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 state that Lancets (code A4259), blood glucose test reagent strips (code A4253), glucose control 
solutions (code A4256) and spring powered devices for lancets (code A4258) are covered for beneficiaries for 
whom the glucose monitor is covered. 
 
The quantity of test strips (code A4253) and lancets (code A4259) that are covered depends on the 
usual medical needs of the beneficiary and whether or not the beneficiary is being treated with 
insulin, regardless of their diagnostic classification as having Type 1 or Type 2 diabetes mellitus. 
 
Coverage of testing supplies is based on the following guidelines: 
 
Usual Utilization 
For a beneficiary who is not currently being treated with insulin administrations, up to 100 tests 
strips and up to 100 lancets every 3 months are covered if the basic coverage criteria (1)-(2) 
(above) are met. 
 
For a beneficiary who is currently being treated with insulin administrations, up to 300 test strips 
and up to 300 lancets every 3 months are covered if basic coverage criteria (1)-(2) (above) are met. 
 
High Utilization 
For a beneficiary who is not currently being treated with insulin administrations, more than 100 
test strips and more than 100 lancets every 3 months are covered if criteria (a)  (c) below are 
met. 
 
For a beneficiary who is currently being treated with insulin administrations, more than 300 test 
strips and more than 300 lancets every 3 months are covered if criteria (a)  (c) below are met. 
a. Basic coverage criteria (1)-(2) listed above for all home glucose monitors and related 
accessories and supplies are met; and, 
b. Within the six (6) months prior to ordering quantities of strips and lancets that exceed the 
utilization guidelines, the treating practitioner has had an in-person visit with the beneficiary 
to evaluate their diabetes control and their need for the specific quantity of supplies that 
exceeds the usual utilization amounts described above; and, 
c. Every six (6) months, for continued dispensing of quantities of testing supplies that exceed 
the usual utilization amounts, the treating practitioner must verify adherence to the high 
utilization testing regimen. You can find this information in the Local Coverage Determination (LCD): Glucose 
Monitors (L33822). 
 
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 genes not identified as having actionable use are not considered reasonable and necessary. 
The algorithms employed in combinatorial testing are also not currently considered reasonable and necessary 
components of multi-gene testing. Pharmacogenomics (PGx) testing is not covered when a treating clinician is 
not considering treatment with a medication that has an actionable drug-gene interaction, or when the use of a 
medication with a drug-gene interaction is not reasonable and necessary. You can find this rule in Local 
Coverage Determination (LCD) MolDX: Pharmacogenomics Testing L38394. 
 
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 modifier - KX (Requirements specified in the medical policy have been met) must be used 
as an attestation by the practitioner and/or provider of the service that documentation is on file verifying the 
patient has a symptomatic arrhythmia or a high potential for progression of the rhythm disturbance requiring a 
permanent pacemaker for Groups I and II. Bradycardia that is the consequence of essential long-term drug 
therapy of a type and dose for which there is no acceptable alternative does not exclude the use of modifier - 
KX. You can find this rule in the Local Coverage Article (LCA) for Billing and Coding: Single Chamber and 
Dual Chamber Permanent Cardiac Pacemakers (A54909). 
 
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 the -GY modifier identifies an item or service that is statutorily excluded or does not meet 
the definition of any Medicare benefit. Liability will rest with the provider, unless a modifier is used to assign 
liability to the beneficiary (i.e., -GL, -GY), when the beneficiary has been informed, prior to service delivery, 
that he/she may be liable for payment. You can find this rule in the Centers for Medicare & Medicaid Services, 
Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 60.4.2. 
 
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 PVA (percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP)) is covered in 
patients with BOTH the following: 
 
1. Inclusion criteria (ALL are required):  
 
Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic Vertebral Compression Fracture (VCF) (T1  L5) by 
recent (within 30 days) advanced imaging (bone marrow edema on magnetic resonance imaging (MRI) or 
bone-scan/single photon emission computed tomography (SPECT)/computed tomography (CT) uptake) 
Symptomatic (ONE): 
Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score = 8) 
Non-hospitalized with moderate-to-severe pain (NRS or VAS =5) despite optimal non-surgical management 
(NSM) (ONE): 
Worsening pain 
Stable-to-improved pain (but NRS or VAS still =5) (with = 2 of the following): 
Progression of vertebral body height loss 
> 25% vertebral body height reduction 
Kyphotic deformity 
Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) >17) 
*Consider including pedicle periosteal infiltration 
 
c. Continuum of care (BOTH): 
 
