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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for a person who meets the following criteria: 1. The person must have a personal mobility deficit; 2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, grooming and bathing in customary locations within the home; 3. The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 4. The person must be capable of safely operating the PMD. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). The rules say that all of the following basic criteria (A-C) must be met for a power mobility device (K0856) or a push-rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are listed below. A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that: Prevents the beneficiary from accomplishing an MRADL entirely, or Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or Prevents the beneficiary from completing an MRADL within a reasonable time frame. B. The beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. C. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function. An optimally configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories. You can find this information in Medicare's Local Coverage Determination (LCD): Power Mobility Devices (L33789).
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 indications for surgical treatment of varicose veins and sclerotherapy are: 
 
1. A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive 
therapy, and avoidance of prolonged immobility where appropriate, has failed, AND 
2. The patient is symptomatic and has one, or more, of the following: 
 
a. Pain, aching, cramping, burning, itching and/or swelling during activity or after prolonged standing severe 
enough to impair mobility 
b. Recurrent episodes of superficial phlebitis 
c. Non-healing skin ulceration 
d. Bleeding from a varicosity 
e. Stasis dermatitis 
f. Refractory dependent edema  
 
3. The treatment of spider veins/telangiectasis will be considered medically necessary only if there is associated 
hemorrhage. 
 
You can find this rule in the Local Coverage Determination (LCD) - Treatment of Varicose Veins of the Lower 
Extremities (L34536) - Effective September 30, 2021. 
 
The rules say that for coverage of endovenous radiofrequency ablation or laser ablation, in addition to the 
above, the patient's anatomy and clinical condition must be amenable to the proposed treatment, including ALL 
of the following: 
 
1. Absence of aneurysm in the target segment. 
2. Maximum vein diameter of 20 mm for ERFA or 30 mm for laser ablation. 
3. Absence of thrombosis or vein tortuosity, which would impair catheter advancement. 
4. The absence of significant peripheral arterial diseases. 
 
You can find this rule in the Local Coverage Determination (LCD) - Treatment of Varicose Veins of the Lower 
Extremities (L34536) - Effective September 30, 2021. 
 
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 term interface in the code narrative and definitions describes the mechanism for controlling the movement of a power wheelchair. Examples of interfaces include, but are not limited to, joystick, sip and puff, chin control, head control, etc. The term controller describes the microprocessor and other related electronics that receive and interpret input from the joystick (or other drive control interface) and convert that input into power output which controls speed and direction. A high-power wire harness connects the controller to the motor and gears. An expandable controller can accommodate one or more of the following additional functions:
 Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.)
 Non-proportional input devices (e.g., sip and puff, head array, etc.)  Operate 3 or more powered seating actuators through the drive control.
 A separate display (i.e., for alternate control devices)
 Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control)
 An attendant control
You can find this rule in the Local Coverage Article for Wheelchair Options/Accessories, A52504.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay $375 copayment for outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information in chapter 4 on page 104 of the Plan's 2022 Evidence of Coverage 
(EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 pages 39-44 of the Plan's 2022 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
 
  
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 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 $375 copayment for outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information in chapter 4 on pages 104-105 of the Plan's 2022 Evidence of 
Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $350 copayment for ambulance services. You can find this information in 
chapter 4 on pages 69-70 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a second diagnostic facet procedure is considered medically necessary to confirm validity 
of the initial diagnostic facet procedure when administered at the same level. The second diagnostic procedure 
may only be performed a minimum of 2 weeks after the initial diagnostic procedure. Clinical circumstances 
that necessitate an exception to the two-week duration may be considered on an individual basis and must be 
clearly documented in the medical record. 
 
For the first diagnostic facet joint procedure: 
a. For the first diagnostic facet joint procedure to be considered medically reasonable and necessary, the 
patient must meet the criteria outlined under indications for facet joint interventions. 
b. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and 
necessary in patients who meet all the following criteria: 
i. The patient meets the criteria for the first diagnostic procedure; and 
ii. 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 information in Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L35936). 
 
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 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. 
 
You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L33930). 
 
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 of lower urinary tract symptoms/benign prostatic hyperplasia will be considered 
medically reasonable and necessary when performed ONCE in patients with the following: 
 
1. Indications including ALL of the following: 
 
a. Age 80 or younger 
b. Prostate volume of 30-150cc by transrectal ultrasound (TRUS) 
c. Persistent moderate to severe symptoms despite maximal medical management including ALL of the 
following: 
 
i. International Prostate Symptom Score (IPSS) 124 
ii. Maximum urinary flow rate (Qmax) of 15 mL/s4 (voided volume greater than 125 cc) 
iii. Failure, contraindication or intolerance to at least three months of conventional medical therapy for 
LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
 
2. Only treatment using a Food and Drug Administration (FDA) approved/cleared device will be considered 
medically reasonable and necessary 
 
You can find this rule in the Local Coverage Determination (LCD) - Transurethral Waterjet Ablation of the 
Prostate (L38712) - Effective December 27, 2020. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay $50 copayment for outpatient diagnostic tests and therapeutic services and 
supplies. You can find this information in chapter 4 on pages 90-91 of the Plan's 2022 Evidence of Coverage 
(EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that it generally would not be considered medically reasonable and necessary for treatment with 
ESI to extend beyond 12 months. Frequent continuation of epidural steroid injections over 12 months may 
trigger a focused medical review. Use beyond twelve months requires the following: 
a. Pain is severe enough to cause a significant degree of functional disability or vocational 
disability. 
b. ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in 
function (using same scale as baseline). 
c. Rationale for the continuation of ESIs including but not limited to patient is high-risk surgical 
candidates, the patient does not desire surgery, recurrence of pain in the same location relieved 
with ESIs for at least three months 
d. The primary care provider must be notified regarding continuation of procedures and prolonged 
repeat steroid use. 
You can find this information in Local Coverage Determination (LCD): Epidural Steroid Injections for Pain 
Management (L38994). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay 20% coinsurance for durable medical equipment and related supplies. 
You can find this information in chapter 4 on page 61 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say 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 home health services under a plan of care are paid based on a 30-day period of care. HHAs 
submit an NOA at the beginning of an admission and then submit one claim for each 30-day period of care. 
The location where services were provided must always be reported along with the first visit reported on the 
claim. You can find this rule 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 state that when a patient is admitted for observation care and then is discharged on a different 
calendar date, the physician shall report Initial Observation Care, from CPT code range 99218  99220, and 
CPT observation care discharge CPT code 99217. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 12, Section 30.6.8. 
 
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.