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 consider Total Hip Arthroplasty (THA) medically reasonable and necessary 
when three or more of the following indications are met: 
 
    Advanced joint disease demonstrated by radiographic supported evidence or when conventional radiography 
is not adequate, magnetic resonance imaging (MRI) supported evidence (subchondral cysts, subchondral 
sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis); 
    Pain and functional disability from injury due to trauma or arthritis of the joint; activities of daily living 
(ADLs) are diminished despite completing a plan of care with activity restrictions as is reasonable, assistive 
device use, appropriate weight reduction, flexibility and muscle strengthening exercises with supervised 
physical therapy. 
    History of unsuccessful conservative treatment or non-surgical medical management that is clearly 
documented in the pre-procedure medical record. Non-surgical medical management is usually implemented 
for 3 months or more to assess effectiveness. Conservative treatment, as clinically appropriate for the patients 
current episode of care, typically includes one or more of the following: anti-inflammatory medications, 
analgesics, or therapeutic injections when appropriate, with physical therapy or assist devices. 
    Distinct structural abnormalities 
        Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; 
        Avascular necrosis (osteonecrosis of femoral head); 
        Fracture of the femoral neck; Acetabular fracture; 
        Non-union or failure of previous hip fracture surgery; Mal-union of acetabular or proximal femur fracture; 
    Failed previous Hip Arthroplasty necessitating revision as indicated by the following: 
        Loosening, fracture or mechanical failure of the implant; 
        Instability of one or more components; 
        Recurrent or irreducible dislocation; 
        Infection; 
        Displaced periprosthetic fracture; 
        Clinically significant leg length inequality; 
        Progressive soft tissue or bone reaction or substantial bone loss, 
        Clinically significant audible noise; or 
        Bearing surface wear leading to symptomatic synovitis 
        Other disease or destructive process that renders the hip impaired to the extent to preclude employment or 
functional activities 
 You can find this information in Medicare's Local Coverage Determination (LCD): Lower Extremity Major 
Joint Replacement (Hip and Knee) (L36007). 
 
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 high frequency chest wall oscillation devices (HFCWODs) are covered when they are 
medically necessary for enrollees who have: 
 a. cystic fibrosis; or 
 b. bronchiectasis that has been confirmed by computed tomography (CT) scan; or  
 c. one of these neuromuscular diseases: post-polio, acid maltase deficiency, anterior horn cell diseases, 
multiple sclerosis, quadriplegia, hereditary muscular dystrophy, myotonic disorders, other myopathies, or 
paralysis of the diaphragm.  
 
Medical records must show failure of standard treatments to clear secretions. The rules also say that chronic 
bronchitis and chronic obstructive pulmonary disease (COPD) do not meet criteria for coverage when there is 
no diagnosis of bronchiectasis. You can find these rules in the Medicare Local Coverage Determination (LCD) 
L33785, High Frequency Chest Wall Oscillation Devices. This LCD is effective for services provided on or 
after July 1, 2016. 
 
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 sacroiliac (SI) joint injections would be considered medically reasonable and necessary for 
the diagnosis and/or treatment of chronic low back pain that is considered to be secondary to suspected 
sacroiliac joint dysfunction. Diagnostic and therapeutic injections of the SI joint would not likely be performed 
unless conservative therapy and noninvasive treatments (i.e., rest, physical therapy, NSAIDs, etc.) have failed. 
 
Diagnostic blocks of a sacroiliac joint can be performed to determine whether it is the source of low back pain. 
Arthropathy (joint disease) is diagnosed through a double-comparative local anesthetic blockade of the joint by 
the intra-articular injection of a small volume of local anesthetics of different durations of actions. A positive 
response should demonstrate initial pain relief greater than or equal to (> /=) 75% - 100% and the ability to 
perform previously painful maneuvers. Steroids may be injected in addition to the local anesthetic. 
 
Therapeutic sacroiliac (SI) joint injections of an anesthetic and/or steroid to block the joint for immediate, and 
potentially long lasting, pain relief are considered medically reasonable and necessary if it is determined that 
the SI joint is the source of pain in the lower back. The local anesthetic used for the procedure should not be 
billed. 
 
