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 does not include 
collection and application of autologous blood concentrate product and a bone graft. You can find this 
information in the 2023 Dental Benefits Chart.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 supplemental coverage is provided for hearing aids. This benefit includes coverage 
for hearing aids only when purchased from the Plans select hearing aid provider. You can find this information 
on page 64 of the Plans 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 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 say that treatment for lower urinary tract systems (LUTS)/benign prostatic hyperplasia (BPH) will be 
considered reasonable and necessary when performed once in patients with the following: 
 
Indications including all of the following: 
Age 80 
Prostate volume of 30-150 cc by transrectal ultrasound (TRUS) 
Persistent moderate to severe symptoms despite maximal medical management including all of the following: 
International Prostate Symptom Score (IPSS) 12 
Maximum urinary flow rate (Qmax) of 15 mL/s (voided volume greater than 125 cc) 
Failure, contraindication or intolerance to at least three months of conventional medical therapy for LUTS/BPH 
(e.g., alpha blocker, finasteride/dutasteride) 
Only treatment using a Food and Drug Administration (FDA) approved/cleared device will be considered 
reasonable and necessary. 
Limitations 
 
The following are considered not reasonable and necessary: 
Body mass index  42kg/m2 
Known or suspected prostate cancer or a prostate specific antigen (PSA) >10 ng/mL unless the patient has had 
a negative prostate biopsy within the last 6 months. 
Bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum 
Active urinary tract or systemic infection 
Treatment for chronic prostatitis 
Diagnosis of urethral stricture, meatal stenosis, or bladder neck contracture 
Damaged external urinary sphincter 
Known allergy to device materials 
Inability to safely stop anticoagulants or antiplatelet agents preoperatively. 
 
Summary of Evidence 
Background BPH is a histological diagnosis defined as an increased number of epithelial and stromal cells in the prostate. It 
is common in men over the age of 40, and the incidence increases with age. In the United States, 8 million men 
older than 50 years old suffer from BPH. Many cases are asymptomatic; however, symptoms may occur with 
prostate enlargement and compression of the urethra leading to bothersome LUTS, including voiding 
symptoms such as (hesitancy, weak stream, straining, prolonged voiding), and storage symptoms (frequency, 
urgency, and nocturia). Serious consequences can develop, including acute urinary retention, recurrent urinary 
tract infections, bladder stones and diverticula, hematuria, and renal insufficiency. The condition impacts 
quality of life (QOL) and is a substantial economic burden with a United States estimated annual expenditure 
over 4 billion dollars. 
 
You can find these rules in the Local Coverage Determination (LCD) Fluid Jet System Treatment for 
LUTS/BPH L38367. 
 
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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. You can find this rule in the Local 
Coverage Determination (LCD): MolDX: Molecular Diagnostic Tests (MDT) (L36021). 
 
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. While the Plan offers a Point-of-Service option for coverage of 
certain out-of-network services, this benefit does not apply to medically necessary medical or surgical services 
furnished in a 
physicians office. You can find this information on pages 31 to 32 and 101 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 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.  
 
The rules say that the Physician Fee Schedule Status Indicator I means that this code is not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment for, these services.  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 23, 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 an initial thermal radiofrequency ablation (RFA) of cervical, thoracic, or lumbar 
paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients 
who have had at least two medically reasonable and necessary diagnostic medical branch blocks (MBBs), with 
each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of 
relief being consistent with the agent used). For each covered spinal region, no more than two radiofrequency 
sessions will be reimbursed per rolling 12 months. 
 
