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 payment may be made under the prosthetic device benefit for implanted peripheral nerve 
stimulators. Use of this stimulator involves implantation of electrodes around a selected peripheral nerve.  
 
Central Nervous System Stimulators (Dorsal Column and Depth Brain Stimulators) 
The implantation of central nervous system stimulators may be covered as therapies for the relief of chronic 
intractable pain, subject to the following conditions: 
 
1. Types of Implantations 
There are two types of implantations covered by this instruction: 
 Dorsal Column (Spinal Cord) Neurostimulation - The surgical implantation of neurostimulator 
electrodes within the dura mater (endodural) or the percutaneous insertion of electrodes in the epidural 
space is covered. 
 Depth Brain Neurostimulation - The stereotactic implantation of electrodes in the deep brain (e.g., 
thalamus and periaqueductal gray matter) is covered. 
 
2. Conditions for Coverage 
No payment may be made for the implantation of dorsal column or depth brain stimulators or services and 
supplies related to such implantation, unless all of the conditions listed below have been met: 
 The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with 
chronic intractable pain; 
 With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or 
contraindicated for the given patient; 
 Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
 All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be 
available; and 
 Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determination for Electrical Nerve Stimulators, 160.7.  
 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 HBOT is covered for diabetic wounds of the lower extremities in patients who meet the 
following three criteria: 
a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; 
b. Patient has a wound classified as Wagner grade III or higher; and 
c. Patient has failed an adequate course of standard wound therapy. 
You can find this rule in the Center for Medicare Services (CMS) Publication 100-03, Medicare National 
Coverage Determination (NCD) Manual, Section 20.29. 
 
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 sacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-
frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation 
to determine if an implantable stimulator would be effective and a permanent implantation in appropriate 
candidates. Both the test and the permanent implantation are covered. 
The following limitations for coverage apply to all three indications: 
 Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or 
surgical corrective therapy) and be an appropriate surgical candidate such that implantation with 
anesthesia can occur. 
 Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes 
with peripheral nerve involvement) which are associated with secondary manifestations of the above 
three indications are excluded. 
 Patient must have had a successful test stimulation in order to support subsequent implantation. Before 
a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement 
through test stimulation. Improvement is measured through voiding diaries. 
 Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical 
results of the implant procedure can be properly evaluated. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determination for Sacral Nerve Stimulation for Urinary Incontinence, 
230.18.  
 
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 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. 
 
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or 
design feature of a given type of foot. 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.
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, 3.3.2.1. 
 
The rules state that all skilled nursing facility (SNF) Part A inpatient services are paid under a prospective 
payment system (PPS). This involves payment based on a Health Insurance Prospective Payment System 
(HIPPS) rate code. Under the new Patient-Driven Payment Model (PDPM), which is effective for services 
provided on or after 10/1/2019, the HIPPS code is structured differently, as a result of there being five case-mix 
adjusted rate components under the revised model. The first position represents the Physical and Occupational 
Therapy case-mix group. The second position represents the Speech-Language Pathology (SLP) case-mix 
group. The third character represents the nursing case-mix group. The fourth character represents the Non-
Therapy Ancillary (NTA) case- mix group. The fifth character represents the assessment indicator code. You 
can find this information in the Centers for Medicare and Medicaid Service (CMS), Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Sections 10, 30, and 120. 
 
The rules say the Resident Assessment Instrument (RAI) consists of three basic components: The Minimum 
Data Set (MDS) Version 3.0, the Care Area Assessment (CAA) process and the RAI Utilization Guidelines. 
The utilization of the three components of the RAI yields information about a residents functional status, 
strengths, weaknesses, and preferences, as well as offering guidance on further assessment once problems have 
been identified. 
 Federal regulations require the Registered Nurse (RN) assessment coordinator to sign and thereby certify that 
the assessment is complete. Steps for Assessment: 
1. Verify that all items on this assessment are complete. 
2. Verify that Item Z0400 (Signature of Persons Completing the Assessment) contains attestation for all MDS 
sections. 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment 
Instrument (RAI) Version 3.0 Manual, Chapters 1 and 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.
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 covers a lung cancer screening counseling and shared decision-making visit, and 
for appropriate beneficiaries, annual screening for lung cancer with LDCT, as an additional preventive service 
benefit under the Medicare program when certain criteria are met. For purposes of Medicare coverage of lung 
cancer screening with LDCT, beneficiaries must meet all of the following eligibility criteria: 
 
1. Age of 50-77 years, 
2. Absence of signs/symptoms of lung cancer, 
3. Tobacco smoking history of at least 20 pack-years (one pack-year equates to smoking one pack/day for one 
year, 
4. Current smoker or former smoker who quit within the last 15 years. 
5.  Receive an order for lung cancer screening with LDCT 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Lung Cancer Screening with 
Low Dose Computed Tomography (LDCT) (210.14). 
 