SI joint arthrography and/or therapeutic injection of an anesthetic/steroid should only be reported when 
imaging confirmation of intra-articular needle positioning with applicable radiological and/or fluoroscopic 
procedures have been performed. 
 
Limitations for Sacroiliac (SI) Joint Injections: 
 
If previous diagnostic or therapeutic SI injections of an anesthetic and/or steroid to block the joint for 
immediate, and potentially long lasting, pain relief have not effectively relieved the pain, further injections 
would not be considered medically necessary. Radiofrequency ablation used for sacro-iliac joint pain is 
considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed 
radiofrequency. You can find this information in Medicare's Local Coverage Determination (LCD): Pain 
Management (L33622). 
 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 Medicare limits reimbursement to items that have sufficient clinical evidence to 
demonstrate that use of the item is safe and effective (see Medicare Program Integrity Manual, Chapter 13). 
Materials that lack sufficient clinical evidence are not recognized as effective and are not considered reasonable 
and necessary. The safety and effectiveness of the following materials have not been established: 
 
1. Balsam of Peru in castor oil 
2. Iodine  other than iodoform gauze packing 
3. Carbon Fiber 
4. Charcoal 
5. Copper 
6. Honey 
7. Silver 
 
The above list is not exhaustive. Any material other than the materials explicitly listed among the reimbursable 
dressing types discussed above (i.e., alginate, collagen, foam, gauze, hydrocolloid, hydrogel, etc.) is not 
considered reasonable and necessary until sufficient credible clinical evidence is available to justify inclusion 
of the material into this policy as a reimbursable surgical dressing component. These rules are found in Local 
Coverage Determination (LCD): Surgical Dressings (L33831). 
 
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 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. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 189 of the Plan's 2022 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 patients medical records must establish medical necessity for a hospital bed due to one of the following 
reasons: 
 
1. The patients condition requires positioning of the body; e.g., to alleviate pain, promote good body 
alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or  
2. The patients condition requires special attachments that cannot be fixed and used on an ordinary bed.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, National Coverage Determinations Manual, Section 280.7(A). 
 
In order to qualify for a semi-electric hospital bed, the patients condition must require frequent change in body 
position and/or there may be an immediate need for a change in body position (i.e., no delay can be tolerated) 
and the patient can operate the controls and cause the adjustments. Exceptions may be made to this last 
requirement in cases of spinal cord injury and brain damaged patients. 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 280.7(D), and Local Coverage Determination (LCD): Hospital Beds And 
Accessories (L33820). 
 
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 single photon emission computed tomograph (SPECT) acquires information on the 
concentration of radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical 
conditions including: 
 
stress fracture. 
spondylosis. 
infection (e.g., discitis). 
tumor (e.g., osteoid osteoma). 
analyze blood flow to an organ, as in the case of myocardial viability. 
differentiate ischemic heart disease from dilated cardiomyopathy. 
Indications and Limitations of Coverage 
Frequency limitations: Medicare Administrative Contractor discretion. 
 
In the case of myocardial viability, FDG positron emission tomography (PET) may be used following a SPECT 
that was found to be inconclusive. However, SPECT may not be used following an inconclusive FDG PET 
performed to evaluate myocardial viability. You can find this information in Medicare's National Coverage 
Determination (NCD): Single Photon Emission Computed Tomography (SPECT) (220.12). 
 
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 the treatments for symptomatic varicose tributaries are either compressive sclerotherapy or 
microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are more than 4 mm in diameter and if the 
patient remains symptomatic after a six-week trial of conservative therapy. The components of the conservative 
therapy include but are not limited to: 
 
1. weight reduction, 
2. a daily exercise plan, 
3. periodic leg elevation, and 
4. the use of graduated compression stockings. 
 
You can find this rule in the Local Coverage Determination (LCD) - Varicose Veins of the Lower Extremity, 
Treatment of (L33575) - Effective November 21, 2019. 
 
