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 to be eligible for coverage of a continuous glucose monitor (CGM) and related supplies, the 
beneficiary must meet all of the following initial coverage criteria (1)-(5): 
 
  
  1. The beneficiary has diabetes mellitus; and, 
2. The beneficiarys treating practitioner has concluded that the beneficiary (or beneficiarys caregiver) has 
sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
3. The CGM is prescribed in accordance with its Food and Drug Administration (FDA) indications for use; 
and, 
4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the 
criteria below: 
   A. The beneficiary is insulin-treated; or, 
   B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the 
following: 
      -     Recurrent level 2 hypoglycemic events that persist despite multiple attempts to adjust  
            medication(s) and/or modify the diabetes treatment plan; or, 
      -     A history of one level 3 hypoglycemic event characterized by altered mental and/or physical state 
requiring third-party assistance for treatment of hypoglycemia 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-
approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1)-
(4) above are met. You can find this information in the Local Coverage Determination (LCD): Glucose 
Monitors (L33822). 
 
The rules say that for claims with dates of service on or after January 1, 2023, a non-adjunctive continuous 
glucose monitor (CGM) must be billed with code E2103. Code E2103 describes a non-adjunctive CGM that 
meets the requirements of the durable medical equipment (DME) benefit. To be eligible for Medicare 
reimbursement, all CGM devices billed as E2103 must have received coding verification review by the Pricing, 
Data Analysis and Coding (PDAC) contractor and be listed on the Product Classification List (PCL) for 
Healthcare Common Procedure Coding System (HCPCS) code E2103. You can find this information in the 
Local Coverage Article: Glucose Monitor - Policy Article (A52464). 
 
The rules say that a Freestyle Libre 3 is specified as a product that may be billed using code E2103, effective 
June 15, 2023. You can find this information in the Product Classification List (PCL) on the Pricing Data 
Analysis, and Coding (PDAC) contractor website 
(https://www4.palmettogba.com/pdac_dmecs/searchProductClassificationResults.do?manufacturer=&codeDeci
sion=k0554&productName=&modelNumber=&classification=). 
 
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 Fluid Jet System Treatment is covered when the following criteria are met: 
 
1. Age 80 or less. 
2. Prostate volume of 30-150 cc by transrectal ultrasound. 
3. Persistent moderate to severe symptoms despite maximal medical management. 
4. Maximum urinary flow rate (Qmax) of less than or equal to 15 mL/s (voided volume greater than 125 cc).  
5. Failure, contraindication or intolerance to at least three months of conventional medical therapy. 
6. Only treatment using a Food and Drug Administration approved/cleared device will be considered 
reasonable and necessary. 
 
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 high-sensitivity C-reactive protein (hsCRP) testing will be considered medically reasonable 
and necessary for the assessment of CAD risk when ALL of the following criteria are met:  
 
1. When the hsCRP would add substantial incremental information in the decision making process to 
optimize/maximize current lipid lowering pharmacologic therapy in a patient who has been identified as being 
at intermediate risk for CAD (10-year risk of coronary heart disease between 10-20% per the ATPIII 
Guidelines). This is to be used for a one time decision point and is not intended to monitor therapy. 
2. The test is performed in patients considered to be metabolically stable and without obvious inflammatory or 
infectious conditions. 
 
You can find this rule in the Local Coverage Determination (LCD) - High Sensitivity C-Reactive Protein 
(hsCRP) (L33908). 
 
