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 for PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) to be covered, none of 
the following exclusion criteria can be present: 
a. Absolute contraindication 
- Current back pain is not primarily due to the identified acute or subacute VCF(s). 
- Osteomyelitis, discitis, active systemic or surgical site infection 
- Pregnancy 
b. Relative contraindication 
- Greater than three vertebral fractures per procedure 
- Allergy to bone cement or opacification agents 
- Uncorrected coagulopathy 
- Spinal instability 
- Myelopathy from the fracture 
- Neurologic deficit 
- Neural impingement 
- Fracture retropulsion/canal compromise 
You can find this information in 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 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 D2950 
when prior authorization is obtained. You can find this information on page 66 of the Plans 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 a Medicare plan may restrict members 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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 in Chapter 3 on pages 26-27 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 Medicare will not pay for items and services involving the care, treatment, filling, removal or 
replacement of teeth or structures directly supporting the teeth. You can find this rule in the Social Security 
Act, Section 1862(a)(12).  
 
The rules say that treatment for temporomandibular joint (TMJ) syndrome may be covered when the actual 
condition or symptom is medical in nature and the services provided are reasonable and necessary for the 
diagnosis and/or treatment of a medical illness or injury. You can find these rules in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 
15, Section 150.1. 
 
The rules state that the patients medical record should include but is not limited to: 
 
   1. The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that 
visit, 
   2.  Relevant medical history 
   3. Results of pertinent tests/procedures 
   4.  Signed and dated office visit record/operative report (Please note that all services ordered or rendered to 
Medicare beneficiaries must be signed.) 
  
You can find this information in the Local Coverage Article (LCA) Billing and Coding: Outpatient Physical 
and Occupational Therapy Services (A57067). 
 
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 the ICD-10-CM has two types of excludes notes. Each type of note has a different definition 
for use, but they are all similar in that they indicate that codes excluded from each other are independent of 
each other. 
a. Excludes1 
A type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. An 
Excludes1 is 
used when two conditions cannot occur together, such as a congenital form versus an acquired form of the 
same condition. 
 
An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each 
other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the 
provider. 
For example, code F45.8, Other somatoform disorders, has an Excludes1 note for "sleep related teeth grinding 
(G47.63)," because "teeth grinding" is an inclusion term under F45.8. Only one of these two codes should be 
assigned for teeth grinding. However psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are 
clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together. 
b. Excludes2 
A type 2 Excludes note represents Not included here. An excludes2 note indicates that the condition 
excluded is not part of the condition represented by the code, but a patient may have both conditions at the 
same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the 
excluded code together, when appropriate. You can find this in the International Classification of Diseases 
(ICD)-10-CM Official Guidelines for Coding and Reporting FY 2023 -- UPDATED April 1, 2023. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that a determination of the type of knee for the prosthesis will be made by the treating 
practitioner and/or the prosthetist based upon the functional needs of the beneficiary. Basic lower extremity 
prostheses include a single axis, constant friction knee. Other prosthetic knees are considered for coverage 
based upon functional classification. 
A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot 
with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot 
system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. 
 
A fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, L5726, L5728, 
L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is covered for 
beneficiaries whose functional level is 3 or above. 
 
L5859 (ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, 
POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY 
TYPE MOTOR(S)) is only covered when the beneficiary meets all of the criteria below: 
1. Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee 
2. K3 functional level only 
3. Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or 
quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled knee 
alone 
4. Is able to make use of a product that requires daily charging 
5. Is able to understand and respond to error alerts and alarms indicating problems with the function of the 
unit 
If these coverage criteria for the knee component are not met, L5859 will be denied as not reasonable and 
necessary. 
 
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 these rules in 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 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. 
 