All patients presenting with VCF should be referred for evaluation of bone mineral density (BMD) and 
osteoporosis education for subsequent treatment as indicated. 
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: 
Current back pain is not primarily due to the identified acute or subacute VCF(s) Osteomyelitis, discitis or active systemic or surgical site infection 
Pregnancy 
b. Relative contraindication: 
 
Allergy to bone cement or opacification agents 
Uncorrected coagulopathy 
Spinal instability 
Myelopathy from the fracture 
Neurologic deficit 
Neural impingement 
Fracture retropulsion/canal compromise 
Greater than 3 vertebral fractures 
Vertebral augmentation and kyphoplasty for VCFs with intractable spinal pain not relieved with medical 
therapy will be covered for osteolytic vertebral metastatic disease or myeloma involving a vertebral body. 
 
You can find these rules in the Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) L38737. 
 
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 D0350 every 36 floating months. You can find this information 
on page 179 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 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 also say that anesthesia care is provided by an anesthesia practitioner who may be a physician, a 
certified registered nurse anesthetist (CRNA) with or without medical direction, or an anesthesia assistant (AA) 
with medical direction. The anesthesia care package consists of preoperative evaluation, standard preparation 
and monitoring services, administration of anesthesia, and post-anesthesia recovery care. You can find this rule 
in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter II. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $35 copayment for standard routine x-rays.  You can find this 
information on page(s) 69 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 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 services. Apically positioned flap (D4245), the localized delivery of 
antimicrobial agents (D4381), gingivectomy or gingivoplasty to allow access for restorative procedure 
(D4212), occlusal adjustment (D9951), and an unspecified adjunctive procedure (D9999) are excluded from 
this benefit. The Plan contract also says cosmetic crowns (such as resin-based, noble metals, and porcelain) and 
pontics are not a covered benefit for molar teeth. Crowns on molar teeth are limited to base metal materials. 
You can find this information on pages 92-94 and on page 121 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 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 
coverage for the maxillary partial denture but is limited to one of (D5110, D5130, D5211, D5213, D5221, 
D5223, D5225, D5227, D5863, D5864) per 60 month(s) per patient. You can find this information on page 54 
of the Plan's 2023 Office Reference Manual.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. Although the Plan has a Point-of-Service (POS) option to cover 
certain out-of-network services, this benefit only applies to covered routine dental services. You can find this 
information on page(s) 37 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a 20% coinsurance of the total cost for Medicare-covered therapeutic 
radiology services. You can find this information on pages 71 to 73 of the Plan's 2023 Evidence of Coverage 
(EOC).  
 
The Plan contract says that enrollees must pay a $50 copayment for Medicare-covered diagnostic radiology. 
You can find this information on pages 71 to 73 of the Plans 2023 Evidence of Coverage (EOC). 
 
The Plan contract says that enrollees must pay a $50 copayment for Medicare-covered diagnostic 
procedures/tests. You can find this information on pages 71 to 73 of the Plans 2023 Evidence of Coverage 
(EOC). 
 
The Pan contract says that enrollees must pay a $225 copayment for Medicare-covered observation services. 
You can find this information on page 73 of the Plans Evidence of Coverage (EOC). 
 
The Plan contract says that enrollees must pay a $25 copay for Medicare-covered specialist services. 
You can find this information on pages 77 to 79 of the Plans 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). 
 
The rules say that thermal destruction of the intraosseous basivertebral nerve (BVN) will be considered 
medically reasonable and necessary for the treatment of chronic low back pain (CLBP) in patients who meet 
ALL the following criteria: 
 
1. Chronic lumbar back pain of greater than or equal to 6 months duration that causes functional deficit 
measured on a pain or disability scale, and  
2. Documented failure to respond to greater than or equal to 6 months of non-surgical management, and 
3. Absence of non-vertebrogenic 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, and 
4. Evidence of Type 1 or Type 2 Modic changes on magnetic resonance imaging (MRI), such as inflammation, 
edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized fibrous tissues within 
the adjacent marrow, hypotensive signals (Type 1 Modic change), and changes to the vertebral body marrow 
including replacement of normal bone marrow by fat, and hypertensive signals (Type 2 Modic change), in 1 or 
more vertebrae from L3-S1. 
 
You can find this information in Local Coverage Determination (LCD): Thermal Destruction of the 
Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain (L39420). 
 
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.