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 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 all services integral to accomplishing a procedure are considered bundled into that procedure 
and, therefore, are considered a component part of the comprehensive code. Many of these generic activities 
are common to virtually all procedures and, on other occasions, some are integral to only a certain group of 
procedures but are still essential to accomplish these particular procedures. Accordingly, it is inappropriate to 
separately report these services based on standard medical and surgical principles. 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 30. A. 
 
The rules say that Train of Four testing is bundled with the intraoperative neuromonitoring of 
electromyography (EMG) or motor evoked potentials (MEP) and, therefore, is not separately reportable. You 
can find this rule from AMA CPT assistant February 2016, Volume 26, Issue 2, pages 13, 14. 
 
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 treatment for lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH) will 
be considered reasonable and necessary once per lifetime in patients with: 
1. All of the following indications: 
a. Age 80 
b. Prostate volume of 30-150 cc transrectal ultrasound (TRUS) 
c. Persistent moderate to severe symptoms despite maximal medical management including all of 
the following: 
i. International Prostate Symptom Score (IPSS) 12 
ii. Maximum urinary flow rate (Qmax) of 15 mL/s (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 reasonable and necessary. 
You can find this information in Local Coverage Determination (LCD): Transurethral Waterjet Ablation of the 
Prostate (L38682). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
  
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
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 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). 
A. Both PVP and PVA will be considered reasonable and necessary when all of the following 
criteria are met: 
i. Acute or subacute osteoporotic vertebrogenic compression fracture (VCF), based on 
symptom onset, and documented by advanced imaging demonstrating bone marrow 
edema on MRI or bone-scan/SPECT/CT uptake and 
ii. The beneficiary is symptomatic and is hospitalized with severe pain or is non-
hospitalized with moderate to severe pain despite optimal non-surgical management 
(NSM)
 with one of the following: 
a. Worsening Pain or 
b. Stable to improved pain when 2 or more of the following are present: 
- Progression of vertebral body height loss 
- > 25% vertebral body height reduction 
- Kyphotic deformity 
- Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire [RDQ] >17 
 
1. Exclusion criteria 
A. Absolute contraindication 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
ii. Osteomyelitis, discitis or active systemic infection 
iii. Pregnancy 
iv. Active surgical site infection 
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 
viii. Fracture retropulsion/canal compromise 
 
You can find this information in Local Coverage Determination (LCD): 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 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 some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on 
the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes 
for both the left and right side. If the side is not identified in the medical record, assign the code for the 
unspecified side. 
 
The rules also say that when laterality is not documented by the patients provider, code assignment for the 
affected side may be based on medical record documentation from other clinicians. If there is conflicting 
medical record documentation regarding the affected side, the patients attending provider should be queried 
for clarification. Codes for unspecified side should rarely be used, such as when the documentation in the 
record is insufficient to determine the affected side and it is not possible to obtain clarification.  
 
You can find these rules in the ICD-10-CM Official Guidelines for Coding and Reporting, FY 2023, Section 
B,13. 
 
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 ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
  
  Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device (BiPAP) is 
made based upon the specifics of each persons medical condition. There must be enough detailed information 
in the medical record to justify the treatment selected. You can find this rule in the Local Coverage 
Determination (LCD): Respiratory Assist Devices (L33800). 
 
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 effective for claims with dates of service on or after February 10, 2022, Medicare has 
determined that the evidence is sufficient to cover, under Medicare Part B, a lung cancer screening counseling 
and shared decision-making visit, and for appropriate beneficiaries, annual screening for lung cancer with 
LDCT, as an additional preventive service benefit under the Medicare program, only if all of the following 
eligibility criteria are met. 
Beneficiaries must meet all of the following eligibility criteria: 
 Age 50  77 years; 
 Asymptomatic (no signs or symptoms of lung cancer); 
 Tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one 
year; 1 pack =20 cigarettes); 
 Current smoker or one who has quit smoking within the last 15 years; and, 
 Receive an order for lung cancer screening with LDCT. 
You can find this rule in the Center for Medicare and Medicaid Services (CMS) Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determination (NCD) Manual, Section 210.14. 
 
