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 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 say that Medicare has determined for which surgical services an assistant surgeon is medically 
necessary. This information can be found in the Medicare Fee Schedule Database. If the database contains an 
assistant at surgery indicator of 1 for the surgical procedure in question, Medicare has determined that an 
assistant is not medically necessary. Assistant surgeons will not be paid for these procedures. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing 
Manual, Chapter 12, Section 40.8. 
 
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 $75 copayment for Diagnostic procedures and tests. You can find this 
information on page(s) 86 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 state that a power wheelchair is covered if: 
 
    All of the basic coverage criteria (A-C) are met; and 
    The beneficiary does not meet coverage criterion D, E, or F for a POV; and 
    Either criterion J or K is met; and 
    Criteria L, M, N, and O are met; and 
    Any coverage criteria pertaining to the specific wheelchair type (see below) are met. 
 
    The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is 
provided; or 
 
    If the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who is 
unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to 
safely operate the power wheelchair that is provided; and 
 
    The beneficiarys weight is less than or equal to the weight capacity of the power wheelchair that is provided 
and greater than or equal to 95% of the weight capacity of the next lower weight class PWC  i.e., a Heavy 
Duty PWC is covered for a beneficiary weighing 285  450 pounds; a Very Heavy Duty PWC is covered for a 
beneficiary weighing 428  600 pounds; an Extra Heavy Duty PWC is covered for a beneficiary weighing 570 
pounds or more. 
 
    The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the power wheelchair that is provided. 
 
    Use of a power wheelchair will significantly improve the beneficiarys ability to participate in MRADLs and 
the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical impairments, 
participation in MRADLs may require the assistance of a caregiver. 
 
    The beneficiary has not expressed an unwillingness to use a power wheelchair in the home. 
 
If a PWC will be used inside the home and if coverage criteria (a)-(e) are not met, it will be denied as not 
reasonable and necessary.  
If a PWC will only be used outside the home, see related Policy Article for information concerning 
noncoverage. 
 
A Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with Multiple Power 
Options (K0861, K0862, K0863, K0864) is covered if: 
 
    The Group 3 criteria IV(A) and IV(B) are met; and 
    The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and 
III[B]) (respectively) are met. 
 
If the PWC base is not covered, then related accessories will be denied. 
 
You can find this information in the 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 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 CPT 25109, Assist Surgeon indicator is 1" which means: "(assistant-at-surgery may not be paid) 
for procedures CMS has determined that an assistant surgeon is not generally medically necessary. You can 
find this information in Medicare's Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule - 
Relative Value File, on assistant surgeon billing for MA plans.  
 
The rules say A/B MACs (B) may not pay assistants-at-surgery for surgical procedures in which a physician is 
used as an assistant-at-surgery in fewer than five percent of the cases for that procedure nationally. This is 
determined through manual reviews. Procedures billed with the assistant-at-surgery physician modifiers -80, -
81, -82, or the AS modifier for physician assistants, nurse practitioners and clinical nurse specialists, are 
*subject to the assistant-at-surgery policy. Accordingly, pay claims for procedures with these modifiers only if 
the services of an assistant-at-surgery are authorized. You can find this information in the Medicare Claims 
Processing Manual Chapter 12, section 20.4.3. 
 
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 Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. 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 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 103 of the Plans 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score  8) 
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.  
You can find this rule at Local Coverage Determination (LCD) L34106: Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (eff. 1/10/21). 
 
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 facet joint interventions are considered medically reasonable and necessary for the 
diagnosis and treatment of chronic pain in patients who meet all of the following criteria: 
 
1.  Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale; AND 
2.  Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive 
conservative care management (as tolerated); AND 
3.  Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst); AND 
4.  There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
    *Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the 
same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for 
functional assessment (if patient qualifies for treatment). 
 
You can find this rule in the Medicare Local Coverage Determination (LCD)- L34892, Facet Joint 
Interventions for Pain Management. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say Components of a Global Surgical Package: The Medicare approved amount for these procedures 
includes payment for the following services related to the surgery when furnished by the physician who 
performs the surgery. The services included in the global surgical package may be furnished in any setting, 
e.g., in hospitals, ASCs, physicians offices. Visits to a patient in an intensive care or critical care unit are also 
included if made by the surgeon. However, critical care services (CPT codes 99291 and 99292) are payable 
separately in some situations. (See section 30.6.12.7 of this chapter for further discussion of critical care visits 
unrelated to the procedure with a global surgical period.) 
Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day before 
the day of surgery for major procedures and the day of surgery for minor procedures; 
 
Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a surgical 
procedure; 
Complications Following Surgery - All additional medical or surgical services required of the surgeon during 
the postoperative period of the surgery because of complications which do not require additional trips to the 
operating room; 
Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to 
recovery from the surgery; 
Postsurgical Pain Management - By the surgeon; 
Supplies - Except for those identified as exclusions; and 
Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative pack; 
removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation 
and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and 
changes and removal of tracheostomy tubes. You can find this information in the Medicare Claims Processing 
Manual, Chapter 12, Section 40.1 A. 
 
The rules say that surgery procedure 56620 has a global value of 090 on the CMS National Physician Fee 
Schedule (NPFS) Relative Value (RVU) file. You can find this information in the Medicare National Physician 
Fee Schedule Relative Value File. 
 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 special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The Plan must have written policies for determining enrollee eligibility and 
must document its determination that an enrollee is a chronically ill enrollee. You can find this information in 
42 CFR 422.102. 
 
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 if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. You can find this information on pages 101 to 
102.
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 determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary's potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to: 1. The beneficiary's past history (including prior prosthetic use if applicable); and 2. The beneficiary's current condition including the status of the residual limb and the nature of other medical problems; and 3. The beneficiary's desire to ambulate.
Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels:
Level 3: 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 records must document the beneficiary's current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications. You can find this rule at Local Coverage Determination (LCD) L33787: Lower Limb Prostheses (eff. 1/1/20).
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 also say that certain data elements are required. Any claim with incomplete, missing, or invalid information for all these elements may be returned as un-processable. You can find this rule in the Medicare Claims Processing Manual, Chapter 1, Section 80.3.1.
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).
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 Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary when:
- The test is performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory
- The test is ordered by a treating doctor
- The member has cancer that's returned (recurrent or relapsed), cancer that does not respond to treatment (refractory), cancer that has spread (metastatic), or advanced stage III or IV cancer
- The member has not been previously tested using the same NGS test for the same primary diagnosis of cancer OR repeat testing is needed because of a new primary cancer diagnosis
- The member has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). Additionally, the requested test must have all the following:
- Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic
- An FDA-approved or -cleared indication for use for the patient's cancer
- Provide results to the treating doctor for management of the patient's cancer using a report template with specific treatment options. Under Medicare, the request is not medically necessary.
You can find this rule in the National Coverage Determination (NCD) for Next Generation Sequencing (NGS) (90.2)
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that 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 a beneficiary is considered discharged when he or she leaves the facility with no expectation of
return, e.g., a beneficiary transferred to another skilled nursing facility (SNF) or discharged to home. Medicare
Benefit Policy Manual, Chapter 8- Coverage of Extended Care (SNF) Services under Hospital Insurance,
Section 20.3, Payment Bans.
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 after the first diagnostic facet joint procedure, there must be a consistent positive response 
of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used). 
You can find this information in Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L38801). 
 
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.