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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for the following indications: 
 
   1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have not 
responded to non-surgical medical management (e.g. narcotic and/or non- narcotic medication, physical 
therapy modalities) with and without methods of immobility (e.g. rest, bracing). 
       - Both PVP and PVA will be considered reasonable and necessary when ALL of the following criteria are 
met: 
           -- Acute (<6 wks) or subacute (6-12 wks) osteoporotic VCF (T1 L5), based on symptom onset, and 
documented by advanced imaging demonstrating bone marrow edema on MRI or bone-scan/SPECT/CT uptake 
and 
           -- The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or 
Visual Analog Scale [VAS] pain score greater than or equal to 8) or is non-hospitalized with moderate to 
severe pain (NRS or VAS greater than or equal to 5) despite optimal non-surgical management (NSM) with 
one of the following: 
               - Worsening Pain or 
               - Stable to improved pain (but NRS or VAS greater than or equal to 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) 
 
You can find this rule in the Local Coverage Determination (LCD) for Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L35130). 
 
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 does not pay for over-the-counter (OTC) items, including non-prescription drugs. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 40.2.  
 
The rules say that starting January 15, most people with a health plan can go online, or to a pharmacy or store 
to purchase an at-home over-the-counter COVID-19 diagnostic test authorized by the U.S. Food and Drug 
Administration (FDA) at no cost, either through reimbursement or free of charge through their insurance. The 
test will either be free directly at the point of sale, if the health plan provides for direct coverage, or by 
reimbursement if you are charged for your test. Medicare Advantage plans may cover this as a supplemental 
benefit starting January 15, 2022, or prior depending on the specific benefits offered by the Plan. You can find 
this information on the Centers for Medicare and Medicaid Services website at  https://www.cms.gov/how-to-
get-your-at-home-OTC-COVID-19-test-for-free. 
 
The rules say that starting April 4, 2022, and until the end of the COVID-19 public health emergency (PHE), 
people with Medicare Part B can get up to eight free over-the-counter tests for the month of April any time 
before April 30, and can then get another set of eight free over-the-counter tests during each subsequent 
calendar month through the end of the COVID-19 PHE. If you are in a Medicare Advantage Plan, you will not 
get this benefit through your plan, but will get it like you would if you were not enrolled in the plan. You might 
need to show your red, white and blue Medicare card to get your free over-the-counter COVID-19 tests (even if 
you have another card for a Medicare Advantage Plan or Medicare Part D Plan.) You can find this information 
online at https://www.cms.gov/newsroom/fact-sheets/medicare-covers-over-counter-covid-19-tests. 
 
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. You can find this information 
on pages 84-93 of the Plans 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiary's potential functional abilities. Potential functional ability is based on the reasonable 
expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to: 

1. The beneficiary's past history (including prior prosthetic use if applicable); and 
2. The beneficiary's current condition including the status of the residual limb and the nature of other 
medical problems; and 
3. The beneficiary's desire to ambulate. 
Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels: 
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. You can find this rule at Local 
Coverage Determination (LCD) L33787: Lower Limb Prostheses (eff. 1/1/20). 
 
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 instrumental assessment of swallowing is indicated for either the evaluation of a patient with 
dysphagia who has a pharyngeal dysfunction or who is at risk for aspiration. Concerns have been expressed 
that the use of such services in a mobile setting lacks evidence of medical effectiveness. Questions of patient 
safety have yet to be resolved for these types of procedures to be performed in a skilled nursing facility, 
nursing home, or home environment, thus requiring physician presence during the procedure in such settings. 
 
This procedure will be reimbursed only when medically necessary and performed in one of the following: 
 Office (11) 
 Inpatient hospital (21) 
 Outpatient hospital (22) 
 Emergency room hospital (23) 
 Comprehensive inpatient rehabilitation facility (61) 
 Comprehensive outpatient rehabilitation facility (62) 
 
You can find this rule in the Local Coverage Determination for Barium Swallow Studies, Modified, L35433.  
 
The rules say that procedures and examinations which are not covered under the portable x-ray provision 
include the following: 
 Procedures involving fluoroscopy; 
 Procedures involving the use of contrast media;  Procedures requiring the administration of a substance to the patient or injection of a substance into the 
patient and/or special manipulation of the patient; 
 Procedures which require special medical skill or knowledge possessed by a doctor of medicine or 
doctor of osteopathy or which require that medical judgment be exercised; 
 Procedures requiring special technical competency and/or special equipment or materials; 
 Routine screening procedures; and 
 Procedures which are not of a diagnostic nature. 
 
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 80.4.4. 
 
