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 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 $950 deductible which applies to certain items and services. The Plan 
deductible applies to outpatient surgery. You can find this information on page 38 of the Plan's 2023 Evidence 
of Coverage (EOC).   
 
The Plan contract also says that enrollees must pay a $395 copayment after meeting the deductible for 
outpatient surgery provided at an outpatient hospital facility. You can find this information on pages 74-75 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 that a K3 ambulator has the ability or potential for ambulation with variable cadence. Typical of 
the community ambulator who has the ability to traverse most environmental barriers and may have vocational, 
therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. 
 
The rules say that a flex-walk system or equal (L5981) and a fluid, pneumatic, or electronic/microprocessor 
knee (L5828, L5848, L5856) are covered for beneficiaries whose functional level is 3 or above. 
 
The rules say that an axial rotation unit (L5984) is covered for beneficiaries whose functional level is 2 or 
above. 
 
The rules say that coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787). 
 
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).  
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 code(s) and related dollar amount(s) identify monetary data that are necessary for the 
processing of this claim. The codes are two alphanumeric digits and each value allows up to nine numeric 
digits (0000000.00). Negative amounts are not allowed. Whole numbers or non-dollar amounts are right 
justified to the left of the dollars and cents delimiter. Some values are reported as cents, so refer to specific 
codes for instructions. If more than one value code is shown for a billing period, show the codes in ascending 
alphanumeric sequence. 
 
Value Code Structure (Only codes used to bill Medicare are shown.): 
48 - Hemoglobin Reading - Code indicates the most recent hemoglobin reading taken before the start of this 
billing period. This is usually reported in three positions with a decimal. Use the right of the delimiter for the 
third digit. The blood sample for the hemoglobin reading must be obtained before the dialysis treatment. If a 
hemoglobin value is not available facilities must report the value 99.99. 
 
49 - Hematocrit Reading - Code indicates the most recent hematocrit reading taken before the start of this 
billing period. This is usually reported in two positions (a percentage) to the left of the dollar/cents delimiter. If 
the reading is provided with a decimal, use the position to the right of the delimiter for the third digit. The 
blood sample for the hemoglobin reading must be obtained before the dialysis. 
 
D5  Result of last Kt/V reading. For in-center hemodialysis patients this is the last reading taken during the 
billing period. For peritoneal dialysis patients and home hemodialysis this may be before the current billing 
period but should be within 4 months of the claim date of service. 
 
You can find this rule in the Centers for Medicare & Medicaid Services, Medicare Claims Processing Manual 
Chapter 8, Section 50.3. 
 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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients 
with BOTH the following: 
1. Inclusion criteria (ALL are required): 
a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5), based on symptom 
onset, and documented by advanced imaging (bone marrow edema on MRI or bone-
scan/SPECT/CT uptake) (1-3,10,25,27) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score  8) (4-7) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS 5) despite optimal non-
surgical management (NSM) (10) (ONE): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still 5) (with  2 of the following): 
A. Progression of vertebral body height loss 
B. > 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) >17 
c. Continuum of care (10) (Both)  
i. All patients presenting with VCF should be referred for evaluation of BMD and 
osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program. 
2. Exclusion criteria (2,5,8-10) (Can have NONE of the following):   
a. Absolute contraindication 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
ii. Osteomyelitis, discitis, active systemic or surgical site infection 
iii. Pregnancy b. Relative contraindication 
i. Greater than three vertebral fractures per procedure 
ii. Allergy to bone cement or opacification agents 
iii. Uncorrected coagulopathy 
iv. Spinal instability 
v. Myelopathy from the fracture 
vi. Neurologic deficit 
vii. Neural impingement 
viii. Fracture retropulsion/canal compromise 
You can find this rule at Local Coverage Determination (LCD) L33569: Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (eff. 12/1/20). 
 
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 while electric nerve stimulation has been employed to control chronic intractable pain for 
some time, its use in the treatment of motor function disorders, such as multiple sclerosis, is a recent 
innovation, and the medical effectiveness of such therapy has not been verified by scientifically controlled 
studies. Where electric nerve stimulation is employed to treat motor function disorders, no reimbursement may 
be made for the stimulator or for the services related to its implantation since this treatment cannot be 
considered reasonable and necessary. You can find this information in the National Coverage Determination 
(NCD) for Treatment of Motor Function Disorders with Electric Nerve Stimulation (160.2). 
 
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). 
 
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 sacroiliac joint injections (SIJI) will be considered medically reasonable and necessary when 
all the following requirements are met: 
 
1. Moderate to severe low back pain primarily experienced over the anatomical location of the SI joints 
between the upper level of the iliac crests and the gluteal fold, AND 
2. Low back pain duration of at least three (3) months, AND 
3. Low back pain below L5 without radiculopathy, AND 
4. Clinical findings and/or imaging studies do not suggest any other diagnosed or obvious cause of the 
lumbosacral pain (such as central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis 
or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, pseudoarthrosis, or 
pain related to spinal instrumentation), AND 
5. At least three positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or 
Posterior Shear, SI Compression, SI Distraction and Yeoman Tests, AND 
6. Low back pain persists despite a minimum of four weeks of conservative therapies. 
 
