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 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 
preventive and comprehensive coverage. Core buildup (D2950) is excluded from this benefit. This benefit also 
covers a limited oral evaluation (D0140), but is limited to one per every six months. This benefit also includes 
a periapical first x-ray (D0220), but is limited to one per three years. You can find this information on pages 
61-62 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 a patient must have at least 1 of the following: 
Radiographic or clinical evidence of instability due to any 1 of the following: 
     a. Congenital deformities, 
     b. Trauma, 
     c. Fractures, 
     d. Chronic degenerative conditions, 
     e. Tumor, 
     f. Infection, 
     g. Erosive conditions, 
     h. Space-occupying lesions, or 
     i. Iatrogenic causes, including expected instability as a consequence of another medically necessary spine 
procedure. 
If more than 1 level is fused under this indication, the record must reflect that each fused level is affected by 1 
of the above conditions. 
You can find these rules in Local Coverage Determination (LCD) Lumbar Spinal Fusion (L37848). 
 
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 plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1.  
 
The rules say that health plans, physicians, hospitals, and other health care providers must comply with the 
Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding 
Guidelines. 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 10.  
 
The rules state that a type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An 
Excludes1 note indicates that the code excluded should never be used at the same time as the code above the 
Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form 
versus an acquired form of the same condition.  You can find this information in the ICD-10-CM Official Guidelines for Coding and Reporting, Section I. 
Conventions, general coding guidelines and chapter specific guidelines. 
 
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, Section 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 state that the codes describing bundled payments made to Opioid Treatment Programs (OTPs) are 
HCPCS codes G2067-G2075. There are add-on codes described by HCPCS codes G2076-G2080, HCPCS 
codes G2215, G2216, and G1028. Only an entity enrolled with Medicare as an OTP can bill these codes. You 
can find this rule in the Centers for Medicare and Medicaid Services Internet Only Manual, Chapter 39, Section 
30.6. 
 
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 to correct visual impairment caused by dermatochalasis, including symptomatic redundant 
skin weighing down on the upper eyelashes (i.e., pseudoptosis) and surgically induced dermatochalasis after 
ptosis repair. 
 
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 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. 
  
The use of hyperbaric oxygen (HBO) therapy is covered as adjunctive therapy only after there are no 
measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in 
addition to standard wound care. Standard wound care in patients with diabetic wounds includes assessment of 
a patients vascular status and correction of any vascular problems in the affected limb if possible, optimization 
of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, 
maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-
loading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard 
wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds 
must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO 
therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of 
treatment. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, Medicare National Coverage Determination for Hyperbaric Oxygen Therapy, 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 state that APOE genetic testing is unlikely to impact therapeutic decision-making, directly impact 
treatment, outcome and/or clinical management in the care of the beneficiary and will be denied as not 
medically necessary. You can find this information in Local Coverage Determination (LCD): Molecular 
Pathology Procedures (L35000). 
 
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 Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL of the following criteria: 
 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional 
deficit measured on pain or disability scale; AND 
2. Pain that has been present for a minimum of 3 months with documented failure to respond to 
noninvasive conservative care management (as tolerated); AND 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused 
by facet joint synovial cyst); AND 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain 
the source of the patients pain, including but not limited to fracture, tumor, infection, or 
significant deformity. 
 
Diagnostic Facet Joint Injection Procedures (IA or MBB): 
1. An initial diagnostic facet joint procedure will be considered medically reasonable and necessary when 
the patient meets the criteria outlined under the indications for facet joint interventions. 
2. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and 
necessary in patients who meet BOTH of the following criteria: 
 The patient meets the criteria for the first diagnostic procedure; AND 
 After the first diagnostic facet joint procedure, there must be a consistent positive response of at 
least 80% relief of primary (index) pain (with the duration of relief being consistent with the 
agent used). 
 
You can find this rule in the Local Coverage Determination for Facet Joint Interventions for Pain Management, 
L34892.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 receive care from a provider that is eligible to participate in Medicare, except 
for emergency care. Enrollees may choose to receive care from either in-network or out-of-network providers. 
If the enrollee uses an out-of-network provider, the share of costs for covered items and services may be 
higher. You can find this information in Chapter 3 on pages 31 to 32 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 repeat ESI when the first injection directly and significantly provided improvement of the 
condition being treated may be considered medically reasonable and necessary when the medical record 
documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from 
baseline using same scale for at least three months. If a patient fails to respond well to the initial ESI, a repeat 
ESI after 14 days can be performed, using a different approach, level and/or medication if appropriate, with the 
rationale and medical necessity for the second ESI documented in the medical record. You can find this rule in 
the Local Coverage Determination (LCD) L38994: Epidural Steroid Injections for Pain Management. 
 
