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 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 that modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(d). 
 
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 the implantable automatic defibrillator is an electronic device designed to detect and treat 
life-threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and 
defibrillating. You can find these rules in the National Coverage Determination (NCD) Implantable Automatic 
Defibrillators 20.4. 
 
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 say that 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: 
 
    Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee 
 
    K3 functional level only 
 
    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 
 
    Is able to make use of a product that requires daily charging 
 
    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. 
 
Other knee systems (L5611, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5810, L5811, L5812, 
L5816, L5818) are covered for beneficiaries whose functional level is 1 or above. 
 
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 the Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules state that a spinal electrical osteogenesis stimulator (E0748) is covered only if any of the following 
criteria are met: 
 
       1. Failed spinal fusion where a minimum of nine months has elapsed since the last surgery, or 
       2. Following a multilevel spinal fusion surgery (see Appendices section), or 
       3. Following spinal fusion surgery where there is a history of a previously failed spinal fusion at the same 
site. 
 
You can find this rule in the Local Coverage Determination (LCD) for Osteogenesis Stimulators (L33796). 
 
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: 
 
1. Stereotactic Body Radiation Therapy (SBRT) is indicated for primary tumors and tumors metastatic to 
the lung, liver, kidney, adrenal gland, or pancreas. 
2. SBRT is indicated for treatment of pelvic and head and neck tumors that have recurred after primary 
irradiation. 
3. SBRT is indicated for patients with clinically localized, low- to intermediate-risk prostate cancer. 
4. SBRT treatment, of any body site or internal organ, is indicated for treatment of recurrence in or near 
previously irradiated regions when a high level of precision and accuracy or a high dose per fraction is 
indicated to minimize the risk of injury to surrounding normal tissues and treatment with conventional methods 
is not appropriate or safe for the particular patient (medical records must describe the specific circumstances). 
 
You can find this information in the Local Coverage Determination (LCD): Stereotactic Radiation Therapy: 
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (L35076). 
 
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 23 of the 
Plan's 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 state that clinical assessments of beneficiary rehabilitation potential must be based on the following 
classification levels: 
- Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance 
and a prosthesis does not enhance their quality of life or mobility. 
- Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at 
fixed cadence. Typical of the limited and unlimited household ambulator. 
- Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental 
barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
- 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. 
- Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, 
exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active 
adult, or athlete. 
 
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. 
You can find these rules in Local Coverage Determination (LCD) Lower Limb Prostheses (L33787). 
 The rules state that protective outer surface covering systems (L5962, L5964, and L5966) are specialized 
covers intended to be worn over an existing prosthesis. They are used by a beneficiary who has special needs 
for protection against unusually harsh environmental situations where it is necessary to protect the lower limb 
prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707. They are not for 
cosmetic or convenience reasons, or for everyday usage in a typical environment. Protective outer surface 
coverings are different from the covering that is already reimbursed as part of L5704, L5705, L5706, 
and L5707. You can find this rule in Local Coverage Article (LCA) Lower Limb Prostheses 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. 
 
Chronic migraine is defined as a headache occurring on 15 or more days a month for more than three months, 
which, on at least eight days/month has the features of migraine headache. Treatment of chronic migraines 
will be covered when they meet the following diagnostic criteria: for migraine with aura and/or criteria for 
migraine without aura. Treatment with botulinum toxin may be given every 12 weeks as multiple injections 
around the head and neck. 
 
