Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
requested item or service but is limited to once every 60 floating months. You can find this information in 
Chapter 4 on pages 97 to 100 of the Plan's 2023 Evidence of Coverage (EOC) and in the Plans dental 
Medicare quick reference guide.
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 crown - 
porcelain/ceramic (D2740) but is limited to restorative - D2542-D2544; D2642-D2644; D2662-D2664; D2710-
D2794 - Cap (crown) or partial crown called an onlay  made of metal, porcelain/ceramic, porcelain fused to 
metal, or titanium. Made outside the mouth and then placed into the mouth. - Only 3 of any (D2542-D2544, 
D2642-D2644, D2662-D2664, D2710-D2794, D6205-D6252, D6545-D6615, D6710-D6783, D6790, D6791, 
D6792, D6794) every 12 months; 1 per tooth every 84 months; requires extensive loss of tooth structure due to 
decay or fracture; requires at least 50% remaining bone support. You can find this information on page 4 and 
14 of the Plans 2023 Dental benefit details 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 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 24 one-way trips with each one-way trip not exceeding 50 miles of driving distance. You can find 
this information on pages 4-75 to 4-76 of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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. 
 
PVA (Percutaneous Vertebroplasty (PVP) or Kyphoplasty (PKP)) is covered in patients with BOTH the 
following: 
1. Inclusion criteria (ALL are required): 
a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5) based on symptom 
onset, and documented by advanced imaging (bone marrow edema on MRI or bone-
scan/SPECT/CT uptake) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score  8) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS 5) despite optimal non-
surgical management (NSM)
 
(ONE): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still 5) (with  2 of the following): 
A. Progression of vertebral body height loss 
B. > 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) >17 c. Continuum of care
 
(Both) 
i. All patients presenting with VCF should be referred for evaluation of 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 or 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 
Local Coverage Determination: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral 
Compression Fracture (VCF) (L34106). 
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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules state that quantitative calcium scoring is not a covered service and will be denied as not medically 
necessary. Calcium scoring reported in isolation is considered a screening service. When performed in 
association with CT angiography, there is neither separate nor additional included reimbursement for the 
calcium scoring. You can find this information in the Local Coverage Determination (LCD) for Cardiac 
Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) (L33559). 
 
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 does not include 
crowns under code D2740, core buildups, or removal of residual tooth roots. You can find this information on 
page 41 of the Plans 2023 Evidence of Coverage (EOC) and the patient charge schedule.
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 Effective January 1, 2011, section 153b of the Medicare Improvement for Patients and 
Providers Act (MIPPA) requires that all drugs and biologicals that are used in the treatment of End Stage Renal 
Disease (ESRD) be provided and billed by the ESRD facility. When a drug or biological is billed by providers 
other than the ESRD facility and the drug or biological furnished is designated as a drug or biological that is 
included in the ESRD PPS (renal dialysis service), the claim will be rejected or denied. In the event that a drug 
or biological generally used in the treatment of ESRD was furnished to an ESRD beneficiary for reasons other 
than for the treatment of ESRD, the provider may report the drug on the claim with modifier AY and receive 
separate payment. For claims with dates of service on or after July 1, 2013, when these drugs are administered 
through the dialysate the provider must append the modifier JE (Administered via Dialysate). You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-104, Chapter 8, 
Section 60.2.1.1. 
 
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 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 
preventive and comprehensive dental services along with specific dental codes that are listed on the dental 
benefit chart. The surgical placement of implant body is covered by the Plan's dental benefits but is limited to 2 
every 12 months and 1 per tooth per 84 months. The Implant/abutment supported removable denture is not 
covered by the Plan's dental benefits. Services or supplies for which no valid dental need can be demonstrated 
and services or supplies that do not meet accepted standards of dental practice are excluded from the Plan's 
dental benefits. You can find this information on pages 4 to 16 of the Plans 2023 Dental Benefit Details 
Handbook.
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 PCD coded as E0652, is covered for the treatment of lymphedema extending onto the 
chest, trunk and/or abdomen when all of the following are met: 
 The beneficiary has lymphedema of an extremity as defined above 
 The coverage criteria for an E0650 or E0651 are met 
 The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the 
limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed 
to improve with a four-week trial. (See below for trial guidelines.) 
A PCD coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen that does not 
meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable 
and necessary. You can find this rule at Local Coverage Determination (LCD) L33829: Pneumatic 
Compression Devices (eff. 6/7/22). 
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 the first injection directly and significantly provided improvement of the condition being 
treated, may be considered medically reasonable and necessary when the medical record documents at least 
50% of sustained improvement in pain relief and/or improvement in function measured from baseline using 
SAME scale for at least three months. If a patient fails to respond well to the initial ESI, a repeat ESI after 14 
days can be performed using a different approach, level and/or medication, if appropriate, with the rationale 
and medical necessity for the second ESI documented in the medical record.  
 