You can find this information in the Local Coverage Determination (LCD): Sacroiliac Joint Injections and 
Procedures (L39462). 
 
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 for parenteral nutrition to be considered reasonable and necessary, the treating practitioner 
must document that enteral nutrition has been considered and ruled out, tried and been found ineffective, or that 
enteral nutrition (EN) exacerbates gastrointestinal tract dysfunction. The beneficiary must have (a) a condition 
involving the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients 
or (b) disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to 
be transported through and absorbed by the gastrointestinal (GI) system. The beneficiary must have a 
permanent impairment. You can find this information in the Local Coverage Determination (LCD) for 
Parenteral Nutrition (L38953). 
 
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 value codes and related dollar amount(s) identify monetary data that are necessary for the 
processing of this claim. Value code 48 is for hemoglobin reading. If a hemoglobin value is not available 
facilities must report the value 99.99. Value code 49 is for hematocrit reading. If a hematocrit value is not 
available facilities must report the value 99.99.  
 
Occurrence codes and associated date(s) defining specific events(s) relating to this billing period are 
shown. Occurrence code 33 is for the First Day of Medicare Coordination Period for ESRD Beneficiaries 
Covered by an Employer Group Health Plan (EGHP). The code indicates the first day of the Medicare 
coordination period during which Medicare benefits are payable under an EGHP. This is required only for 
ESRD beneficiaries. Occurrence code 51 is for the Date of last dialysis adequacy (Kt/V) reading. For in-center 
hemodialysis patients, this is the date of the last reading taken during the billing period. For peritoneal dialysis 
patients and home hemodialysis patients, this date may be before the current billing period but should be within 
4 months of the claim date of service. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 8, Section 50.3. 
 
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 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 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). 
 
The rules say that the test panel is a single test with multiple components and is characterized by a single unit 
of service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact 
that the test reports multiple individual pathogens and/or targets. You can find this rule in the Local Coverage 
Article for the Billing and Coding of Molecular Diagnostics (MolDX): Molecular Syndromic Panels for 
Infectious Disease Pathogen Identification Testing, A58726. 
 
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 if one laboratory procedure evaluates multiple genes using a next generation sequencing 
procedure, the lab shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 
If no CPT code accurately describes the procedure performed, the lab may report CPT code 81479 with one 
unit of service. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be 
reported for the procedure. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare 
National Correct Coding Initiative Manual, Chapter X(F). 
 
The rules say that genetic testing for hereditary cardiovascular disease will be considered medically reasonable 
and necessary if the patient has rigorous disease-appropriate phenotyping to establish clinical diagnosis or 
suspected diagnosis for which the test results would directly impact the management of the patients condition, 
prior to ordering the test, the evidence for the gene-disease association is evaluated by the evidence-based, 
transparent, peer-reviewed process and is determined to demonstrate actionability in clinical decision making; 
and clinical validity and qualitative descriptors from Moderate, Strong & Definitive with contradictory 
evidence NOT being reported as disputed or refuted. You can find this rule in the Local Coverage 
Determination for Genetic Testing for Cardiovascular Disease, L39084.  
 
The rules say that pharmacogenetics testing will be considered medically reasonable and necessary if the 
patient has a condition where clinical evaluation has determined the need for a medication that has a known 
gene-drug interaction(s) for which the test results would directly impact the drug management of the patients 
condition; and the test meets evidence standards for genetic testing as evaluated by a scientific, transparent, 
peer-reviewed process and determined to demonstrate actionability in clinical decision making. You can find 
this rule in the Local Coverage Determination for Pharmacogenomics Testing, L39073. 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 level 3 (K3) ambulator has the ability or potential for ambulation with variable cadence. 
Typical of the community ambulator who has the ability to traverse most environmental barriers and may have 
vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. 
 
The rules say that a shank foot system with vertical loading pylon (L5987) and a fluid, pneumatic, or 
electronic/microprocessor knee (L5828, L5848, L5856) is covered for beneficiaries whose functional level is 3 
or above. 
 
The rules say that an axial rotation unit (L5984) is covered for beneficiaries whose functional level is 2 or 
above. 
 
The rules also say that coverage is extended only if there is sufficient clinical documentation of functional need 
for the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787). 
 
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). 
 
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 an initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint (medial 
branch) nerves is considered medically reasonable and necessary for patients who have 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). 
 
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. 
 
Frequency limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be 
reimbursed per rolling 12 months. 
You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L34892) . 
 
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.