Thermal destruction of the intraosseous BVN will be considered medically reasonable and necessary for the 
treatment of cLBP in patients who meet ALL the following criteria: 
1. Chronic lumbar back pain of 6 months duration that causes functional deficit measured on a pain or 
disability scale, AND 
2. Documented failure to respond to 6 months of non-surgical management, AND 
3. Absence of non-vertebrogenic 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, AND 
4. Evidence of Type 1 or Type 2 Modic changes on MRI, such as inflammation, edema, vertebral 
endplate changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the 
adjacent marrow, hypotensive signals (Type 1 Modic change), and changes to the vertebral body 
marrow including replacement of normal bone marrow by fat, and hypertensive signals (Type 2 Modic 
change), in 1 or more vertebrae from L3-S1 
 
Local Coverage Determination (LCD): Thermal Destruction of the Intraosseous Basivertebral Nerve 
(BVN) for Vertebrogenic Lower Back Pain (L39420).  
 
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. 
Effective for services performed on or after March 16, 2018, the Centers for Medicare & Medicaid Services 
(CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable 
and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments 
(CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements 
are met: 
   a. Patient has: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
   b. The diagnostic laboratory test using NGS must have: 
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
iii. results provided to the treating physician for management of the patient using a report template to 
specify treatment options. 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, National Coverage Determinations (NCD) Manual: 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 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). 
 
Functional blepharoplasty procedures and surgical procedures of the brow  will be considered 
medically reasonable and necessary in the following situations: 
1. When the goal of the surgery is to restore function and normalcy to a structure that has been altered by 
trauma, infection, inflammation, degeneration, neoplasia, or developmental errors or; 
2. When there is interference with visual field, near or far visual impairment, or difficulty reading due to 
any of the following: 
 Dermatochalasis 
 Blepharochalasis 
 Blepharoptosis 
 Brow ptosis causing malposition of the upper eyelid
1
 and demonstrating a MRD1 (Margin reflex 
distance) of 2 mm or less 
 Looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis 
 Pseudoptosis 
 When there is visual impairment secondary to redundant skin weighing down on upper 
lashes
1
 resulting in eye strain, headache and loss of vision. 
 When there is chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid 
skin which has not been successfully treated by conservative measures such as education 
regarding hygiene, antibiotics, etc.; or 3. Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual 
field impairment; or 
4. When there is the presence of prosthesis difficulties in an anophthalmic socket; or 
5. When there is laxity of the lower eyelid tissues causing lower eyelid ectropion resulting in eye irritation 
and inflammation and excessive tearing; or 
6. When there is inward rotation of the eyelid margin causing entropion where the eyelashes are 
contacting the cornea resulting in discomfort, redness, tearing, and foreign body sensation; or 
7. Lower eyelid edema, tumor or mass causing signs and symptoms of eyelid ectropion. 
 
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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
 
The rules say that all of the following basic criteria (A-C) must be met for a power mobility device (K0822) or 
a push-rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific 
devices are listed below. 
 
   A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. A mobility limitation is one that: 
        Prevents the beneficiary from accomplishing an MRADL entirely, or 
        Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the 
attempts to perform an MRADL; or 
        Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
   B. The beneficiarys mobility limitation cannot be sufficiently and safely resolved by the use of an 
appropriately fitted cane or walker. 
 
   C. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured 
manual wheelchair in the home to perform MRADLs during a typical day. 
        Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or 
absence of one or both upper extremities are relevant to the assessment of upper extremity function.         An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating 
options, and other appropriate nonpowered accessories. 
 
You can find this information in the Local Coverage Determination (LCD) for 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. If a procedure has a global 
period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E&M services performed on 
the same date of service as a minor surgical procedure are included in the payment for the procedure. The 
decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and 
shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M 
service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 
25. 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 say that both Initial Hospital Care (CPT codes 99221 - 99223) and Subsequent Hospital Care codes 
are per diem services and may be reported only once per day by the same physician or physicians of the same 
specialty from the same group practice. You can find this rule in Centers for Medicare and Medicaid Services 
(CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 12, Section 
30.6.9. 
 
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.