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 to be eligible for coverage of a continuous glucose monitor (CGM) and related supplies, the 
beneficiary must meet all of the following initial coverage criteria (1)-(5): 
  
   
1. The beneficiary has diabetes mellitus; and, 
2. The beneficiarys treating practitioner has concluded that the beneficiary (or beneficiarys caregiver) has 
sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
3. The CGM is prescribed in accordance with its Food and Drug Administration (FDA) indications for use; 
and, 
4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the 
criteria below: 
   A. The beneficiary is insulin-treated; or, 
   B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the 
following: 
      -     Recurrent level 2 hypoglycemic events that persist despite multiple attempts to adjust  
            medication(s) and/or modify the diabetes treatment plan; or, 
      -     A history of one level 3 hypoglycemic event characterized by altered mental and/or physical state 
requiring third-party assistance for treatment of hypoglycemia 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-
approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1)-
(4) above are met. You can find this information in the Local Coverage Determination (LCD): Glucose 
Monitors (L33822). 
 
The rules say that for claims with dates of service on or after January 1, 2023, a non-adjunctive continuous 
glucose monitor (CGM) must be billed with code E2103. Code E2103 describes a non-adjunctive CGM that 
meets the requirements of the durable medical equipment (DME) benefit. To be eligible for Medicare 
reimbursement, all CGM devices billed as E2103 must have received coding verification review by the Pricing, 
Data Analysis and Coding (PDAC) contractor and be listed on the Product Classification List (PCL) for 
Healthcare Common Procedure Coding System (HCPCS) code E2103. You can find this information in the 
Local Coverage Article: Glucose Monitor - Policy Article (A52464). 
 
The rules say that a Freestyle Libre 3 is specified as a product that may be billed using code E2103, effective 
June 15, 2023. You can find this information in the Product Classification List (PCL) on the Pricing Data 
Analysis, and Coding (PDAC) contractor website 
(https://www4.palmettogba.com/pdac_dmecs/searchProductClassificationResults.do?manufacturer=&codeDeci
sion=k0554&productName=&modelNumber=&classification=). 
 
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 single photon emission computed tomograph (SPECT) acquires information on the concentration of 
radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical conditions 
including: 
 
    stress fracture. 
    spondylosis. 
    infection (e.g., discitis). 
    tumor (e.g., osteoid osteoma). 
    analyze blood flow to an organ, as in the case of myocardial viability. 
    differentiate ischemic heart disease from dilated cardiomyopathy. 
 
Indications and Limitations of Coverage 
 
Frequency limitations: Medicare Administrative Contractor discretion. 
 
In the case of myocardial viability, FDG positron emission tomography (PET) may be used following a SPECT 
that was found to be inconclusive. However, SPECT may not be used following an inconclusive FDG PET 
performed to evaluate myocardial viability. 
 
You can find this information in the National Coverage Determination (NCD) Single Photon Emission 
Computed Tomography (SPECT) 220.12.  
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
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 Breast Cancer Index (BCI) test is covered for postmenopausal women with invasive 
breast cancer when the following criteria are met: 
 Pathology reveals invasive carcinoma of the breast that is ER+ and/or PR+ and HER2 -; and 
 Patient has early-stage disease (T1-3, pN0-N1, M0); and 
 Patient has no evidence of distant breast cancer metastasis (i.e., non-relapsed); and 
 Test results will be used in determining treatment management of the patient for chemotherapy and/or 
endocrine therapy. 
 
To report a BCI service, please submit the following claim information: 
 Select CPT

 code 81518 
 Enter unit of service (UOS) 
 Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT

 code in the comment/narrative 
field for the Part B claim field/types: 
 Select the appropriate ICD-10 CM code. 
 
You can find this rule in the Local Coverage Article for the Billing and Coding of Molecular Diagnostics 
(MolDX): Breast Cancer Index (BCI) Gene Expression Test, A57773.  
 
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. 
 
A spinal electrical osteogenesis stimulator (E0748) is covered only if any of the following criteria are met: 
 
        Failed spinal fusion where a minimum of nine months has elapsed since the last surgery, or 
        Following a multilevel spinal fusion surgery (see Appendices section), or 
        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 information in the Local Coverage Determination (LCD) Osteogenesis Stimulators L33796. 
 
