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 custom 
fabricated abutment when certain criteria is met. You can find this information in Chapter 4 on page 62 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 the following are examples of wound care items which are non-covered under the surgical 
dressing benefit because they do not meet the statutory definition of a dressing (not all-inclusive): 
 
Skin sealants or barriers (A6250) 
Wound cleansers (A6260) or irrigating solutions 
Solutions used to moisten gauze (e.g., saline) 
Silicone gel sheets (A6025) 
Topical antiseptics 
Topical antibiotics 
Enzymatic debriding agents 
Gauze or other dressings used to cleanse or debride a wound but not left on the wound 
First-aid type adhesive bandage (A6413) 
Any item listed in the latest edition of the Orange Book (e.g., an antibiotic-impregnated dressing which 
requires a prescription 
Gradient compression stockings (A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, 
A6541, A6544, A6549) 
Surgical stockings (A4490, A4495, A4500, A4510) 
Non-elastic binder for an extremity (A4465) 
Small adhesive bandages (e.g., Band-Aid or similar product) are not primarily used for the treatment of wounds 
addressed in the Surgical Dressings policy. 
These dressings are noncovered under the surgical dressing benefit. You can find these rules in the Local 
Coverage Determination (LCD): Surgical Dressings L33831 and Local Coverage Article: Surgical Dressings-
Policy Article A54563. 
 
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
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 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 procedure codes with a status indicator of P are bundled/excluded codes. There are no RVUs 
and no payment amounts for these services. No separate payment is made for them under the fee schedule. You 
can find this rule in the Centers for Medicare & Medicaid Services (CMS), Internet-Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 & Medicaid Services, Medicare National Correct Coding Initiative (NCCI) Policy 
Manual for Medicare Services, Chapter I(A). 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare & Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
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 Type of Bill is a required 4-digit alphanumeric code that gives two pieces of 
information. The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this 
bill in this particular period of care. Home health agencies (HHAs) must submit home health (HH) prospective 
payment system (PPS) claims with the 4th digit of 9. These claims may be adjusted with code 7 or 
cancelled with code 8. You can find this information in the Centers for Medicare & 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 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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that the supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies 
(DMEPOS) is required to maintain proof of delivery documentation in their files. You can find this rule in the 
Centers for Medicare & Medicaid Services (CMS), Internet-Only Manual, Publication 100-08, the Medicare 
Program Integrity Manual, Chapter 5, Section 5.2.1. 
 
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 wireless capsule endoscopy (WCE) requires that the patient ingest a small capsule containing 
a disposable light source, miniature color video camera, battery, antenna, and a data transmitter. The self-
contained capsule is made of specially sealed biocompatible material that is resistant to the digestive fluids 
throughout the gastrointestinal (GI) tract. Following ingestion of the capsule, natural contraction and relaxation 
of the GI tract propels the capsule forward. The camera contained in the capsule records images as it travels 
through the digestive system. During the entire procedure, the patient wears a data recorder around the waist, 
which captures and stores images transmitted by the capsules camera. After completion of the procedure, the 
patient data recorder is connected to a computer workstation where the images are downloaded, reviewed, and 
interpreted by the physician. The procedure lasts approximately five minutes for observing the esophageal 
mucosa and approximately 8 hours when observing intestinal mucosa. The capsule is designed to be disposable 
and is excreted naturally from the body. 
 
Covered Indications 
 
Wireless capsule endoscopy of the small bowel is considered medically reasonable and necessary when the 
following conditions have been met:  
 
documented continuous blood loss and anemia secondary to obscure bleeding of the small bowel; 
the site of bleeding could not be previously identified by colonoscopy, or endoscopy, or;  
radiographic exams of the small bowel have failed to reveal a source, or; 
intraoperative enteroscopy is being considered, or; 
initial diagnosis of suspected Crohns Disease when there is no evidence provided by conventional diagnostic 
tests such as small bowel follow-through (SBFT), and upper and lower endoscopy. 
 
Wireless capsule endoscopy of the esophagus is considered medically reasonable and necessary for the 
following condition, if the criteria have been met: 
 
 
 Patient diagnosed with portal hypertension who requires immediate evaluation of esophageal varices  
AND the esophageal capsule endoscopy is performed in lieu of conventional endoscopy because the provider 
who would perform the endoscopy has determined that the patients current medical condition prohibits a 
conventional endoscopy.  
AND the medical record clearly reflects why the patient was not a candidate for conventional endoscopy and 
how the capsule endoscopy would contribute to the patients care. 
 
You can find these rules in the Local Coverage Determination (LCD) Wireless Capsule Endoscopy L33774. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator I means that this code is not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment for, these services. You can find this 
information in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
The rules also say that the Physician Fee Schedule Status Indicator P means that there are no payment amounts 
for these services. No separate payment should be made for them under the fee schedule. If the item or service 
is covered as incident to a physician service and is provided on the same day as a physician service, payment 
for it is bundled into the payment for the physician service to which it is incident. You can find this information 
in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 23, Section 30.2.2. 
 