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
coverage for specific items or services, but only when they are received from an in-network provider. You can
find this information on page 64 of the Plan's 2023 Evidence of Coverage (EOC).

This benefit also includes coverage for only those items and services specifically listed in your Plan contract.
Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per
tooth is not listed as covered. You can find this information on pages 64-69 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 edits based on established CMS policies may limit unit of service (UOS). For example, the MUE 
value for a surgical procedure may be based on the bilateral surgery indicator on the Medicare Physician Fee 
Schedule Database (MPFSDB). If the bilateral surgery indicator is "1", a bilateral surgical procedure must be 
reported with "1" unit of service and modifier 50 (bilateral modifier). 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 Modifiers -LT or -RT apply to codes, which identify procedures, which can be performed on 
paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries. Modifiers -LT and -RT should be used 
whenever a procedure is performed on only one side. Hospitals use the appropriate -LT or -RT modifier to 
identify which of the paired organs was operated upon. These modifiers are required whenever they are 
appropriate. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Sections 20.6.2 and 20.6.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
The rules say that cosmetic surgery is performed to reshape normal structures of the body to improve the 
patient's appearance and self-esteem. Cosmetic surgery performed purely for the purpose of enhancing one's 
appearance is not eligible for coverage. However, surgery to correct congenital defects, developmental 
abnormalities, trauma, infections, tumors or disease may be covered, because the surgery is considered 
reconstructive in nature. Cosmetic surgery performed to treat psychiatric or emotional problems is generally 
not covered. Corrective facial surgery will be considered cosmetic, rather than reconstructive, when there is no 
functional impairment present. However, some congenital, acquired, traumatic or developmental anomalies 
may not result in functional impairment, but are so severely disfiguring as to merit consideration for corrective 
surgery, e.g., craniofacial anomalies associated with Treacher Collins syndrome may be considered on an 
individual basis. 
 
You can find this information in the Local Coverage Determination (LCD): Cosmetic and Reconstructive 
Surgery (L33428). 
 
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).  
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say urinary catheters and external urinary collection devices are covered to drain or collect urine for a 
beneficiary who has permanent urinary incontinence or permanent urinary retention. Permanent urinary 
retention is defined as retention that is not expected to be medically or surgically corrected in that beneficiary 
within 3 months. 
 
If the catheter or the external urinary collection device meets the coverage criteria then the related supplies that 
are necessary for their effective use are also covered. Urological supplies that are used for purposes not related 
to the covered use of catheters or external urinary collection devices (i.e., drainage and/or collection of urine 
from the bladder) will be denied as non-covered. 
 
A meatal cup female external urinary collection device (A4327) is a plastic cup, which is held in place around 
the female urethra by suction or pressure and is connected to a urinary drainage container such as a bag or 
bottle. 
 
A pouch type female external collection device (A4328) is a plastic pouch which is attached to the periurethral 
area with adhesive and which can be connected to a urinary drainage container such as a bag or bottle. 
You can find this information in the Local Coverage Article (LCA): Urological Supplies (A52521). 
 
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
{preventive and comprehensive dental services along with specific dental codes that are listed on the dental
benefit chart. The bone replacement graft is not covered by the Plan's dental benefits. You can find this
information on pages 4-58 to 4-71 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 modifiers XE, XS, XP, XU: These modifiers were effective January 1, 2015. These 
modifiers were developed to provide greater reporting specificity in situations where modifier 59 was 
previously reported and may be used in lieu of modifier 59 whenever possible. The modifiers are defined as 
follows: 
XU  Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual 
components of the main service. 
 
You can find this rule in the Medicare National Correct Coding Initiative Policy Manual for Medicare Services, 
Chapter 1- General Correct Coding Policies, Section E. 
 
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 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. Procedure codes E0978 and E0995 are column II codes to column I code K0856. You can find this rule at Local Coverage Article (LCA) A52504: Wheelchair Options/Accessories (eff. 5/16/23).

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.