Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet 
joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet ALL the 
following criteria: 
-Initial thermal RFA:  After the patient has had at least two (2) medically reasonable and necessary diagnostic 
MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with 
the duration of relief being consistent with the agent used) AND 
-Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary 
provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months or at 
least 50% consistent improvement in the ability to perform previously painful movements and ADLs as 
compared to baseline measurement using the same scale. You can find this rule at the Medicare Local 
Coverage Determination (LCD)- L35936, Facet Joint Interventions for Pain Management. 
 
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 Hospital Discharge Day Management Services, CPT code 99238 or 99239 is a face-to-face 
evaluation and management (E/M) service between the attending physician and the patient. The E/M discharge 
day management visit shall be reported for the date of the actual visit by the physician or qualified non-
physician practitioner even if the patient is discharged from the facility on a different calendar date. Only one 
hospital discharge day management service is payable per patient per hospital stay. 
 
Only the attending physician of record reports the discharge day management service. Physicians or qualified 
non-physician practitioners, other than the attending physician, who have been managing concurrent health 
care problems not primarily managed by the attending physician, and who are not acting on behalf of the 
attending physician, shall use Subsequent Hospital Care (CPT code range 99231 - 99233) for a final visit. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.9.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
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 covered drugs include: Drugs that usually arent self-administered by the patient and are injected 
or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. You can 
find this information in Chapter 4 on page 80 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(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.
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 (or Insertable Loop) Recorder (ILR) is another type of pre-symptom Memory 
Loop Recorder (MLR) that 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 Holter monitor or a traditional pre-symptom MLR. You can find this information in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medical National 
Coverage Determinations Manual, Section 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 say that epidural steroid injections (ESIs) to treat non-specific low back pain (LBP), axial spine 
pain...widespread diffuse pain, pain from neuropathy from other causes...investigational and therefore are not 
considered medically reasonable and necessary. You can find this information in Medicare's Local Coverage 
Determination (LCD): Epidural Steroid Injections for Pain Management (L39036). 
 
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 the primary indication of a diagnostic facet joint procedure is to diagnose whether the patient 
has facet syndrome. Intraarticular (IA) facet block(s) are considered reasonable and necessary as a diagnostic 
test only if medial branch blocks (MMB) cannot be performed due to specific documented anatomic 
restrictions or there is an indication to proceed with therapeutic intraarticular injections. These restrictions must 
be clearly documented in the medical record and made available upon request. 
 
Diagnostic procedures should be performed with the intent that if successful, radiofrequency ablation (RFA) 
procedure would be considered the primary treatment goal at the diagnosed level(s). 
 
A second diagnostic facet procedure is considered medically necessary to confirm validity of the initial 
diagnostic facet procedure when administered at the same level. The second diagnostic procedure may only be 
performed a minimum of 2 weeks after the initial diagnostic procedure. Clinical circumstances that necessitate 
an exception to the two-week duration may be considered on an individual basis and must be clearly 
documented in the medical record. 
For the first diagnostic facet joint procedure: 
 
    For the first diagnostic facet joint procedure to be considered medically reasonable and necessary, the patient 
must meet the criteria outlined under indications for facet joint interventions. 
    A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in 
patients who meet ALL the following criteria: 
        The patient meets the criteria for the first diagnostic procedure; AND 
        After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% 
relief of primary (index) pain (with the duration of relief being consistent with the agent used). 
 
Frequency limitation: For each covered spinal region, no more than four (4) diagnostic joint sessions will be 
reimbursed per rolling 12 months, in recognition that the pain generator cannot always be identified with the 
initial and confirmatory diagnostic procedure. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Interventions 
for Pain Management (L38841). 
 
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 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. 
 
