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 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). 
 
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 also says that we must end your membership in the plan if you become incarcerated (go to prison). 
You can find this information on pages 202-203 in the Plan's 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. 
 
Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of 
chronic pain in patients who meet ALL 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* 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
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 rule in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L38801). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
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 the 
requested item or service but is limited to one procedure every five plan years. You can find this information in 
Chapter 4 on page 68 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 percutaneous vertebral augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients with BOTH the following: 
1. Inclusion criteria (ALL are required): 
   a. Acute (fewer than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture 
(VCF) (T1  L5), based on symptom onset, and documented by advanced imaging (bone marrow edema on 
magnetic resonance imaging (MRI) or bone-scan/ single-photon emission computerized tomography 
(SPECT)/computed tomography (CT) uptake) 
   b. Symptomatic (ONE): 
      i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
greater than or equal to 8) 
      ii. Non-hospitalized with moderate to severe pain (NRS or VAS fewer than or equal to 5) despite optimal 
non-surgical management (NSM) (ONE): 
         1. Worsening pain 
         2. Stable to improved pain (but NRS or VAS still fewer than or equal to 5) (with fewer than or 
equal to 2 of the following): 
            A. Progression of vertebral body height loss 
            B. Less than 25 percent vertebral body height reduction 
            C. Kyphotic deformity 
            D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
greater than 17 
   c. Continuum of care (Both)  
      i. All patients presenting with VCF should be referred for evaluation of bone mineral density (BMD) and 
osteoporosis education for subsequent treatment as indicated. 
      ii. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment 
program. 
2. Exclusion criteria (Can have NONE of the following):   
   a. Absolute contraindication 
      i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
      ii. Osteomyelitis, discitis, active systemic or surgical site infection 
      iii. Pregnancy 
   b. Relative contraindication 
      I. Greater than three vertebral fractures per procedure 
      II. Allergy to bone cement or opacification agents       III. Uncorrected coagulopathy 
      IV. Spinal instability 
      V. Myelopathy from the fracture 
      VI. Neurologic deficit 
      VII. Neural impingement 
      VIII. Fracture retropulsion/canal compromise 
 
You can find this information in the Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L33569). 
 
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 Centers for Medicare & Medicaid Services (CMS) has determined that Percutaneous Image-Guided 
Lumbar Decompression (PILD) will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED) for 
beneficiaries with lumbar spinal stenosis (LSS) who are enrolled in an approved clinical study. 
 
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 150.13. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 code E0118 describes a crutch substitute which can be either a device strapped to the lower 
leg with a platform or a device with wheels and a platform the beneficiary propels with their sound limb. You 
can find this rule in the Local Coverage Article Canes and Crutches - Policy Article A52459. 
 
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 Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 12 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 a power tilt and recline seating system (E1006, E1007, E1008) includes: a solid seat platform 
and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; 
fixed or swingaway detachable legrests; fixed or flip-up footplates; two motors and related electronics with or 
without variable speed programmability; a switch control which is independent of the power wheelchair drive 
control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not 
include a headrest. It must have the following features: ability to tilt to greater than or equal to 20 degrees from 
horizontal; ability to recline to greater than or equal to 150 degrees from horizontal; back height of at least 20 
inches; ability to support beneficiary weight of at least 250 pounds. 
 
Coding for a power tilt system (E1002), power recline system (E1003, E1004 and E1005), and tilt/recline 
system (E1006, E1007 and E1008) are all-inclusive. Usage of K0108 to bill for additional heavy duty or 
bariatric features is considered unbundling and is not allowed. 
 
A power tilt seating system or power tilt and recline seating system which does not achieve a tilt of greater than 
or equal to 20 degrees is considered to be the same as the standard seat included in the base wheelchair. Codes 
E1002, E1003, E1004, E1005, E1006, E1007, E1008 must not be used to describe a power tilt seating system 
or a power tilt and recline seating system which does not achieve a tilt of greater than or equal to 20 degrees. 
These seating systems must be coded as A9900 and are not separately payable. 
 
A mechanical shear reduction feature (E1004 and E1007) consists of two separate back panels. As the posterior 
back panel reclines or raises there is a mechanical linkage between the two panels which allows the 
beneficiary's back to stay in contact with the anterior panel without sliding along that panel. You can find these 
rules in the Local Coverage Article Wheelchair Options/Accessories - Policy Article 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 that ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device is made 
based upon the specifics of each persons medical condition. There must be enough detailed information in the 
medical record to justify the treatment selected. 
 
There must be documentation in the beneficiarys medical record about the progress of relevant symptoms and 
beneficiary usage of the device up to that time. Failure of the beneficiary to be consistently using the device for 
an average of four hours per 24 hour period by the time of the re-evaluation (on or after 61 days after initiation 
of therapy) would represent non-compliant utilization for the intended purposes and expectations of benefit of 
this therapy. This would constitute reason for Medicare to deny continued coverage as not reasonable and 
necessary. 
 
You can find this rule in the Local Coverage Determination (LCD): Respiratory Assist Devices (L33800). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will 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 persons 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). 
 
Medicare rules also state that a Group 2 Power Wheelchair is covered if all of the coverage criteria for a Power 
wheelchair are met and if: 
 
1. The beneficiary requires a drive control interface other than a hand or chin-operated standard proportional 
joystick (examples include but are not limited to head control, sip and puff, switch control). 
2. The beneficiary meets coverage criteria for a power tilt or a power recline seating system and the system is 
being used on the wheelchair. 
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical 
professional, such as a physical therapist (PT) or occupational therapist (OT), or practitioner who has specific 
training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for 
the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or practitioner 
may have no financial relationship with the supplier. 
4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional 
(ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection 
for the beneficiary. 
 
This information is found in Medicare 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. 
 
Medicare rules state that 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 greater than 4 mm in diameter 
and if the patient remains symptomatic after a six-week trial of conservative therapy. This information is found 
in Local Coverage Determination (LCD): Varicose Veins of the Lower Extremity, Treatment of 
(L33575). 
 
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 pages 66 to 67 of the Plan's 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 home health (HH) Prospective Payment System (PPS) claims must report a 0023 revenue 
code line which contains a HIPPS code. Home health agencies (HHAs) enter only one 0023 revenue code per 
claim in all cases. 
 
Claims must also report all services provided to the beneficiary within the period of care. All services must be 
billed on one claim for the entire period. The A/B MAC (HHH) will return to the provider TOB 0329 when 
submitted without any visit charges. 
 
Each service must be reported in line item detail. Each service visit (revenue codes 042x, 043x, 044x, 055x, 
056x and 057x) must be reported as a separate line. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 40.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that contractors shall return to provider/return as unprocessable claims for BOS containing 
HCPCS procedure code 36522 along with one of the allowable ICD-10 codes if the claim is missing diagnosis 
code Z00.6 (as 
primary/secondary diagnosis, institutional only), condition code 30 (institutional claims only), clinical trial 
modifier Q0/Q1, and value code D4 with an 8-digit clinical trial identifier number (A/MACs only). You can 
find this rule in the Center for Medicare Services (CMS) Publication 100-04, Medicare Claims Processing 
Manual, Chapter 32, Section 190.3. 
 
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.
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 when billing multiple units of a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code, providers must enter the actual number of units 
provided on the claim form. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.4. 
 
The rules say that the A/B MAC (A) does not count the day of discharge or death for cost report, utilization or 
Pricer purposes unless the admission and discharge day are the same day. You can find this rule in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 3, Section 40.1.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.