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 minimally-invasive surgical (MIS) fusion of the sacroiliac joint (SIJ) is considered 
medically necessary when ALL of the following criteria are met: 
 Have moderate to severe pain with functional impairment and pain persists despite a minimum six 
months of intensive nonoperative treatment that must include medication optimization, activity 
modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip 
including a home exercise program 
 Patients report of typically unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized 
over the posterior SIJ, and consistent with SIJ pain 
 A thorough physical examination demonstrating localized tenderness with palpation over the sacral 
sulcus (Fortins point, i.e. at the insertion of the long dorsal ligament inferior to the posterior superior 
iliac spine (PSIS)) in the absence of tenderness of similar severity elsewhere (e.g. greater trochanter, 
lumbar spine, coccyx) and that other obvious sources for their pain do not exist 
 Positive response to a cluster of 3 provocative tests (e.g. thigh thrust test, compression test, Gaenslens 
test, distraction test, Patricks sign, posterior provocation test). 
 Absence of generalized pain behavior (e.g. somatoform disorder) or generalized pain disorders (e.g. 
fibromyalgia) 
 Diagnostic imaging studies that include ALL of the following: 
o Imaging (plain radiographs and a computed tomography (CT) or magnetic resonance imaging 
(MRI)) of the SI joint that excludes the presence of destructive lesions (e.g. tumor, infection), 
fracture, traumatic SIJ instability, or inflammatory arthropathy that would not be properly 
addressed by percutaneous SIJ fusion 
o Imaging of the pelvis (anteroposterior (AP) plain radiograph) to rule out concomitant hip 
pathology 
o 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 
 At least 75 percent reduction of pain for the expected duration of two anesthetics (on separate visits 
each with a different duration of action), and the ability to perform previously painful maneuvers, 
following an image-guided, contrast-enhanced intra-articular SIJ injection. 
 A trial of at least one therapeutic intra-articular SIJ injection (i.e. corticosteroid injection) You can find this information in the Local Coverage Determination (LCD): Minimally-invasive Surgical (MIS) 
Fusion of the Sacroiliac (SI) Joint (L36406). 
 
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 respiratory pathogen panel test is a single service with a single unit of service (UOS=1). A 
respiratory pathogen panel test must not be unbundled and billed as individual components regardless of the 
fact that the panel reports multiple individual pathogens and/or targets. 
You can find this rule in the Local Coverage Article Billing and Coding: Respiratory Pathogen Panel Testing, 
A58575. 
 
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 effective for claims with dates of service on and after December 23, 2009, the Centers for 
Medicare and Medicaid Services (CMS) determines that the evidence is adequate to conclude that outpatient 
intravenous (IV) insulin therapy (OIVIT) does not improve health outcomes in Medicare beneficiaries. 
Therefore, CMS determines that OIVIT is not reasonable and necessary for any indication under section 
1862(a)(1)(A) of the Social Security Act. Services comprising an Outpatient Intravenous Insulin Therapy 
regimen are nationally non-covered under Medicare when furnished pursuant to an OIVIT regimen. You can 
find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 40.7. 
 
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 state that emergency department coding is not appropriate if the site of service is an office or 
outpatient setting or any sight of service other than an emergency department. The emergency department 
codes should only be used if the patient is seen in the emergency department and the services described by the 
HCPCS code definition are provided. The emergency department is defined as an organized hospital-based 
facility for the provision of unscheduled or episodic services to patients who present for immediate medical 
attention. 
 
The rules also say that if the patient is admitted to the hospital by the patients personal physician, then the 
patients regular physician should bill only the appropriate level of the initial hospital care (codes 99221 - 
99223) because all evaluation and management services provided by that physician in conjunction with that 
admission are considered part of the initial hospital care when performed on the same date as the admission. 
The ED physician who saw the patient in the emergency department should bill the appropriate level of the ED 
codes. 
 
You can find these rules in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.11. 
 
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 entitys NPI, when required, is entered in block 33a of the claim form. You can find this 
rule in the Center for Medicare and Medicaid Services (CMS) Internet-Only Manual Publication 100-04, 
Medicare Claims Processing Manual, Chapter 1, Section 30.2.13. 
 
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 since the need for "intermittent" skilled nursing care makes the patient eligible for other 
covered home health services, the Medicare contractor should evaluate each claim involving skilled nursing 
services furnished less frequently than once every 60 days. In such cases, payment should be made only if 
documentation justifies a recurring need for reasonable, necessary, and medically predictable skilled nursing 
services. You can find this rule in the Centers for Medicare & Medicaid Services, Medicare Benefit Policy 
Manual, Chapter 7, Section 40.1.3. 
 
The rules say that if the claim is for a period of care in which there are no skilled home health (HH) visits in the 
billing period, but a policy exception that allows billing for covered services is documented at the home health 
agency (HHA), the HHA enters condition code 54. You can find this information in the Centers for Medicare 
and Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, 
Chapter 10, Section 40.2. 
 