One to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or 
four-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 (i.e., 
MBB, IA, facet cyst ruptures, and RFA ablations) that are performed during the same day. You can find this 
information in Local Coverage Determination (LCD): 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 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 X means that these codes represent an item or 
service that is not in the statutory definition of "physician services" for fee schedule payment purposes. No 
relative value units (RVUs) or payment amounts are shown for these codes, and no payment may be made 
under the physician fee schedule. 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 sacroiliac joint injections (SIJI) will be considered medically reasonable and necessary 
when there is documentation of at least three positive findings with provocative maneuvers: FABER, Gaenslen, 
Thigh Thrust or Posterior Shear, SI Compression, SI Distraction and Yeoman Tests. You can find this rule in 
Local Coverage Determination:  Sacroiliac Joint Injections and Procedures (L39455). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that The Families First Coronavirus Response Act waives cost-sharing under Medicare Part B 
(coinsurance and deductible amounts) for Medicare patients who got COVID-19 testing-related services. These 
services are medical visits under the HCPCS E/M categories described below when outpatient providers, 
physicians, or other providers and suppliers who bill Medicare for Part B services order or administer COVID-
19 lab tests regardless of the HCPCS codes they use to report the tests. Physicians/non-physician practitioners, 
hospital outpatient departments, rural health clinics, federally qualified health centers, critical access hospitals 
and Method II critical access hospitals should use the CS modifier on applicable claim lines. You can find this 
rule in the Centers for Medicare and Medicaid Services, MLN Matters, Medicare Fee-for-Service Response to 
the Public Health Emergency on COVID-19, MLN SE20011. 
 
The rules say that clinical diagnostic laboratories will be paid for clinical diagnostic lab tests (CDLTs) making 
use of high throughput technologies for the detection of SARS-CoV-2 or the diagnosis of the virus that causes 
COVID-19. per test. Beginning January 1, 2021, the revised payment amounts will be effectuated as follows: 
  CMS will establish a payment amount of $75 per test for CDLTs making use of high throughput 
technologies for the detection of SARS-CoV-2 or the diagnosis of the virus that causes COVID-19, as 
identified by HCPCS codes U0003 and U0004. 
  CMS will establish a new add-on payment of $25 as identified by HCPCS code U0005. As required by the 
HCPCS code U0005 descriptor, this add-on payment may be billed with either HCPCS code U0003 or HCPCS 
code U0004 when the applicable test is completed within 2 calendar days of the specimen being collected. 
 
You can find this rule in the Centers for Medicare and Medicaid Services Ruling CMS-2020-1-R2. 
 
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 standard walker (E0143) and related accessories are covered if all of the following criteria 
(1-3) are met: 
 
1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADL) in the home. A mobility limitation is one that: 
a. Prevents the beneficiary from accomplishing the MRADL entirely, or 
b. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the 
attempts to perform the MRADL, or 
c. Prevents the beneficiary from completing the MRADL within a reasonable time frame; and 
 
2. The beneficiary is able to safely use the walker; and 
3. The functional mobility deficit can be sufficiently resolved with use of a walker. 
 
You can find this rule in the Local Coverage Determination (LCD) - Walkers (L33791). 
 
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 follow-up polysomnography or sleep studies are not routinely indicated for patients treated 
with continuous positive airway pressure (CPAP) whose symptoms continue to be resolved with CPAP 
treatment. Follow-up polysomnography studies may be indicated, however, for the following conditions: 
 
    - After substantial weight loss has occurred in patients on CPAP for treatment of sleep-related breathing 
disorders to ascertain whether CPAP is still needed at the previously titrated pressure; 
    - After substantial weight gain has occurred in patients previously treated with CPAP successfully, who are 
again symptomatic despite the continued use of CPAP, to ascertain whether pressure adjustments are needed; 
or 
    - When clinical response is insufficient or when symptoms return despite a good initial response to treatment 
with CPAP. 
 
You can find this information in the Local Coverage Determination (LCD) for Outpatient Sleep Studies 
(L35050). 
 
The rules say that if a positive airway pressure (PAP) device is replaced during the 5 year reasonable useful 
lifetime (RUL) because of loss, theft, or irreparable damage due to a specific incident, there is no requirement 
for a new clinical evaluation, sleep test, or trial period. 
 
The rules also say if a PAP device is replaced following the 5 year RUL, there must be an in-person evaluation 
by their treating practitioner that documents that the beneficiary continues to use and benefit from the PAP 
device. There is no requirement for a new sleep test or trial period. 
 
You can find this information in the Local Coverage Determination (LCD) for Positive Airway Pressure (PAP) 
Devices for the Treatment of Obstructive Sleep Apnea (L33718). 
 
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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 48 one-way trips each year. You can find this information on page 113 of the Plans 2023 
Evidence of Coverage (EOC).