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 3-3 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 custodial care is not covered. Custodial care is personal care for a person who does not need 
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of 
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, 
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also 
custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
The Plan contract says that custodial care is personal care that does not require the continuing attention of 
trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as 
bathing or dressing and is not covered under any condition. Homemaker services include basic household 
assistance, including light housekeeping or light meal preparation and is not covered under any condition. You 
can find this information in Chapter 4 on pages 99-100 of the Plan's 2022 Evidence of Coverage. 
 
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 CONTINUED COVERAGE: 
 
    For wounds and ulcers described under A or B above, once placed on a NPWT pump and supplies, in order 
for coverage to continue, a licensed medical professional must do the following: 
 
            On a regular basis, 
 
                Directly assess the wound(s) being treated with the NPWT pump, and 
                Supervise or directly perform the NPWT dressing changes, and 
 
            On at least a monthly basis, document changes in the ulcers dimensions and characteristics. 
 
If criteria C-1 and C-2 are not fulfilled, continued coverage of the NPWT pump and supplies will be denied as 
not reasonable and necessary. 
 
 
WHEN COVERAGE ENDS: 
 
    For wounds and ulcers described under A or B above, a NPWT pump and supplies will be denied as not 
reasonable and necessary with any of the following, whichever occurs earliest: 
 
            Criteria C1-C2 cease to occur, 
 
            In the judgment of the treating practitioner, adequate wound healing has occurred to the degree that 
NPWT may be discontinued, 
 
            Any measurable degree of wound healing has failed to occur over the prior month. Wound healing is 
defined as improvement occurring in either surface area (length times width) or depth of the wound 
 
            4 months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) 
have elapsed using a NPWT pump in the treatment of the most recent wound 
             Once equipment or supplies are no longer being used for the beneficiary, whether or not by the treating 
practitioners order 
 
Coverage is provided up to a maximum of 15 dressing kits (A6550) per wound per month. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Negative Pressure Wound 
Therapy Pumps (L33821). 
 
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 effective for claims with dates of service on or after January 1, 2014, it is mandatory to 
report a clinical trial number on claims for items/services provided in clinical trials/studies/registries, or under 
CED. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Medicare Claims Processing Manual, Chapter 32, Section 69.2. 
 
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 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 also say that an OPPS payment status indicator is assigned to every HCPCS code. The status 
indicator identifies whether the service described by the HCPCS code is paid under the OPPS and if so, 
whether payment is made separately or packaged. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 4, Section 10.1.1. 
 
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 Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
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 covered drugs include: Drugs that usually arent self-administered by the patient and are injected 
or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. You can 
find this information in Chapter 4 on pages 4-39 to 4-40 of the Plan's 2022 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. 
 
It is expected that an injection (Synvisc-One TM, Gel-One, Durolane) or course of the injections (Synvisc, 
Hyalgan, Supartz or Visco-3TM, EuflexxaTM, Orthovisc, GelSyn-3TM, GenVisc 850, 
Hymovis, TriViscTM, SynojoyntTM, TriluronTM) will not be repeated within six months time. 
A repeat series of injections may be allowed when: 
1. The indications continue to be met; and 
2. Significant improvement in pain and functional capacity from the prior series of injections is 
documented in the medical record; and 
3. The last injection (in a prior course) was given at least six (6) months ago. 
You can find this information in the Local Coverage Article (LCA): Billing and Coding: Hyaluronans Intra-
articular Injections (A52420). 
 
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 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 also say that providers or suppliers shall use anatomic modifiers (e.g., RT, LT, FA, F1-F9, TA, T1-
T9, E1-E4) and report procedures with differing modifiers on individual claim lines when appropriate. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims 
Processing Manual, Chatper 23, Section 20.9.3.2. 
 
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 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 the Physician Fee Schedule Status Indicator T means that there are payment amounts for 
these services, but they are only paid if there are no other services payable under the physician fee schedule 
billed on the same date by the same provider. If any other services payable under the physician fee schedule are 
billed on the same date by the same provider, these services are bundled into the physician services for which 
payment is made. You can find this information in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, 30.2.2. 
 
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.