The rules say that the Physician Fee Schedule Status Indicator X means that this code represents an item or 
service that is not in the statutory definition of "physician services" for fee schedule payment purposes. No 
payment amounts are shown for this code, and no payment may be made under the physician fee schedule. You 
can find this information in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
The rules also say that Local Coverage Article (LCA) A57668 provided a list of diagnosis codes that support medical necessity for neuromuscular junction testing (code 95937). You can find this information in the Local 
Coverage Article (LCA) for Billing and Coding: Nerve Conduction Studies and Electromyography (A57668). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that Centers for Medicare & Medicaid Services (CMS) does not pay any provider or supplier 
other than the facility or hospital for services furnished to the beneficiary while an inpatient. The facility or 
hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements 
made between the facility and hospital and outside providers. You can find this information in 42 CFR 409.10.  
 
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 stress echocardiogram is reasonable and necessary in addition to an electrical stress test in 
the following instances: 
An electrical stress test alone is not useful or effective, and a stress echocardiogram is needed. Such 
circumstances may include: 
An abnormal resting ECG due to digitalis, left ventricular hypertrophy, bundle branch block, preexcitation 
syndrome (Wolff-Parkinson-White), electronically paced ventricular rhythm, or greater than 1 mm of resting 
ST depression; 
A prior equivocal stress ECG; or 
A history of posterior wall MI. 
The patient has significant valvular heart disease, and measuring the physiologic changes with exercise is 
necessary to determine the need for a valve intervention, 
When needed to determine the significance or the extent of myocardial ischemia (or scar), or to assess 
myocardial viability (e.g., risk stratification following acute myocardial infarction), 
When information from the clinical assessment and an electrical stress test does not adequately assess 
functional capacity, and such information is needed to manage the patient (e.g., for a patient with angina and 
left bundle branch block to assess the level of exercise tolerance for treatment planning), 
When needed to aid in diagnosis of hypertrophic or dilated cardiomyopathy, 
When needed to differentiate ischemic from non-ischemic cardiomyopathy, 
As part of a preoperative evaluation of a patient who is at intermediate or high risk for CAD when the surgery 
is likely to induce significant cardiac stress. You can find this information in the Local Coverage Determination 
(LCD) for Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress 
Echocardiography (L36889). 
 
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 Plan used Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L38803) 
in its review. We found that this LCD does not address procedure code 22102. Therefore, we referenced the 
following Medicare citation for general medical necessity. 
 
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.
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). 
The rules say that TENS is covered for chronic, intractable pain other than chronic low back pain when all of 
the following criteria must be met:  
a. The presumed etiology of the pain must be a type that is accepted as responding to TENS 
therapy. Examples of conditions for which TENS therapy is not considered to be reasonable and 
necessary are (not all-inclusive):  
i. headache 
ii. visceral abdominal pain 
iii. pelvic pain 
iv. temporomandibular joint (TMJ) pain 
b. The pain must have been present for at least three months. 
c. Other appropriate treatment modalities must have been tried and failed. 
TENS therapy for chronic pain that does not meet these criteria will be denied as not reasonable and necessary. 
TENS therapy for Chronic Low Back Pain (CLBP) will be denied as not reasonable and necessary. You can 
find this rule in Local Coverage Determination (LCD) Transcutaneous Electrical Nerve Stimulators (TENS) 
L33802. 
  
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 Professional Component (PC)/Technical Component (TC) Indicator 0 = Physician service 
codes: This indicator identifies codes that describe physician services. Examples include visits, consultations, 
and surgical procedures. The concept of r Professional Component (PC)/Technical Component (TC) does not 
apply since physician services cannot be split into professional and technical components. Modifiers 26 & TC 
cannot be used with these codes. The total Relative Value Units (RVUs) include values for physician work, 
practice expense and malpractice expense. There are some codes with no work RVUs. You can find this 
information in the Medicare Claims Processing Manual, Chapter 23, Section 50.6  Physician Fee Schedule 
Payment Policy Indicator File Record Layout. 
 
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 Medicare covers Food and Drug Administration (FDA) approved monoclonal antibodies 
directed against amyloid for the treatment of Alzheimer's disease (AD) for patients who have a clinical 
diagnosis of mild cognitive impairment (MCI) due to AD or mild AD dementia, both with confirmed presence 
of amyloid beta pathology consistent with AD. The rules also say that in order for payment to be made for the 
monoclonal antibodies, there must be evidence that the beneficiary was enrolled in a Coverage with Evidence 
Development (CED) study. You can find this information in the Centers for Medicare and Medicaid Service, 
Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual: 
Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimers Disease (AD) (200.3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.