The rules say that the conservative therapy must be documented in the medical record. Inability to tolerate 
compressive bandages or stockings and the reason for such intolerance must be documented in the medical 
record. You can find this rule in the Local Coverage Determination (LCD) - Varicose Veins of the Lower 
Extremity, Treatment of (L33575) - Effective November 21, 2019. 
 
The rules say that the patient is considered symptomatic if any of the following signs and symptoms of 
significantly diseased vessels of the lower extremities are documented in the medical record: 
 
1. stasis ulcer of the lower leg, 
2. significant pain and significant edema that interferes with activities of daily living, 
3. bleeding associated with the diseased vessels of the lower extremities, 
4. recurrent episodes of superficial phlebitis, 
5. stasis dermatitis, or 
6. refractory dependent edema. 
 
You can find this rule in the Local Coverage Determination (LCD) - Varicose Veins of the Lower Extremity, 
Treatment of (L33575) - Effective November 21, 2019. 
 
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 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. 
 
The rules say that chemodenervation of the detrusor urinae muscle for the treatment of over activity associated 
with a neurologic condition in adults with an inadequate response to anticholinergic treatment and for the 
treatment of overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and frequency, in 
adults who have an inadequate response to or are intolerant of an anticholinergic medication. 
 
You can find this information in the Local Coverage Determination (LCD): Chemodenervation (L33458). 
 
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 following are considered not medically reasonable and necessary: The routine and 
repetitive monitoring of patients beyond the first cardiac stress test, in the absence of a documented change in 
condition (e.g., new symptoms or progression of existing symptoms). You can find this information in 
Medicare's Local Coverage Determination (LCD): Cardiology Non-emergent Outpatient Stress Testing 
(L35083). 
 
The rules say that in the case of myocardial viability, FDG positron emission tomography (PET) may be used 
following a SPECT that was found to be inconclusive. However, SPECT may not be used following an 
inconclusive FDG PET performed to evaluate myocardial viability. You can find this information in Medicare's 
National Coverage Determination (NCD): Single Photon Emission Computed Tomography (SPECT) (220.12). 
 
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. 
 
Medicare rules state that a total electric hospital bed is not covered. The height adjustment feature is a 
convenience feature. You can find this rule in the Local Coverage Determination (LCD): Hospital Beds and 
Accessories (L33820). 
 
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 knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints 
(L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury 
to or a surgical procedure on the knee(s). Refer to the diagnoses listed in the Groups 2 or 4 ICD-10 Codes in 
the LCD-related Policy Article. 
 
Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is 
ambulatory and has knee instability due to a condition specified in the Group 4 ICD-10 Codes in the LCD-
related Policy Article. 
 
A knee orthosis, Swedish type, prefabricated (L1850) is covered for a beneficiary who is ambulatory and has 
knee instability due to genu recurvatum - hyperextended knee, congenital or acquired (refer to the Group 5 
ICD-10 Codes in the LCD-related Policy Article). 
 
For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by 
examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, 
anterior/posterior Drawer test). 
 
Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and 
necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied 
if only pain or a subjective description of joint instability is documented. 
 
Addition codes are grouped into four (4) categories in relation to knee orthosis base codes. 
 
    Eligible for separate payment 
 
    Not reasonable and necessary 
 
    Not separately payable 
 
    Incompatible 
 
You can find this information in the Local Coverage Determination (LCD) Knee Orthoses L33318.  
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 TMS of the brain for severe MDD, single or recurrent episode, is considered medically 
reasonable and necessary for up to six weeks3,5,6,16-19 when the following criteria are met: 
 
    The patient has a confirmed diagnosis of severe MDD as defined by the current DSM. 
    AND 
    The patient has demonstrated a failure of one or more trials of a pharmacological 
medication and/or demonstrates an intolerance to psychopharmacologic medications as defined in the 
definition section above. 
    AND 
    The order for TMS procedure is written by a psychiatrist (MD or DO), who has examined the patient face to 
face and reviewed the record.20 
 
You can find this information in the Local Coverage Determination (LCD) Transcranial Magnetic Stimulation 
(TMS) in the Treatment of Adults with Major Depressive Disorder L34998. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.