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 all other indications not specified under 270.4(A) are not covered under the Medicare 
program. No program payment may be made for any conditions other than those listed in 270.4(A). 
 
No program payment may be made for HBO in the treatment of the following conditions: 
 
    Cutaneous, decubitus, and stasis ulcers. 
    Chronic peripheral vascular insufficiency. 
    Anaerobic septicemia and infection other than clostridial. 
    Skin burns (thermal). 
    Senility. 
    Myocardial infarction. 
    Cardiogenic shock. 
    Sickle cell anemia. 
    Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency. 
    Acute or chronic cerebral vascular insufficiency. 
    Hepatic necrosis. 
    Aerobic septicemia. 
    Nonvascular causes of chronic brain syndrome (Picks disease, Alzheimers disease, Korsakoffs disease). 
    Tetanus. 
    Systemic aerobic infection. 
    Organ transplantation. 
    Organ storage. 
    Pulmonary emphysema. 
    Exceptional blood loss anemia. 
    Multiple Sclerosis. 
    Arthritic Diseases. 
    Acute cerebral edema. 
 You can find this information in the National Coverage Determination (NCD) Hyperbaric Oxygen Therapy 
20.29. 
 
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 coverage is provided up to a maximum of 15 dressing kits (A6550) per wound per month. 
 
Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers 
must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify 
with the treating practitioners that any changed or atypical utilization is warranted. 
 
Regardless of utilization, a supplier must not dispense more than a one (1)-month quantity at a time. 
 
You can find this rule at the Medicare Local Coverage Determination (LCD) L33821: Negative Pressure 
Wound Therapy Pumps. 
 
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 therapeutic facet joint procedures are considered medically reasonable and necessary for 
patients who meet all of the following criteria: 
 
        The patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with 
each one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of relief 
being consistent with the agent used); AND 
        Subsequent therapeutic facet joint procedures at the same anatomic site result in at least consistent 50% 
pain relief for at least three (3) months from the prior therapeutic procedure or at least 50% consistent 
improvement in the ability to perform previously painful movements and activities of daily living (ADLs) as 
compared to baseline measurement using the same scale; AND 
        Documentation of why the patient is not a candidate for radiofrequency ablation (such as established 
spinal pseudarthrosis, implanted electrical device) is in the medical record. 
 
Frequency limitation: For each covered spinal region no more than four (4) therapeutic facet joint injection 
(IA) 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.
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 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 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. 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. The only exception is as 
follows:  
 
For the same date of service only one physician of the same specialty in the group practice may report code 
99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care 
services with CPT code 99292. 
 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 20.9. 
 
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 pontic - porcelain fused to high noble metal (D6240) but is limited to one per 60 month(s), per 
patient, per tooth. Pre-operative x-ray(s) are required documentation for review. You can find this information 
on page 98 of the Plans 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 20% coinsurance for outpatient diagnostic tests/therapeutic radiology 
services and a $10 copayment for outpatient diagnostic tests/lab services. You can find this information on 
pages 72 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 the implantation of a phrenic nerve stimulator is covered for selected patients with partial or 
complete respiratory insufficiency. You can find this information in Medicare's National Coverage 
Determination (NCD): Phrenic Nerve Stimulator (160.19). 
 
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 pancreas transplants alone (PA) are reasonable and necessary for Medicare beneficiaries in 
the following limited circumstances: 
1. PA will be limited to those facilities that are Medicare-approved for kidney transplantation. 
2. Patients must have a diagnosis of type I diabetes: 
o Patient with diabetes must be beta cell autoantibody positive; or 
o Patient must demonstrate insulinopenia defined as a fasting C-peptide level that is less than or 
equal to 110% of the lower limit of normal of the laboratory's measurement method. Fasting C-
peptide levels will only be considered valid with a concurrently obtained fasting glucose  225 
mg/dL; 
3. Patients must have a history of medically-uncontrollable labile (brittle) insulin-dependent diabetes 
mellitus with documented recurrent, severe, acutely life-threatening metabolic complications that 
require hospitalization. Aforementioned complications include frequent hypoglycemia unawareness or 
recurring severe ketoacidosis, or recurring severe hypoglycemic attacks; 
4. Patients must have been optimally and intensively managed by an endocrinologist for at least 12 months 
with the most medically recognized advanced insulin formulations and delivery systems; 
5. Patients must have the emotional and mental capacity to understand the significant risks associated with 
surgery and to effectively manage the lifelong need for immunosuppression; and, 
6. Patients must otherwise be a suitable candidate for transplantation. 
 