A. Migraine with aura: 
1. At least two attacks fulfilling the following criteria a and b 
a. One or more of the following fully reversible aura symptoms 
o Visual (aura, changes in vision) 
o sensory (e.g., tingling in hands or face, pins and needles, numbness 
o speech and/or language difficulties 
o motor (e.g., weakness) 
o brainstem (e.g., vertigo, tinnitus, loss of hearing, diploplia, ataxia not attributable to sensory 
deficit, and decreased level of consciousness) 
o retinal (visual disturbance, flash of light, blind spot) 
b. At least three of the following six characteristics: 
o at least one aura symptom spreads gradually over greater than 5 minutes 
o two or more aura symptoms occur in succession 
o each individual aura symptoms last 5-60 minutes 
o at least one aura symptom is unilateral 
o at least one aura symptom is positive 
o the aura is accompanied, or followed within 60 minutes, by headache 
 
B. Migraine without aura: 
1. At least five attacks fulfilling the following criteria 
- Headache attacks lasting 4-72 hours (when untreated or unsuccessfully treated) 
- Headache has at least two of the following: 
o unilateral location 
o pulsating quality 
o moderate or severe pain intensity 
o aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs) 
- During headache at least one of the following: o nausea and/or vomiting 
o photophobia and phonophobia 
You can find this information in the Local Coverage Determination (LCD): Botulinum Toxin Type A & Type 
B (L34635). 
 
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 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) by recent (within 30 days) 
advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake)
1-3,10,25,27
 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain 
score  8)
4-7
 
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) 
* consider including pedicle periosteal infiltration
7
 
c. Continuum of care
10
 (BOTH): 
1.  
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) L38737: Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (eff. 8/21/22). 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 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 effective October 1, 2006, the following non-OPPS providers may elect to bill using the C-
codes or an appropriate CPT code on Types of Bill (TOBs) 12X, 13X, or 85X: 
Critical Access Hospitals (CAHs); 
Indian Health Service Hospitals (IHS); 
Hospitals located in American Samoa, Guam, Saipan or the Virgin Islands; and 
Maryland waiver hospitals. 
 
The OPPS providers shall continue to receive pass-through payment on items or services that qualify for pass 
through payment. Non-OPPS providers are not eligible for pass through payments. 
 
The C-codes shall be replaced with permanent codes. Whenever a permanent code is established to replace a 
temporary code, the temporary code is deleted and cross-referenced to the new permanent code. Upon deletion 
of a temporary code, providers shall bill using the new permanent code. 
 
Providers are encouraged to access the CMS Web site to view the quarterly HCPCS Code updates. The URL to 
view the quarterly updates is http://www.cms.hhs.gov/HCPCSReleaseCodeSets/. 
 
The billing of C-codes by Method I and Method II Critical Access Hospitals (CAHs) is limited to the billing for 
facility (technical) services. The C-codes shall not be billed by Method II CAHs for professional services with 
revenue codes 96X, 97X, or 98X. 
 
You can find these rules in the Centers for Medicare & Medicaid Services, Medicare Claims Processing 
Manual, Chapter 4, Section 20.7. 
 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 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. 
 
The rules state that chronic migraine is defined as a headache occurring on 15 or more days a month for more 
than three months, which, on at least eight days/month has the features of migraine headache. Treatment of 
chronic migraines will be covered when they meet the following diagnostic criteria: for migraine with aura 
and/or criteria for migraine without aura. Treatment with botulinum toxin may be given every 12 weeks as 
multiple injections around the head and neck. You can find this information in Local Coverage Determination 
(LCD): You can find this information in Local Coverage Determination (LCD): Botulinum Toxin Type A & 
Type B (L34635). 
 
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). 
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 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.  
You can find this rule in Local Coverage Determination (LCD) Facet Joint Interventions for Pain Management 
L38803. 
 
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 while electric nerve stimulation has been employed to control chronic intractable pain for 
some time, its use in the treatment of motor function disorders, such as multiple sclerosis, is a recent 
innovation, and the medical effectiveness of such therapy has not been verified by scientifically controlled 
studies. Where electric nerve stimulation is employed to treat motor function disorders, no reimbursement may 
be made for the stimulator or for the services related to its implantation since this treatment cannot be 
considered reasonable and necessary. You can find these rules in the National Coverage Determination (NCD) 
Treatment of Motor Function Disorders with Electric Nerve Stimulation 160.2. 
 
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.