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 minimally invasive surgical (MIS) fusion of the sacroiliac joint (SIJ) utilizing a lateral 
transfixation approach is considered medically necessary when ALL of the following criteria are met: 
 
1. Have moderate to severe pain with functional impairment and pain that persists, despite a minimum 6 
months of intensive nonoperative treatment that must include medication optimization, activity 
modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip 
including a home exercise program 
2. Patients report of typically unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized 
over the posterior SIJ, and consistent with SIJ pain 
3. A thorough physical examination demonstrating localized tenderness with palpation over the sacral 
sulcus (Fortins point, i.e., at the insertion of the long dorsal ligament inferior to the posterior superior 
iliac spine (PSIS)) in the absence of tenderness of similar severity elsewhere (e.g., greater trochanter, 
lumbar spine, coccyx) and that other obvious sources for their pain do not exist 
4. Positive response to a cluster of 3 provocative tests (e.g., thigh thrust test, compression test, Gaenslens 
test, distraction test, Patricks sign, posterior provocation test) 
5. Absence of generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g., 
fibromyalgia) 
6. Diagnostic imaging studies that include ALL of the following: 
a) Imaging (plain radiographs and a computed tomography (CT) or magnetic resonance imaging 
(MRI)) of the SIJ that excludes the presence of destructive lesions (e.g., tumor, infection), 
fracture, traumatic SIJ instability, or inflammatory arthropathy that would not be properly 
addressed by percutaneous SIJ fusion (SIJF) 
b) Imaging of the pelvis (anteroposterior (AP) plain radiograph) to rule out concomitant hip 
pathology 
c) Imaging of the lumbar spine (CT or MRI) to rule out neural compression or other degenerative 
condition that can be causing low back or buttock pain d) At least 75% reduction of pain for the expected duration of 2 anesthetics (on separate visits, 
each with a different duration of action), and the ability to perform previously painful 
maneuvers, following an image-guided, contrast-enhanced intra-articular SIJ injection 
7. A trial of at least 1 therapeutic intra-articular SIJ injection (i.e., corticosteroid injection) 
8. If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
9. The Plan contract says that the Plan covers items and services in accordance with Medicare rules.  
 
You can find these rules in Local Coverage Determination (LCD) Minimally Invasive Surgical (MIS) Fusion of 
the Sacroiliac Joint (SIJ) L39025.
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 definitive UDT is reasonable and necessary for the following circumstances: 
 
-Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT screen; 
-Definitively identify specific drugs in a large family of drugs; 
-Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, -
Meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
-Identify drugs when a definitive concentration of a drug is needed to guide management  
-Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients self- 
report, presentation, medical history, or current prescribed pain medication plan; 
-Rule out an error as the cause of an unexpected presumptive UDT result; 
-Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 
-Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
 
Definitive UDT may be reasonable and necessary based on patient specific indications, including historical use, 
medication response, and clinical assessment, when accurate results are necessary to make clinical decisions. 
The clinicians rationale for the definitive UDT and the tests ordered must be documented in the patients 
medical record. 
 
You can find this information in Local Coverage Determination (LCD): Controlled Substance Monitoring and 
Drugs of Abuse Testing (L36393). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a 50% coinsurance for dental services/out-of-network. You can find this 
information on pages 53-55 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 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 
D5110 or D5120. You can find this information on pages 103-114 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 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 state that an "order" is a communication from the treating physician/practitioner requesting that a 
diagnostic test be performed for a beneficiary. While a physician order is not required to be signed, the 
physician must clearly document, in the medical record, his or her intent that the test be performed. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit 
Policy Manual, Chapter 15, Section 80.6.1. 
 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 the treatments for symptomatic varicose tributaries are either compressive sclerotherapy or 
microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are more than than 4 mm in diameter and if 
the patient remains symptomatic after a six-week trial of conservative therapy. You can find this rule in the 
Local Coverage Determination (LCD) - Varicose Veins of the Lower Extremity, Treatment of (L33575). 
 
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 an 
annual dental allowance amount of $1,000 for covered dental services. You can find this information on page 
76 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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
The rules say that an "order" is a communication from the treating physician/practitioner requesting that a 
diagnostic test be performed for a beneficiary. While a physician order is not required to be signed, the 
physician must clearly document, in the medical record, his or her intent that the test be performed. You can 
find this information in the Medicare Benefit Policy Manual, Chapter 15, Section 80.6. 
 
The rules state that the date of service (DOS) for laboratory tests must be the date the specimen was collected. 
One exception is testing on stored specimens which only changes the DOS if it would be medically 
inappropriate to have collected the sample other than during the hospital procedure for which the patient was 
admitted. There are other exceptions for chemotherapy sensitivity testing on live tissue and advanced 
diagnostic laboratory/molecular pathology tests. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
16, Section 40.8. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 also say observation care is a well-defined set of specific, clinically appropriate services, which 
include ongoing short-term treatment, assessment, and reassessment, that are furnished while a decision is 
being made regarding whether patients will require further treatment as hospital inpatients or if they are able to 
be discharged from the hospital. Observation services are commonly ordered for patients who present to the 
emergency department and who then require a significant period of treatment or monitoring in order to make a 
decision concerning their admission or discharge. You can find this information in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Publication 100-04, 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a 0% or 20% coinsurance for Medicare Part B drugs when administration 
or observation by medical personnel is required and the drugs are administered to you by a network provider. 
Please call Member Services to find out which drugs are provided at the 20% coinsurance. You can find this 
information on pages 80 to 81 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 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 certain 
preventative and comprehensive services which are listed in the Plan's contract. You can find this information 
on pages 54-55 and 90-102 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. 
 
Medicare rules state that a total electric hospital bed is not covered. The height adjustment feature is a 
convenience feature. You can find this rule in the Local Coverage Determination (LCD): Hospital Beds and 
Accessories (L33820). 
 
The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. The term 
room confined means that the patients condition is such that leaving the room is medically contraindicated. 
The accessibility of bathroom facilities generally would not be a factor in this determination. However, 
confinement of a patient to a home in a case where there are no toilet facilities in the home may be equated to 
room confinement. You can find this information in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medical National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
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 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 
D6106. You can find this information on pages 115-136 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 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 state that the following indications are covered for implanted permanent single chamber or dual 
chamber cardiac pacemakers: 
1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and 
2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree 
atrioventricular block. 
 
You can find these rules in National Coverage Determination (NCD) Cardiac Pacemakers: Single Chamber and 
Dual Chamber Permanent Cardiac Pacemakers (20.8.3). 
 
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.