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 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. 
 
You can find this rule in the Local Coverage Determination for 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 a second confirmatory diagnostic facet joint procedure is considered medically reasonable 
and necessary in patients who meet ALL the following criteria: 
 
 The patient meets the criteria for the first diagnostic procedure; AND 
 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 rule at Local Coverage Determination (LCD) L38773: Facet Joint Interventions for Pain 
Management (eff. 3/17/22). 
 
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 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 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; AND 
    Documentation of why the patient is not a candidate for radiofrequency ablation (such as established spinal 
pseudarthrosis, implanted electrical device) 
 
Frequency Limitations: For each covered spinal region no more than four (4) therapeutic facet joint (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 L35936. 
 
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 transcutaneous electrical nerve stimulation (TENS) TENS is not reasonable and necessary 
for the treatment of chronic low back pain (CLBP) under section 1862(a)(1)(A) of the Act. You can find this 
rule in the National Coverage Determination (NCD) for Transcutaneous Electrical Nerve Stimulation (TENS) 
for Chronic Low Back Pain (CLBP) (160.27). 
 
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 physician may not bill the hospital observation discharge management code or an 
outpatient/office visit for the care provided while the patient received hospital outpatient observation services 
on the date of admission to inpatient status. You can find this rule in the Medicare Claims Processing Manual, 
Chapter 12, Section 30.6.8. 
 
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 that non-invasive vascular studies are considered medically necessary if the ordering physician 
has reasonable expectation that their outcomes will potentially impact the clinical management of the patient. 
Services are deemed medically necessary when the following conditions are met: 
 
1. Significant signs/symptoms of arterial or venous disease are present; and/or 
2. The information is necessary for appropriate medical and/or surgical management; and/or 
3. The test is not redundant of other diagnostic procedures that must be performed. 
 
You can find this rule in the Local Coverage Determination (LCD) - Non-Invasive Vascular Studies (L33627) - 
Effective October 1, 2019. 
 
The rules say that peripheral artery studies may be considered medically necessary if the following signs and 
symptoms are present: 
 
1. Claudication of such severity that it interferes significantly with the patients occupation or lifestyle, or 
claudication with inability to stress the patient; 
2. Rest pain (typically including the forefoot), usually associated with absent pulses, which becomes 
increasingly severe with elevation and diminishes with placement of the leg in a dependent position; 
3. Tissue loss defined as gangrene or pre-gangrenous changes of the extremity, or ischemic ulceration of the 
extremity occurring in the absence of pulses; 
4. Aneurysmal disease; 
5. Evidence of thromboembolic events; 
6. Blunt or penetrating trauma (including complications of diagnostic and/or therapeutic procedures); and/or 
7. Follow-up of grafts or other vascular intervention 
 
You can find this rule in the Local Coverage Determination (LCD) - Non-Invasive Vascular Studies (L33627) - 
Effective October 1, 2019.  
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 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 follow-up services are included in the global surgical package. You can find this rule in the 
Center for Medicare Services (CMS) Internet-Only Manual Publication 100-04, Medicare Claims Processing 
Manual, Chapter 12, Section 40.1. 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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 1-8 of the 2023 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 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). 

The rules say that both percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA) 
will be considered reasonable and necessary for osteoporotic conditions when ALL of the following criteria are 
met: 

- Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1 - L5) based on symptom onset, and 
documented by recent (within 30 days) advanced imaging (bone marrow edema on MRI or bone-
scan/SPECT/CT uptake) 
- The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or 
visual Analog Scale [VAS] pain score  8) or is non-hospitalized with moderate to severe pain (NRS or 
VAS  5) despite optimal non-surgical management (NSM) with one of the following: 

o Worsening pain or 
o Stable to improved pain (but NRS or VAS  5) when 2 or more of the following are present:  
 Progression of vertebral body height loss 
 >25% vertebral body height reduction 
 Kyphotic deformity 
 Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire 
(RDQ) > 17) 
 Steroid-induced fractures 
 Reinforcement or stabilization of vertebral body prior to surgery 

You can find these rules in Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) L38213. 
 
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 a flex-walk system or equal is covered for beneficiaries whose functional level is 3 or above. You can find this information in Local Coverage Determination (LCD): Lower Limb Prosthesis (L33787).

The rules also say that use of L5968 is based on the beneficiary's K-level modifier (K0-K4), as referenced in the LCD. You can find this information in Local Coverage Article: Lower Limb Prosthesis - Policy Article (A52496).

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. 
 
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 if you are sent outside of your community for a transplant, we will arrange or pay for 
appropriate lodging and transportation costs for you and a companion. You can find this information on page 
83 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 epidural steroid injection (ESI) will be considered medically reasonable and necessary 
when certain criteria are met. History, physical, and radiological testing must show Lumbar, cervical or 
  
  thoracic radiculopathy, radicular pain and/or neurogenic claudication due to central disc herniation, osteophyte 
or osteophyte complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis; Post-
laminectomy syndrome; or Acute herpes zoster related pain. This pain must be severe enough to greatly impact 
quality of life or function. There should also be medical documentation of failure to respond to four (4) weeks 
of noninvasive conservative care.  
 
You can find this information in the Local Coverage Determination (LCD): Epidural Steroid Injections for Pain 
Management (L38994). 
 
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 up to 100 days of skilled care in a SNF in each benefit period. A benefit 
period begins upon admission to a hospital or SNF and ends after 60 days in a row without the patient receiving 
hospital or skilled SNF services. You can find this rule in the Social Security Act, Section 1862(a)(18), at 42 
CFR Sections 409.60(a) and (b) and Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, Section 
10.4. 
 
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 a test panel is a single test with multiple components and is characterized by a single unit of 
service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact that 
the test reports multiple individual pathogens and/or targets. If additional organisms are not included in a panel, 
testing for those organisms separately may be reasonable and necessary when ordered in addition to the panel 
and supported by documentation in the medical record. You can find this information in the Centers for 
Medicare and Medicaid Services, Local Coverage Article (LCA): Billing and Coding: MolDX: Molecular 
Syndromic Panels for Infectious Disease Pathogen Identification Testing (A58761). 
 
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 does not include 
dental extractions due to decay or periodontal disease or for the purpose to obtain dentures You can find this 
information in Chapter 4 on page 37 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 that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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 pages 1-7 and 1-8 of the 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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers routine transportation when each one-way trip does not exceed 50 miles of driving distance.. You can 
find this information on page 121 of the Plans 2023 Evidence of Coverage (EOC).