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 ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure (BiPAP) device is 
made based upon the specifics of each persons medical condition. There must be enough detailed information 
in the medical record to justify the treatment selected. Ventilators fall under the Frequent and Substantial 
Servicing (FSS) payment category, and payment policy requirements preclude FSS payment for devices used to 
deliver continuous and/or intermittent positive airway pressure, regardless of the illness treated by the device. 
This means that products currently classified as Healthcare Common Procedure Coding System (HCPCS) code 
E0465, E0466, or E0467 when used to provide continuous positive airway pressure (CPAP) or BiPAP (with or 
without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS 
payment category and will be denied as not reasonable and necessary. You can find this rule in the Local 
Coverage Determination (LCD): Respiratory Assist Devices (L33800). 
 
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 the patient must have a significant health problem in the form of a neuromusculoskeletal 
condition necessitating treatment and the manipulative services rendered must have a direct therapeutic 
relationship to the patients condition and provide reasonable expectation of recovery or improvement of 
function. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam. 
Most spinal joint problems fall into the following categories: 
 
    Acute subluxation - A patients condition is considered acute when the patient is being treated for a new 
injury identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is 
expected to be an improvement in or arrest of progression of the patients condition. 
    Chronic subluxation - A patients condition is considered chronic when it is not expected to significantly 
improve or be resolved with further treatment (as is the case with an acute condition) but where the continued 
therapy can be expected to result in some functional improvement. Once the clinical status has remained stable 
for a given condition, without expectation of additional objective clinical improvements, further manipulative 
treatment is considered maintenance therapy and is not covered. 
 
An acute exacerbation is a temporary but marked deterioration of the patients condition that is causing 
significant interference with activities of daily living (ADLs) due to an acute flare-up of the previously treated 
condition. The patients clinical record must specify the date of occurrence, nature of the onset or other 
pertinent factors that would support the medical necessity of treatment. As with an acute injury, treatment 
should result in improvement or arrest of the deterioration within a reasonable period of time. 
 
A. Maintenance Therapy 
 
Maintenance therapy includes services that attempt to avert disease, facilitate health and extend and improve 
the quality of life; or therapy that is implemented to preserve or avoid deterioration of a chronic condition. The 
treatment is considered maintenance therapy when additional clinical advancement cannot logically be 
expected from constant ongoing care and the chiropractic treatment becomes auxiliary rather than curative in 
nature.  
You can find this information in the Local Coverage Determination (LCD) Chiropractic Services L37387. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 $120 copayment for radiological diagnostic services, not including x-
rays. It is noted that ultrasounds fall into this benefit category. You can find this information on page 70 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 percutaneous minimally invasive fusion/stabilization of the sacroiliac joint (SIJ) for the 
treatment of back pain is indicated for the treatment of SIJ pain for patients with low back/buttock pain who 
meet all of the following criteria: 
 
a) Have undergone and failed a minimum six months of intensive non-operative treatment that must include 
medication optimization, activity modification, and active physical therapy; 
b) Patients report of non-radiating, unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized 
over the posterior SIJ, and consistent with SIJ pain; 
c) Localized tenderness with palpation of the posterior SIJ in the absence of tenderness of similar severity 
elsewhere (e.g. greater trochanter, lumbar spine, coccyx) and other obvious sources for their pain do not exist; 
d) Positive response to the thigh thrust test OR compression test AND 2 of the following additional provocative 
tests: Gaenslens test, Distraction test, Patricks sign; 
e) Absence of generalized pain behavior (e.g. somatoform disorder) or generalized pain disorders (e.g. 
fibromyalgia); 
f) Diagnostic imaging studies that include ALL of the following: 
 
1. Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of destructive lesions 
(e.g. tumor, infection) or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ 
fusion; 
2. Imaging of the ipsilateral hip (plain radiographs) to rule out osteoarthritis; 
3. 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; 
 
g) At least 75 percent reduction of pain for the expected duration of the anesthetic used following an image-
guided, contrast-enhanced SIJ injection on two separate occasions 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous minimally 
invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain (L36000). 
 If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 for the items addressed, the reasonable and necessary criteria, based on Social Security Act 
Section 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical 
necessity. L5781 describes a complete device that is an addition to a lower limb prosthesis. The primary 
function of the vacuum pump is to suspend the prosthetic limb. Additionally, products coded L5781 provide 
residual limb volume management and moisture evacuation. The pump mechanism evacuates air and 
accumulated moisture between the limb and socket walls. The pump mechanism can be actuated by either 
external power and/or mechanical system(s). You can find this rule in the Local Coverage Determination and 
Article for Lower Limb Prostheses, L33787 and 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. 
 