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 for all adult manual wheelchairs (E1161, K0001, K0002, K0003, K0004, K0005, K0006, 
K0007, K0008, K0009), payment for seat widths and/or seat depths of 15-19 inches is included in the payment 
for the base code. These seat dimensions should not be billed separately. Codes E2201, E2202, E2203, E2204 
describe seat widths and/or depths of 20 inches or more for manual wheelchairs. 
 
For power wheelchairs, there is no separate billing for nonstandard seat frame dimensions (width, depth, or 
height) with the following exceptions: For Group 3 and 4 power wheelchairs, with a sling/solid seat/back, the 
following items may be billed separately using code K0108: 
 
    a. For Standard Duty, seat width and/or depth greater than 20 inches; 
 
    b. For Heavy Duty, seat width and/or depth greater than 22 inches; 
 
    c. For Very Heavy Duty, seat width and/or depth greater than 24 inches; 
 
    d. For Extra Heavy Duty, no separate billing 
 
For Group 3 and 4 PWCs with a sling/solid seat/back, the following items may be billed separately using code 
K0108: 
 
    a. For Standard Duty, back width greater than 20 inches; 
 
    b. For Heavy Duty, back width greater than 22 inches; 
 
    c. For Very Heavy Duty, back width greater than 24 inches;     d. For Extra Heavy Duty, no separate billing 
 
Code K0108 may not be billed for nonstandard dimensions of a power tilt and/or recline seating system 
(E1002, E1003, E1004, E1005, E1006, E1007, E1008). The definition of those codes includes any frame width 
and depth. A pneumatic tire (E2211, E2214) is a rubber tire which is used in conjunction with a separate tube 
(E2212, E2215) which is filled with air. A flat free insert (E2213) is a removable ring of firm material that is 
placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured. 
This code may not be used for a foam filled tire. You can find these rules in the Local Coverage Article 
Wheelchair Options/Accessories - Policy Article A52504. 
 
The rules say that a solid support base for a seat cushion is a rigid piece of plastic or other material which is 
attached with hardware to the seat frame of a wheelchair in place of a sling seat. A cushion is placed on top of 
the support base. Use code E2231 for a solid support base that is used with a manual wheelchair. A solid 
support base is included in the allowance for the power wheelchair codes. There should be no separate billing 
with power wheelchairs. You can find this rule in the Local Coverage Article Wheelchair Seating - Policy 
Article A52505. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, 30.2.2. 
 
The rules say Medicare Physician's Fee Schedule Database (MPFSDB) Status Code of P is defined as 
Bundled/excluded codes. There are no Relative Value Units (RVUs), and no payment amounts for these 
services. No separate payment is made for them under the fee schedule. If the item or service is covered as 
incident to a physician service and is provided on the same day as a physician service, payment for it is bundled 
into the payment for the physician service to which it is incident. 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 30.2.2. 
 
The rules say that the Physician Fee Schedule Status Indicator I means that this code is not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment for, these services. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, 30.2.2. 
 
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.
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 specific 
dental procedure codes included in the dental benefits chart. Pontic - porcelain fused to high noble metal 
(D6240) is not covered by the Plan's dental benefits. You can find this information on pages 95-97 of the Plans 
2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 the 
intraoral - periapical each additional radiographic image (D0230) but is limited to one procedure code per 
calendar year. You can find this information on page 92 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will pay for durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers 
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment 
already available to an enrollee. You can find these rules in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(C). 
 
The rules say that the supplier who provides oxygen equipment for the first month must continue to provide 
any necessary oxygen equipment and all related items and services through the 36-month rental period, unless 
one of the following exceptions is met:  
 Beneficiary relocates temporarily or permanently outside of the suppliers service area  
 Beneficiary elects to obtain oxygen from a different supplier 
 Individual case exceptions made by CMS or DME MAC  
 Item becomes subject to competitive bidding  
 
Providing different oxygen equipment/modalities (e.g., concentrator [stationary or portable], gaseous, liquid, 
trans-filling equipment) is not permitted unless one of the following requirements is met:  
 Supplier replaces the equipment with the same or equivalent item  
 Treating practitioners orders different equipment  
 Beneficiary chooses to receive an upgrade and signs an Advance Beneficiary Notice of Non-coverage (ABN) 
 CMS or the DME MAC determines that a change in equipment is warranted 
 
You can find this information in the Article - Oxygen and Oxygen Equipment - Policy Article (A52514). 
 
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 an electronic interface used to control lights or other electrical devices is non-covered 
because it is not primarily medical in nature. You can find this rule in Local Coverage Article Wheelchair 
Options/Accessories - Policy Article A52504. 
 
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 a fluid, pneumatic, or electronic/microprocessor knee (L5830) is covered for beneficiaries 
whose functional level is 3 or above. 
 
Other knee systems (L5616) 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 this information 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.