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 only 
those items and services specifically listed in your Plan contract. Complete denture - maxillary (D5110) and 
complete denture - mandibular (D5120) are not covered under the Plans dental benefits. You can find this 
information on pages 73-75 and 77-82 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 SIJ Denervation (also called Radiofrequency Ablation or RFA) is not considered reasonable 
and necessary. You can find this rule at the Medicare Local Coverage Determination (LCD) L39464: Sacroiliac 
Joint Injections and Procedures. 
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). 
 
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 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 50 percent of the Plan-allowed amount in all service settings for out-of-
network services. Note: All genetic testing requires prior authorization. You can find this information in 
Chapter 4 on page 98 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that payment maybe made for a one-time ultrasound screening for AAA for beneficiaries who 
meet the following criteria: (i) receives a referral for such an ultrasound screening from the beneficiarys 
attending physician, physician assistant, nurse practitioner or clinical nurse specialist; (ii) receives such 
ultrasound screening from a provider or supplier who is authorized to provide covered ultrasound diagnostic 
services; (iii) has not been previously furnished such an ultrasound screening under the Medicare Program; and 
(vi) is included in at least one of the following risk categories-- (I) has a family history of abdominal aortic 
aneurysm; (II) is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or (III) is a 
beneficiary who manifests other risk factors in a beneficiary category recommended for screening by the 
United States Preventive Services Task Force regarding AAA, as specified by the Secretary of Health and 
Human Services, through the national coverage determination process. You can find this information in the 
Medicare Claims Processing Manual Chapter 18 Preventive and Screening Services Section 110.2.  
 
The rules say that personal history codes may be used in conjunction with follow-up codes and family history 
codes may be used in conjunction with screening codes to explain the need for a test or procedure. History 
codes are also acceptable on any medical record regardless of the reason for visit. A history of an illness, even 
if no longer present, is important information that may alter the type of treatment ordered. The reason for the 
encounter (for example, screening or counseling) should be sequenced first and the appropriate personal and/or 
family history code(s) should be assigned as additional diagnos(es). You can find this in the International 
Classification of Disease (ICD)-10-CM Official Guidelines for Coding and Reporting Section C.21.C.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 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 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 indicates that the 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 
International Classification of Diseases (ICD)-10-CM Official Guidelines for Coding and Reporting, Section 
12. Excludes Notes. 
 
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 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 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.  
 
An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each 
other. For example, code F45.8, Other somatoform disorders, has an Excludes1 note for "sleep related teeth 
grinding (G47.63)," because "teeth grinding" is an inclusion term under F45.8. Only one of these two codes 
should be assigned for teeth grinding. However psychogenic dysmenorrhea is also an inclusion term under 
F45.8, and a patient could have both this condition and sleep related teeth grinding. In this case, the two 
conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 
together. 
 
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. 
 
 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 1 to 2 levels, either unilateral or bilateral, are allowed per session per spine region. The 
need for a 3 or 4-level procedure bilaterally may be considered under unique circumstances and with sufficient 
documentation of medical necessity on appeal. A session is a time period, which includes all procedures that 
are performed during the same day. You can find this information in the Local Coverage Determination (LCD): 
Facet Joint Interventions for Pain Management (L38765). 
 
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 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 (less than 6 wks) or subacute (6-12 wks)18,28,42 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 1-3,8,26,43 and 
            The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or 
Visual Analog Scale [VAS] pain score = 8)4-7 or is non-hospitalized with moderate to severe pain (NRS or 
VAS equals 5) despite optimal non-surgical management (NSM) with one of the following: 
                Worsening Pain or 
                Stable to improved pain (but NRS or VAS equals 5) when 2 or more of the following are present: 
                    Progression of vertebral body height loss 
                    Greater than 25% vertebral body height reduction 
                    Kyphotic deformity 
                    Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] 
greater than 17) 
 
Continuum of care: All patients presenting with vertebral compression fractures (VCF) should be referred for 
evaluation of bone mineral density and osteoporosis education for subsequent treatment as indicated and 
instructed to take part in an osteoporosis prevention/treatment program. 
 
   2. Malignant Vertebral Fractures 
 
Osteolytic vertebral metastasis or myeloma with severe back pain related to a destruction of the vertebral body, not involving the major part of the cortical bone. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L34976). 
 
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 percutaneous vertebroplasty (PVP) 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 percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA) will be considered 
reasonable and necessary when ALL of the following criteria are met: 
- Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1 
L5), based on symptom onset, and documented by advanced imaging demonstrating bone marrow edema on 
magnetic resonance imaging (MRI) or bone-scan/Single-Photon Emission Computerized Tomography 
(SPECT)/computed tomography (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 
- greater than 25% vertebral body height reduction 
- Kyphotic deformity 
- Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] greater than 17) 
 
You can find this information in the Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L34976). 
 
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). 
 
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). 
o 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 Vertebral Compression Fracture 
(VCF) (T1- L5), based on symptom onset, and documented by advanced imaging 
demonstrating bone marrow edema on imaging uptake and 
 The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating 
Scale [NRS] or Visual Analog Scale [VAS] pain score  8) or is non-hospitalized with 
moderate to severe pain (NRS or VAS 5) despite optimal non-surgical management 
(NSM)8
 with one of the following: 
 Worsening Pain or 
 Stable to improved pain (but NRS or VAS 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 information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD): 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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) 
procedures will be considered medically reasonable and necessary for the following indications: 
 
    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 (less than 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 = 8)4-7 or is non-hospitalized with moderate to severe pain (NRS or 
VAS equals 5) despite optimal non-surgical management (NSM)8 with one of the following: 
                Worsening Pain or 
                Stable to improved pain (but NRS or VAS =5) when 2 or more of the following are present: 
                    Progression of vertebral body height loss 
                    Greater than 25 percent vertebral body height reduction 
                    Kyphotic deformity 
                    Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] 
greater than 17) 
 
You can find this information in Medicare's Local Coverage Determination (LCD): 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.
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 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.  
 
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). 
 
 
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 crowns 
but is subject to a 20% coinsurance. You can find this information on pages 59-60 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 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 20% coinsurance for Medicare Part B drugs. You can find this 
information on page 75 of the Plan's 2022 Evidence of Coverage (EOC). 
 
The Plan contract also says that enrollees must pay a $25 copayment for each specialist office visit. You can 
find this information on pages 82-83 of the Plans 2022 EOC.