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 Percutaneous Vertebral Augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients with BOTH the following: 
1. Inclusion criteria (ALL are required): 
   1. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic Vertebral Compression Fracture 
(VCF) (T1  L5), based on symptom onset, and documented by advanced imaging 
   2. Symptomatic (ONE): 
      1. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
greater than or equal to 8) 
      2. Non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) despite optimal 
non-surgical management (NSM) (ONE): 
         1. Worsening pain 
         2. Stable to improved pain (but NRS or VAS still greater than or equal to 5) (with greater than or 
equal to 2 of the following): 
            1. Progression of vertebral body height loss 
            2. Greater than 25% vertebral body height reduction 
            3. Kyphotic deformity 
            4. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
greater than 17 
   3. Continuum of care (10) (Both)  
      1. All patients presenting with VCF should be referred for evaluation of bone mineral density (BMD) and 
osteoporosis education for subsequent treatment as indicated. 
      2. 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):   
   1. Absolute contraindication 
      1. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
      2. Osteomyelitis, discitis, active systemic or surgical site infection 
      3. Pregnancy    2. Relative contraindication 
      1. Greater than three vertebral fractures per procedure 
      2. Allergy to bone cement or opacification agents 
      3. Uncorrected coagulopathy 
      4. Spinal instability 
      5. Myelopathy from the fracture 
      6. Neurologic deficit 
      7. Neural impingement 
      8. Fracture retropulsion/canal compromise 
You can find this information in the 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. 
 
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 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. 
 
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 health plans, physicians, hospitals, and other health care providers must comply with the 
Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding 
Guidelines. You can find this rule in the Medicare Claims Processing Manual, Chapter 23, Section 10. 
  
The rules also 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. You can find this information in the ICD-10-CM Official Guidelines for Coding and 
Reporting, Section I, Conventions, general coding guidelines and chapter specific guidelines. 
 
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 $280 copayment for outpatient hospital facility visit. You can find this 
information on page(s) 78-79 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 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 $0 copayment for each day days 1-20 and a $196 copayment each day 
for days 21-60. You can find this information on page 99 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $45 copayment for lab services - outpatient hospital. You can find this 
information on page(s) 66 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that neuromuscular electrical stimulation/functional electrical stimulation (NMES/FES) for 
walking will be covered in spinal cord injury patients with all of the following characteristics: 
 
1. Persons with intact lower motor units (L1 and below) (both muscle and peripheral nerve); 
2. Persons with muscle and joint stability for weight bearing at upper and lower extremities that can 
demonstrate balance and control to maintain an upright support posture independently; 
3. Persons that demonstrate brisk muscle contraction to NMES and have sensory perception electrical 
stimulation sufficient for muscle contraction; 
4. Persons that possess high motivation, commitment and cognitive ability to use such devices for walking; 
5. Persons that can transfer independently and can demonstrate independent standing tolerance for at least 3 
minutes; 
6. Persons that can demonstrate hand and finger function to manipulate controls; 
7. Persons with at least 6-month post recovery spinal cord injury and restorative surgery; 
8. Persons without hip and knee degenerative disease and no history of long bone fracture secondary to 
osteoporosis; and 
9. Persons who have demonstrated a willingness to use the device long-term. 
 
You can find this rule in the National Coverage Determination (NCD) - Neuromuscular Electrical Stimulation 
(NMES) (160.12). 
 
The rules say that NMES/FES for walking will not be covered in SCI patient with any of the following: 
 
1. Persons with cardiac pacemakers; 
2. Severe scoliosis or severe osteoporosis; 
3. Skin disease or cancer at area of stimulation; 
4. Irreversible contracture; or 5. Autonomic dysflexia. 
 
You can find this rule in the National Coverage Determination (NCD) - Neuromuscular Electrical Stimulation 
(NMES) (160.12). 
 
The rules say that coverage of NMES to treat muscle atrophy is limited to the treatment of disuse atrophy 
where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-
neurological reasons for disuse atrophy. Some examples would be casting or splinting of a limb, contracture 
due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training 
begins). You can find this rule in the National Coverage Determination (NCD) - Neuromuscular Electrical 
Stimulation (NMES) (160.12). 
 
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 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. The Plan has a Point-of-Service (POS) option to cover certain 
out-of-network services. You must obtain prior authorization from the Plan before seeking care. You can find 
this information on pages 64-66 of the Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract also says that authorization rules apply for out-of-network outpatient diagnostic tests and 
therapeutic services, including an ECG. You can find this information on pages 178-182 of the Plans 2023 
EOC. 
 
The Plan contract also says that authorization rules apply for out-of-network physician/practitioner services. 
You can find this information on pages 198-203 of the Plans 2023 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 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 20% coinsurance for in-network outpatient surgery provided at an 
outpatient hospital. You can find this information on page(s) 31 of the Plan's 2023 Other.
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. The Plan has a Point-of-Service (POS) option to cover out-of-
network services. You will need to obtain authorization from the Plan prior to seeking care. You can find this 
information on pages 38-39 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 health plans, physicians, hospitals, and other health care providers must comply with the 
Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding 
Guidelines. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 10.  
 
The rules state that certain Z codes/categories may only be reported as the principal/first-listed diagnosis, 
except when there are multiple encounters on the same day and the medical records for the encounters are 
combined. You can find this information in the ICD-10-CM Official Guidelines for Coding and Reporting, 
Section I.C, Chapter 21, Subsection 21.16. 
 
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 Group 3 power wheelchair can be covered only for enrollees who have a mobility 
limitation that is due to: 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
You can find this rule in Local Coverage Determination (LCD): 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 state that the Centers for Medicare & Medicaid Services (CMS) has determined that Percutaneous 
Image-Guided Lumbar Decompression (PILD) will be covered by Medicare when provided in a clinical study 
under section 1862(a)(1)(E)of the Social Security Act (the Act) through Coverage with Evidence Development 
(CED) for beneficiaries with lumbar spinal stenosis (LSS) who are enrolled in an approved clinical study that 
meets the criteria. You can find this information in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual Section 150.13. 
 
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 Medicare does not cover chiropractic maintenance care. When further clinical improvement 
cannot be reasonably expected from ongoing care, the care is considered maintenance. You can find this rule in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 15, Section 240.1.3. 
 
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 the only covered chiropractic service is manual manipulation of the spine to correct 
subluxation. You can find this information on page 64 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 $40 copayment for in-network physician/practitioner services, including 
doctors office visits. You can find this information on page(s) 114 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 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).  
 
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 also says that there is a $1000 deductible and a 30% coinsurance for out-of-network durable medical 
equipment (DME) and related supplies which applies to certain items and services. The Plan deductible applies 
to CPAP supplies. You can find this information on pages 53, 77, and 78 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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
The rules say that providers performing validity testing on urine specimens utilized for drug testing should not 
separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, 
creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not 
separately billed. You can find this information in the National Correct Coding Initiative (NCCI) Policy 
Manual, Chapter X, page X-7. 
 
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.