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 kyphoplasty (PKP)) is covered in patients with 
BOTH the following: 
 
   1. Inclusion criteria (ALL are required): 
       a. Acute (les than 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 
greater than or equal to 8)  
           ii. Non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) despite 
optimal non-surgical management (NSM) (10) (ONE): 
               1. Worsening pain 
               2. Stable to improved pain (but NRS or VAS still greater than or equal to 5) (with greater than or 
equal to 2 of the following): 
                   A. Progression of vertebral body height loss 
                   B. Greater 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 (10) (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. 
 
You can find this information in Medicare's 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.
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 to repair means to fix or mend and to put the equipment back in good condition after 
damage or wear. Repairs to equipment which a beneficiary owns are covered when necessary to make the 
equipment serviceable. However, do not pay for repair of previously denied equipment or equipment in the 
frequent and substantial servicing or oxygen equipment payment categories. If the expense for repairs exceeds 
the estimated expense of purchasing or renting another item of equipment for the remaining period of medical 
need, no payment can be made for the amount of the excess. 
 
However, more extensive maintenance which, based on the manufacturers recommendations, is to be 
performed by authorized technicians, is covered as repairs for medically necessary equipment which a 
beneficiary owns. 
 
During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but not actual 
replacement) for medically necessary equipment owned by the beneficiary. 
 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2. 
 
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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. MUEs for codes with an MAI of 3 are per day edits based on clinical 
benchmarks. Codes with an MAI of 3 are based on criteria combined with data such that it would be 
possible, but medically unlikely, that higher values would represent correctly reported medically necessary 
services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, 
were correctly coded, and were medically necessary.  
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(V). 
 
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 Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. You can find this rule at 42 CFR Section 422.111(a) and (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. The Plan 
contract also says that in-network diabetic test strips (blood glucose test strips) are limited to two specified 
manufacturers, Ascensia (Contour) and LifeScan (OneTouch) products, when obtained at the pharmacy. You 
can find this information on pages 59 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 state that a panel is a single test with multiple components and is characterized by a single unit of 
service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact that 
the test reports multiple individual pathogens and/or targets. You can find this rule in the Local Coverage 
Articles (LCA) for Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen 
Identification Testing (A58710). 
 
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 fabric supports are not covered because they are nonreusable and not rental-type items. 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 280.1. 
 
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 state that the following bisphosphonate injections (administered intravenously [IV]) will be 
considered medically reasonable and necessary when administered as outlined in this LCD. The coverage of IV 
bisphosphonates must be supported in the medical record. 
 
Criteria for the diagnosis of osteoporosis, and 
History of treatment as related to progression of disease and ongoing risk factors, and 
Description of treatment failure, or contraindication, or adverse side effects, of oral or self-administered drugs 
for osteoporosis as applicable to the patient that supports IV therapy in lieu of standard oral treatment protocol. 
The following IV bisphosphonate injections are considered medically reasonable and necessary when 
administered as outlined in this LCD: 
 
Ibandronate sodium injection (Boniva) 
Pamidronate (Aredia) 
Zoledronic acid injection (Reclast) 
Zoledronic acid injection (Zometa) 
You can find this information under Local Coverage Determination (LCD) Biophosphonates (Intravenous [IV]) 
and Monoclonal Antibodies in the Treatment of Osteoporosis and Their Other Indications (L33270). 
 
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 both PVP and PVA will be considered reasonable and necessary for osteoporotic conditions 
when ALL of the following criteria are met: 

- Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1 - L5) based on symptom onset, and 
documented by recent (within 30 days) advanced imaging (bone marrow edema on MRI or bone-
scan/SPECT/CT uptake)
1-3, 10,25,27
 and 
- The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or 
visual Analog Scale [VAS] pain score  8)
4-7
 or is non-hospitalized with moderate to severe pain (NRS 
or VAS  5) despite optimal non-surgical management (NSM)
8
 with one of the following: 
o Worsening pain or 
o Stable to improved pain (but NRS or VAS  5) when 2 or more of the following are present:  
 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) 
 Steroid-induced fractures 
 Reinforcement or stabilization of vertebral body prior to surgery 
- Continuum of Care 
All patients presenting with vertebral compression fractures (VCF) should be referred for evaluation of 
bone mineral density and osteoporosis education for subsequent treatment as indicated and instructed to 
take part in an osteoporosis prevention/treatment program.
8
 
You can find this rule at Local Coverage Determination (LCD) L38213: Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (eff. 9/1/22). 
 
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 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. A crown - porcelain fused to high noble metal (D2750) is excluded 
from this benefit. You can find this information on pages 4-55 to 4-59 of the Plans 2021 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 the 
requested item or service but is limited to one procedure every five years. You can find this information on 
pages 84-88 of the Plan's 2023 Evidence of Coverage (EOC).