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 Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. You can find this rule at 42 CFR Section 422.111(a) and (b). 
 
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-preferred brands are not covered. You can find this information in Chapter 4 on 
page 39 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 state that Medicare covers a pneumatic compression device (PCD) when medically necessary for the 
treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 
You can find this in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
03, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.6. 
 
The rules say that PCDs coded as E0650, E0651, E0652 are used only in the treatment of lymphedema or CVI 
with venous stasis ulcers. Reimbursement for these items is based upon the criteria in the following sections. 
PCD coded as E0675 is used in the treatment of PAD. Claims for E0675 will be denied as not reasonable and 
necessary as outlined below. 
 
A PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with 
chronic and severe lymphedema when all of the following three requirements are met: 
 
The beneficiary has a diagnosis of lymphedema as defined above, and 
The beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence of 
at least one of the following clinical findings: 
Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
Papillomatosis cutis lymphostatica, 
Deformity of elephantiasis, 
Skin breakdown with persisting lymphorrhea, 
Detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a 
likely etiology, and 
In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other 
clinical treatment over the course of a required four-week trial. (See below for trial guidelines.) 
A PCD coded as E0650 or E0651 used to treat lymphedema that does not meet all of the requirements above is 
not eligible for reimbursement. Claims will be denied as not reasonable and necessary. 
 
 
 A PCD coded as E0650 or E0651 used to treat edema from causes other than lymphedema is not eligible for 
reimbursement. Claims will be denied as not reasonable and necessary. You can find these rules in the Local 
Coverage Determination (LCD) Pneumatic Compression Devices L33829. 
 
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 Left Prefrontal rTMS of the brain is considered medically necessary for use in an adult who 
meets all four of the following criteria: 
 
1. Has a confirmed diagnosis of severe major depressive disorder (MDD) single or recurrent episode; and 
 
2. One or more of the following: 
 
Resistance to treatment with psychopharmacologic agents as evidenced by a lack of a clinically significant 
response to two trials of psychopharmacologic agents in the current depressive episode from at least two 
different agent classes. 
At least one of the treatment trials must have been administered at an adequate course of mono- or poly-drug 
therapy; or 
 
Inability to tolerate psychopharmacologic agents as evidenced by four trials of psychopharmacologic agents 
from at least two different agent classes, with distinct side effects; or 
 
History of response to rTMS in a previous depressive episode; or 
If patient is currently receiving electro-convulsive therapy, rTMS may be considered reasonable and necessary 
as a less invasive treatment option. 
Resistance to treatment is defined by a failure to achieve a 50% reduction in depressive symptoms, in 
accordance with objective measures such as PHQ-9 and/or HAM-D, from a pharmacologic trial where the 
medication is administered at the recommended adult dose, per the FDA label, for a period of not less than 6 
weeks. 
 
Psychopharmacologic agent side effects will be considered intolerable, when those side effect are of a nature 
where they are not expected to diminish or resolve with continued administration of the drug 
 
AND 
 3. A trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an adequate 
frequency and duration without significant improvement in depressive symptoms as documented by 
standardized rating scales that reliably measure depressive symptoms. 
 
AND 
 
4. The order for treatment (or retreatment) is written by a psychiatrist (MD or DO) who has examined the 
patient and reviewed the record. The psychiatrist will have experience in administering TMS therapy. The 
treatment shall be given under direct supervision of this psychiatrist (physician present in the area and 
immediately available but does not necessarily personally provide the treatment). 
 
You can find this information in the Local Coverage Determination (LCD) Transcranial Magnetic Stimulation 
(TMS) L36469. 
 
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 Medicare will consider invasive procedures (only with the techniques outlined in this local 
coverage determination (LCD) and under the conditions described) as reasonable and necessary when 
documentation in the medical record includes a history, physical examination, clinical, etiology, anatomic, 
pathophysiology clinical classification, and a venous duplex scan documenting reflux (greater than 500 msec). 
 
Liquid sclerotherapy will be considered reasonable and necessary to treat telangiectasias, reticular veins, small 
varicose veins (3-6 mm), residual or recurrent veins following endovenous ablation or surgery, and perforator 
veins. Treatment of telangiectasias and reticular veins (C1) (less than 3 mm) is considered reasonable and 
necessary with documentation of spontaneous and/or traumatic venous hemorrhage, OR for dilated intradermal 
veins in the elderly judged to be a substantial risk for hemorrhage with minimal trauma, OR near an active or 
healed ulcer if judged to contribute to local venous hypertension. You can find this rule in the Local Coverage 
Determination (LCD) L39121: Treatment of Varicose Veins of the Lower Extremities. 
 
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.