You can find these rules in Local Coverage Determination (LCD) Epidural Steroid Injections for Pain 
Management (L36920).  
 
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 spinal electrical osteogenesis stimulator (E0748) is covered only if any of the following 
criteria are met: 
1. Failed spinal fusion where a minimum of nine months has elapsed since the last surgery, or 
2. Following a multilevel spinal fusion surgery (see Appendices section), or 
3. Following spinal fusion surgery where there is a history of a previously failed spinal fusion at 
the same site. 
A spinal electrical osteogenesis stimulator will be denied as not medically necessary if none of the criteria 
above are met. You can find this rule at Local Coverage Determination (LCD) L33796: Osteogenesis 
Stimulators (eff. 7/2/23). 
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 Genomic Sequential Analysis Panel will be considered reasonable and necessary in the 
evaluation of blood or bone marrow samples in the following clinical circumstances: 
 
    Patients with clinical signs or symptoms of myelodysplastic syndromes (MDS) or 
myelodysplastic/myeloproliferative overlap syndromes (MDS/MPN), in whom clinical, laboratory, and 
pathologic assessment are nondiagnostic. 
    Newly diagnosed MDS or MDS/MPN patients either 
        stratified by the IPSS or IPSS-R as intermediate risk, or 
        in MDS with ringed sideroblasts/RARS.  
 
 Limitations 
 
    Repeat Genomic Sequential Analysis Panel testing is not reasonable and necessary in MDS after initial 
diagnosis and risk stratification. 
 
You can find this information in the Local Coverage Determination (LCD) Genomic Sequence Analysis Panels 
in the Treatment of Hematolymphoid Diseases L37606. 
 
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 therapeutic sacroiliac joint injections (SIJI) will be considered medically reasonable and 
necessary for patients who meet ALL the following criteria:  
1. The patient must meet the criteria of Covered Indications for SIJI, AND 
2. The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI was 
measured by the SAME pain scale at baseline. The measurements of pain were taken pre-injection on the day 
of the diagnostic SIJ injection, post-intervention on the day of the diagnostic injection, and the days following 
the diagnostic SIJ injection to substantiate and corroborate consistent pain relief for the duration of the local 
anesthetic and/or steroid used, AND 
3. Subsequent therapeutic SIJI are considered medically reasonable and necessary when the subsequent SIJI are 
provided at the same anatomic site as therapeutic SIJI, AND the therapeutic SIJI produced at least consistent 
50% pain relief or at least 50% consistent improvement in the ability to perform previously painful movements 
and activities of daily living (ADLs) for at least three (3) months from the proximate therapeutic SIJI procedure 
and compared to baseline measurements for ADLS and painful movements or pain relief using the same pain 
scale AND 
4. The SI joint injections must be performed under computed tomography (CT) or fluoroscopy image guidance 
with contrast, except ultrasound guidance may be considered reasonable and necessary when there is a 
documented contrast allergy or pregnancy, since the accuracy with ultrasound guidance is inferior to 
fluoroscopic guidance. 
 
You can find this information in the Local Coverage Determination (LCD): 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 a group 3 power wheelchair (PWC) with Single Power Option (such as code K0856) is 
covered if: 
A. All of the basic coverage criteria for a PWC are met; and 
B. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital 
skeletal deformity; and 
C. Criterion 1 or 2 is met; and 
D. Criteria 3 and 4 are met. 
1. The beneficiary requires a drive control interface other than a hand or chin-operated standard 
proportional joystick. 
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 Rehabilitation Engineering and 
Assistive Technology Society of North America (RESNA)-certified Assistive Technology 
Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in 
the wheelchair selection for the beneficiary.  
If the base power wheelchair is not covered, all related accessories will also be denied.  
 
You can find these rules in 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.