The following procedure is not considered reasonable and necessary within the meaning of section 
1862(a)(1)(A) of the Social Security Act: 
1. Transplantation of partial pancreatic tissue or islet cells (except in the context of a clinical trial 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determination for Pancreas Transplants, 260.3.  
 
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 state that indications for surgical treatment and sclerotherapy are 
 
    A. 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive 
therapy, and avoidance of prolonged immobility where appropriate, has failed, AND 
    B. The patient is symptomatic and has one, or more, of the following: 
        Pain, aching, cramping, burning, itching and/or swelling during activity or after prolonged standing severe 
enough to impair mobility 
        Recurrent episodes of superficial phlebitis 
        Non-healing skin ulceration 
        Bleeding from a varicosity 
        Stasis dermatitis 
        Refractory dependent edema 
    The treatment of spider veins/telangiectasis will be considered medically necessary only if there is associated 
hemorrhage. 
 
Indications for endoluminal radiofrequency ablation (ERFA) or laser ablation: 
In addition to the above, the patient's anatomy and clinical condition are amenable to the proposed treatment 
including ALL of the following: 
 
    Absence of aneurysm in the target segment. 
    Maximum vein diameter of 20 mm for ERFA or 30 mm for laser ablation. 
    Absence of thrombosis or vein tortuosity, which would impair catheter advancement. 
    The absence of significant peripheral arterial diseases. 
 
You can find this information in the Local Coverage Determination (LCD) Treatment of Varicose Veins of the 
Lower Extremities L34536. 
 
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 performed to facilitate the infusion or injection or hydration, the use of local anesthesia is 
included and not separately billable. 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 30.5(C). 
 
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 inpatient routine services in a hospital or skilled nursing facility generally are those services 
included in by the provider in a daily service charge--sometimes referred  to as the "room and board" charge. 
Routine services are composed of two board components; (l) general routine services, and (2) special care units 
(SCU's), including coronary care units (CCU's) and intensive care Units (ICU's). Included in routine services 
are the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, 
psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not 
customarily made. You can find this rule in the Center for Medicare Services (CMS) Provider Reimbursement 
Manual, Chapter 22, Section 2202.6. 
 
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 a RAP and a claim must be submitted for all episodes for which Medicare makes payment 
based on HIPPS codes. HHAs may submit both a RAP and a claim in these instances if they choose, but only 
the claim is required. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), 
Internet-Only Manual, Medicare Claims Processing Manual, Chapter 10, Section 40.3. 
 
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 when a patient is discharged/transferred from an acute care Prospective Payment System 
(PPS) hospital, and is readmitted to the same acute care PPS hospital on the same day for symptoms related to, 
or for evaluation and management of, the prior stays medical condition, hospitals shall adjust the original 
claim generated by the original stay by combining the original and subsequent stay onto a single claim. You 
can find this rule in the Center for Medicare Services (CMS) Publication 100-04, Medicare Claims Processing 
Manual, Chapter 3, Section 40.2.5. 
 
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 coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design 
feature of a given type of knee. This information must be retained in the treating practitioner's or prosthetist's 
files. You can find this information in the Local Coverage Determination (LCD): Lower Limb Prostheses 
(L33787). 
 
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 there is a $0 copayment for one annual physical exam per calendar year. You can find this 
information on page 55 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 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 a Medicare plan may restrict enrollees to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the plan must 
arrange for specialty care outside of the plan provider network when network providers are unavailable or 
inadequate to meet an enrollees medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community based 
services. You can find this rule at 42 CFR Section 422.112. 
 
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 4 of the Plan's 2023 
Evidence of Coverage.