephalogram (EEG) to measure global neural encephalographic activity using electrodes 
placed on the scalp. 
    Electrooculogram (EOG) to measure eye movements using electrodes placed near the outer 
    canthus of each eye. 
    A submental electromyogram (EMG) to measure submental electromyographic activity using 
    electrodes placed over the mentalis, submentalis muscle, and/or masseter regions. 
    Rhythm electrocardiogram (ECG). 
    Nasal and/or oral airflow via both thermistor and nasal pressure sensor. 
    Respiratory effort by chest-wall and abdominal movement measured using respiratory 
    inductive plethysmography, endoesophageal pressure or by intercostal EMG. 
    Gas exchange (oxygen saturation [SpO2]) by oximetry or transcutaneous monitoring. 
    Bilateral anterior tibialis muscle activity, motor activity-movement using EMG. 
    Body positions by directly applied sensors or by direct observation. 
 
PSG and other sleep test monitoring devices are generally classified based on the number of biologic sensors 
applied and physiologic parameters recorded. 
 
A. Criteria for Coverage of Diagnostic Tests 
All reasonable and necessary diagnostic tests given for the medical conditions listed in subsection B are 
covered when the following criteria are met: 
 
        The clinic is either affiliated with a hospital or is under the direction and control of physicians. Diagnostic 
testing routinely performed in sleep disorder clinics may be covered even in the absence of direct supervision 
by a physician; 
        Patients are referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record of the attending physician's orders; and 
        The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and 
laboratory tests. 
 
Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the 
results are still pertinent is not covered because it is not reasonable and necessary under 1862(a)(1)(A) of the 
Act. 
 
You can find this information in the Local Coverage Determination (LCD) Polysomnography and Other Sleep 
Studies L36861. 
 
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 the Medicare approved amount for global surgery procedures includes payment for the 
following services related to the surgery when furnished by the physician who performs the surgery. 
 
- Preoperative Visits  
- Intra-operative Services  
- Complications Following Surgery  
- Postoperative Visits  
- Postsurgical Pain Management  
- Supplies  
- Miscellaneous Services 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.1. 
 
The rules say that modifier "-24" reports an unrelated evaluation and management service by same physician 
during a postoperative period. The physician may need to indicate that an evaluation and management service 
was performed during the postoperative period of an unrelated procedure. This circumstance is reported by 
adding the modifier "-24" to the appropriate level of evaluation and management service. 
 
Services submitted with the "-24" modifier must be sufficiently documented to establish that the visit was 
unrelated to the surgery. A diagnosis code that clearly indicates that the reason for the encounter was unrelated 
to the surgery is acceptable documentation.  

You can find this rule in the Centers for Medicare and Medicaid Services, Publication 100-04, Medicare 
Claims Processing Manual Chapter 12, 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 state that Urine culture testing is only covered for certain diagnosis codes. A list of covered diagnosis 
codes can be found in National Coverage Determination (NCD): Urine Culture, Bacterial (190.12). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 does not include 
coverage for the dental service code D7250. You can find this information in Chapter 4 on page 95 of the 
Plans 2022 Evidence of Coverage (EOC).