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 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 on page 38 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 ultraviolet light therapy systems are covered for selected patients with generalized 
intractable psoriasis when medical and other factors justify treatment at home rather than at alternative sites, 
e.g., outpatient department of a hospital. You can find this information in the National Coverage Determination 
(NCD) for Durable Medical Equipment Reference List (280.1) 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
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. 
 
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 does not clearly disclose that the Plan determines that a less expensive alternate procedure, service, or 
course of treatment can be performed in place of a proposed treatment to correct a dental condition; and the 
alternate treatment will produce a professionally satisfactory result; then the maximum the Plan will allow will 
be the charge for the less expensive treatment for dental services. The contract does not clearly disclose that the 
intraoral complete series of radiographic images are limited 1 time per 3-year period.
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 for these patients identified in B3, a formal shared decision making encounter must occur 
between the patient and a physician (as defined in Section 1861(r)(1) of the Act or qualified non-physician 
practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in 
1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The 
shared decision making encounter may occur at a separate visit. 
For these patients identified in B4, a formal shared decision making encounter must occur between the patient 
and a physician (as defined in Section 1861(r)(1) of the Act) or qualified non-physician practitioner (meaning a 
physician assistant, nurse practitioner, or clinical nurse specialist as defined in 1861(aa)(5) of the Act) using 
an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making 
encounter may occur at a separate visit. 
 
    Patients who have severe, ischemic, dilated cardiomyopathy but no personal history of sustained VT or 
cardiac arrest due to VF, and have NYHA Class II or III heart failure, LVEF = 35%. Additionally, patients 
must not have: 
        Had a CABG, or PCI with angioplasty and/or stenting, within the past three (3) months; or, 
        Had an MI within the past 40 days; or, 
        Clinical symptoms and findings that would make them a candidate for coronary revascularization. 
    Patients who have severe, non-ischemic, dilated cardiomyopathy but no personal history of cardiac arrest or 
sustained VT or cardiac arrest due to VF, and have NYHA Class II or III heart failure, LVEF = 35%, been on 
optimal medical therapy for at least three (3) months. Additionally, patients must not have: 
        Had a CABG or PCI with angioplasty and/or stenting, within the past three (3) months; or, 
        Had an MI within the past 40 days; or, 
        Clinical symptoms and findings that would make them a candidate for coronary revascularization. 
 
You can find this information in the National Coverage Determination (NCD) Implantable Cardioverter 
Defibrillators (ICDs) 20.4. 
 
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 state that a spinal electrical osteogenesis stimulator (E0748) is covered only if any of the following 
criteria are met: 
 
        Failed spinal fusion where a minimum of nine months has elapsed since the last surgery, or 
        Following a multilevel spinal fusion surgery (see Appendices section), or 
        Following spinal fusion surgery where there is a history of a previously failed spinal fusion at the same 
site. 
 
A spinal electrical osteogenesis stimulator will be denied as not medically necessary if none of the criteria 
above are met. 
 
You can find this information in the Local Coverage Determination (LCD) Osteogenesis Stimulators L33796. 
 
The noninvasive stimulator device is covered only for the following indications: 
 
    Nonunion of long bone fractures; 
    Failed fusion, where a minimum of 9 months has elapsed since the last surgery; 
    Congenital pseudarthroses; 
    Effective July 1, 1996, as an adjunct to spinal fusion surgery for patients at high risk of pseudarthrosis due to 
previously failed spinal fusion at the same site or for those undergoing multiple level fusion. A multiple level 
fusion involves 3 or more vertebrae (e.g., L3-L5, L4-S1, etc). 
    Effective September 15, 1980, nonunion of long bone fractures is considered to exist only after 6 or more 
months have elapsed without healing of the fracture. 
    Effective April 1, 2000, nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical osteogenic stimulator. Serial radiographs must include a minimum of 2 sets of radiographs, each 
including multiple views of the fracture site, separated by a minimum of 90 days. 
 
You can find this information in the National Coverage Determination (NCD) Osteogenic Stimulators 150.2.  
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.