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 20% coinsurance for Medicare Part B Prescription Drugs. You can find 
this information on pages 76 and 77 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 no provider or supplier shall receive payment for services furnished to a Medicare beneficiary 
unless the provider or supplier is enrolled in the Medicare program. Further, it is essential that each provider 
and supplier enroll with the appropriate Medicare fee-for-service contractor. Chapter 15 - Medicare Enrollment 
 
A provider is defined and generally means a hospital, critical access hospital, skilled nursing facility, 
comprehensive outpatient rehabilitation facility, home health agency or hospice, that has in effect an agreement 
to participate in Medicare; or a clinic, rehabilitation agency, or public health agency that has in effect a similar 
agreement but only to furnish outpatient physical therapy or speech pathology services; or a community mental 
health center that has in effect a similar agreement but only to furnish partial hospitalization services. You can 
find this rule at 42 CFR 400.202. 
 
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 currently, these procedures are considered non-covered due to the fact that current peer-reviewed 
literature does not support the efficacy of the services. Claims will be denied as "not proven effective." 
 
The Stretta procedure is an endoluminal treatment for GERD in which radiofrequency energy is delivered to 
smooth muscle of the lower esophageal sphincter (LES). A flexible catheter equipped with special needle 
electrodes for precise energy delivery is placed by mouth into the esophagus and carefully controlled 
radiofrequency energy is then delivered to the LES and gastric cardia, creating thermal lesions. The 
manufacturer maintains that the changes that occur immediately, and over time, result in a "tighter" LES and a 
less compliant gastric cardia. Additionally, the interruption of nerve pathways in the LES area is believed to 
reduce the incidence of inappropriate LES "relaxations," leading to an improvement in GERD symptoms. 
Substantial peer-reviewed evidence to fully support these assumptions remains to be published. 
 
The Bard EndoCinch Suturing System and the Plicator are intended for use in endoscopic placement of 
suture(s) in the soft tissue of the esophagus and stomach and for approximation of tissue for treatment of 
symptomatic gastroesophageal reflux disease. 
 
Clinical data from various studies are emerging. At this time, open-label studies or patient registries with short 
term follow-ups are the dominant source of data. The overwhelming preponderance of reviewers remains 
equivocal in their support and have called for randomized controlled trials with long-term follow-ups. In the 
absence of evidence from such studies, and in the absence of wide acceptance, endoscopic treatments for 
GERD are not proven effective. Therefore, they are not reimbursable even though some of the treatments may 
have associated CPT or OPPS codes. You can find this rule in Local Coverage Determination (LCD) 
Endoscopic Treatment of GERD L34659. 
 
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 Physician Fee Schedule Status Indicator N means that this is a non-covered service. 
These codes are carried on the Healthcare Common Procedure Coding System (HCPCS) tape as noncovered 
services. There will be no payment amounts for these codes. You can find this information in the Medicare 
Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
The rules say that when a physician furnishes a Medicare beneficiary a covered visit at the same place and on 
the same occasion as a noncovered preventive medicine service (CPT codes 99381-99397), consider the 
covered visit to be provided in lieu of a part of the preventive medicine service of equal value to the visit. A 
preventive medicine service (CPT codes 99381-99397) is a noncovered service. The physician may charge the 
beneficiary, as a charge for the noncovered remainder of the service, the amount by which the physicians 
current established charge for the preventive medicine service exceeds his/her current established charge for the 
covered visit. Pay for the covered visit based on the lesser of the fee schedule amount or the physicians actual 
charge for the visit. The physician is not required to give the beneficiary written advance notice of noncoverage 
of the part of the visit that constitutes a routine preventive visit. However, the physician is responsible for 
notifying the patient in advance of his/her liability for the charges for services that are not medically necessary 
to treat the illness or injury. You can find this information in the Medicare Claims Processing Manual, Chapter 
12, Section 30.6.2. 
 
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. 
 
If subsequent courses of treatment are given, the medical records must support the effectiveness of the prior 
treatment and must clearly establish reduction of patient symptomatology and medication usage. This 
documentation must be submitted upon request. Claims submitted without requested supporting evidence in the 
medical record will be denied as being not medically necessary. 
 
Repeat treatments are considered medically necessary for patients being treated for osteoarthritis of the knee, 
who meet both of the following criteria: 
 Significant improvement in knee pain and known improvement in functional capacity resulted from the 
previous series of injections which has been documented in the record; and 
 At least six (6) months have elapsed since the last injection in the series. 
You can find this rule in the Local Coverage Article (LCA): Billing and Coding-Intraarticular Knee Injections 
of Hyaluronan (A56157). 
 
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 ambulance services are only covered when the patient's clinical condition is such that other 
methods of transport are contraindicated. You can find this rule at 42 CFR Section 410.40(e). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that non-emergency transportation by ambulance is appropriate if it is documented that the 
members condition is such that other means of transportation could endanger the persons health and that 
transportation by ambulance is medically required. You can find this information on page 64 of the Plan's 2022 
Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules 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 (NCCI) Policy 
Manual for Medicare Services, Chapter I(A). 
 
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 pay for an inpatient rehabilitation facility (IRF) admission when the services 
are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary 
approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one 
therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must 
need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. 
This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at 
least five days per week. The patient does not need to be expected to achieve complete independence in self-
care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a 
rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 
412.622. 
 
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.