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 (less than 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5), based on symptom 
onset, and documented by advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake)  
       b. Symptomatic (ONE): 
           i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
equals 8)  
           ii. Non-hospitalized with moderate to severe pain (NRS or VAS equals5) despite optimal non-surgical 
management (NSM) (10) (ONE): 
               1. Worsening pain 
               2. Stable to improved pain (but NRS or VAS still equals 5) (with equals 2 of the following): 
                   A. Progression of vertebral body height loss 
                   B. Greater than 25 percent vertebral body height reduction 
                   C. Kyphotic deformity 
                   D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
greater than 17 
       c. Continuum of care (10) (Both)  
           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 
 
            2. Exclusion criteria (Can have NONE of the following): 
       d. a. Absolute contraindication 
        i. Current back pain is not primarily due to the identified acute or 
        subacute VCF(s). 
        ii. Osteomyelitis, discitis, active systemic or surgical site infection         iii. Pregnancy 
        b. Relative contraindication 
        i. Greater than three vertebral fractures per procedure 
        ii. Allergy to bone cement or opacification agents 
        iii. Uncorrected coagulopathy 
        iv. Spinal instability 
        v. Myelopathy from the fracture 
        vi. Neurologic deficit 
        vii. Neural impingement 
        viii. Fracture retropulsion/canal compromise 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L33569). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
  
  pulmonary disease (COPD). You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure (biPAP) device is 
made based upon the specifics of each persons medical condition. There must be enough detailed information 
in the medical record to justify the treatment selected. Ventilators fall under the Frequent and Substantial 
Servicing (FSS) payment category, and payment policy requirements preclude FSS payment for devices used to 
deliver continuous and/or intermittent positive airway pressure, regardless of the illness treated by the device. 
This means that products currently classified as Healthcare Common Procedure Coding System (HCPCS) code 
E0465, E0466, or E0467 when used to provide continuous positive airway pressure (CPAP) or BiPAP (with or 
without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS 
payment category and will be denied as not reasonable and necessary. You can find this rule in the Local 
Coverage Determination (LCD): Respiratory Assist Devices (L33800). 
 
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 in Chapter 3 on pages 39 to 40 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 say that a group 2 multiple power option power wheelchair (PWC) (K0841, K0842, K0843) is 
covered if all of the basic coverage criteria for a PWC are met and if:  
A. Criterion 1 or 2 is met; and 
B. Criteria 3 and 4 are met.  
1. The beneficiary meets coverage criteria for a power tilt and recline seating system and 
the system is being used on the wheelchair. 
2. The beneficiary uses a ventilator which is mounted on the wheelchair. 
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified 
medical professional, such as a physical therapist (PT) or occupational therapist (OT), or 
practitioner who has specific training and experience in rehabilitation wheelchair 
evaluations and that documents the medical necessity for the wheelchair and its special 
features. The PT, OT, or practitioner may have no financial relationship with the 
supplier. 
4. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and 
Assistive Technology Society of North America (RESNA) certified Assistive 
Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-
person involvement in the wheelchair selection for the beneficiary. 
If a Group 2 Multiple Power Option PWC is provided and if criterion (A) or (B) is not met, it will be denied as 
not reasonable and necessary. 
If the PWC base is not covered, then related accessories will be denied. 
 
You can find this information in the Local Coverage Determination (LCD) for Power Mobility Devices 
(L33789). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure (biPAP) device is 
made based upon the specifics of each persons medical condition. There must be enough detailed information 
in the medical record to justify the treatment selected. Ventilators fall under the Frequent and Substantial 
Servicing (FSS) payment category, and payment policy requirements preclude FSS payment for devices used to 
deliver continuous and/or intermittent positive airway pressure, regardless of the illness treated by the device. 
This means that products currently classified as Healthcare Common Procedure Coding System (HCPCS) code 
E0465, E0466, or E0467 when used to provide continuous positive airway pressure (CPAP) or BiPAP (with or 
without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS 
payment category and will be denied as not reasonable and necessary. You can find this rule in the Local 
Coverage Determination (LCD): Respiratory Assist Devices (L33800). 
 
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 can be used for 
most dental treatments, and dental services are covered at a $0 copayment until the maximum allowable benefit 
of $3,000 is reached annually. However, the allowance cannot be used on implants or cosmetic services and 
any type of implant and all related services are excluded. You can find this information in Chapter 4 on pages 
81 to 83 and pages 88 to 89 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 state that PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP) is covered in patients with 
osteoporotic VCF when BOTH the following: 
 
    Inclusion criteria (ALL are required): 
        Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5), based on symptom onset, and 
documented by advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake) (1-
3,10,25,27) 
        Symptomatic (ONE): 
            Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score = 
8) (4-7) 
            Non-hospitalized with moderate to severe pain (NRS or VAS =5) despite optimal non-surgical 
management (NSM) (10) (ONE): 
                Worsening pain 
                Stable to improved pain (but NRS or VAS still =5) (with = 2 of the following): 
                    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 
 
You can find this information in Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) L38201. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.