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 Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says covered drugs include: Drugs that usually arent self-administered by the patient and are injected 
or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. You can 
find this information in Chapter 4 on page 4-38 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 dorsal column stimulators may be covered as therapies for the relief of chronic intractable 
pain under the following circumstances: 
1. To treat chronic pain caused by lumbosacral arachnoiditis that has not responded to medical 
management including physical therapy. 
2. To treat intractable pain caused by nerve root injuries, post-surgical or post-traumatic including that of 
post-laminectomy syndrome (failed back syndrome). 
3. To treat intractable pain caused by complex regional pain syndrome I & II. 
4. To treat intractable pain caused by phantom limb syndrome that has not responded to medical 
management. 
5. To treat intractable pain caused by end-stage peripheral vascular disease, when the patient cannot 
undergo revascularization or when revascularization has failed to relieve painful symptoms and the pain 
has not responded to medical management. 
6. To treat intractable pain caused by post-herpetic neuralgia. 
7. To treat intractable pain caused by plexopathy. 
8. To treat intractable pain caused by intercostal neuralgia that did not respond to medical management 
and nerve blocks. 
9. To treat intractable pain caused by cauda equina injury. 
10. To treat intractable pain caused by incomplete spinal cord injury. 
 
You can find these rules in Local Coverage Determination (LCD) Spinal Cord Stimulation (Dorsal Column 
Stimulation) (L35450). 
 
The rules state that no payment may be made for the implantation of dorsal column or depth brain stimulators 
or services and supplies related to such implantation, unless all of the conditions listed below have been met: 
1. The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with 
chronic intractable pain; 
2. With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or 
contraindicated for the given patient; 
3. Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 4. All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be 
available; and 
5. Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find these rules in National Coverage Determination (NCD) Electrical Nerve Stimulators (160.7). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 only the 
items and services listed in the Dental Rider. A bone replacement graft (D4263) and guided tissue regeneration 
(D4267) are not covered by the Plan's dental benefits. You can find this information on pages 113-146 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 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 $10 copayment for each Medicare covered visit with a primary care 
physician (PCP). You can find this information in Chapter 4 on page 111 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 purified natural hyaluronans have been approved by the Food and Drug Administration 
(FDA) for the treatment of pain associated with osteoarthritis of the knee in patients who have failed to respond 
adequately to conservative nonpharmacologic therapy and simple analgesics. The synovial fluid's capacity to 
lubricate and absorb shock is typically reduced in joints affected by osteoarthritis. These changes are partly due 
to a reduction in the concentration and size of hyaluronic acid molecules that are naturally present in synovial 
fluid. In addition to the FDA-approved use, hyalurons have been recognized as a therapeutic option in 
osteoarthritis of the shoulder. 
 
A repeat series of injections may be allowed when: 
1. The indications continue to be met; and 
2. Significant improvement in pain and functional capacity from the prior series of injections is documented in 
the medical record; and 
3. The last injection (in a prior course) was given at least six (6) months ago. 
 
Repeat injections for shoulder arthritis are limited to a single repeat course. You can find this information in the 
Local Coverage Article: Billing and Coding: Hyaluronans Intra-articular Injections of (A52420). 
 
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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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 the only covered chiropractic service is manual manipulation of the spine to correct 
subluxation. You can find this information on page 67 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 Medicare Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says covered drugs include: Drugs that usually arent self-administered by the patient and are injected 
or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. You can 
find this information in Chapter 4 on page 4-36 of the plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says covered drugs include: Drugs that usually aren't self-administered by the patient and are injected 
or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. You can 
find this information in Chapter 4 on page 4-39 of the plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 in the case of a molecular pathology test performed by a laboratory other than a blood bank 
or center, a test designated by CMS as an ADLT under paragraph (1) of the definition of an advanced 
diagnostic laboratory test in Section 414.502, a test that is a cancer-related protein-based Multianalyte Assays 
with Algorithmic Analyses, or the test described by CPT code 81490, the date of service of the test must be the 
date the test was performed only if - 
(i) The test was performed following a hospital outpatient's discharge from the hospital outpatient department; 
(ii) The specimen was collected from a hospital outpatient during an encounter (as both are defined in  410.2 
of this chapter); 
(iii) It was medically appropriate to have collected the sample from the hospital outpatient during the hospital 
outpatient encounter; 
(iv) The results of the test do not guide treatment provided during the hospital outpatient encounter; and 
(v) The test was reasonable and medically necessary for the treatment of an illness. 
 
You can find this rule in CFR 42, Section 414.510(b)(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 say that Medicare pays for ambulance services that meet certain requirements. One requirement is 
that the vehicle used as an ambulance must be equipped with emergency warning lights and sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. Another requirement is that the vehicle used as an ambulance must be staffed with two 
people, one of whom is certified as an emergency medical technician. You can find this rule at 42 CFR 
Sections 410.41(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.
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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, 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 page 36 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 PILD will be covered by Medicare when provided in a clinical study through Coverage 
with Evidence Development (CED) for beneficiaries with lumbar spinal stenosis (LSS) who are enrolled in an 
approved clinical study. You can find this information in the Centers for Medicare and Medicaid Services 
(CMS), Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) 
Manual, Section 150.13. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. 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. 
 
The rules say Technical Component Only Codes identify stand- alone codes that describe the technical 
component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code 
that describes the professional component of the diagnostic test only. An example of a technical component 
only code is CPT code 99153-MOD SED SAME PHYS/QHP EA. It also identifies codes that are covered only 
as diagnostic tests and therefore do not have a related professional code. Modifiers 26 and TC cannot be used 
with these codes. The total RVUs for technical component only codes include values for practice expense and 
malpractice expense only. 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. 
 
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 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 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
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. 
 
Subsequent therapeutic facet joint procedures at the same anatomic site results 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. You can find these rules in Local Coverage Determination (LCD) 
Facet Joint Interventions for Pain Management (L38765). 
 
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.