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 a determination of the type of knee for the prosthesis will be made by the treating 
practitioner and/or the prosthetist based upon the functional needs of the beneficiary. Basic lower extremity 
prostheses include a single axis, constant friction knee. Other prosthetic knees are considered for coverage 
based upon functional classification. 
 
A high activity knee control frame (L5930) is covered for beneficiaries whose functional level is 4. 
 
A fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, L5726, L5728, 
L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is covered for 
beneficiaries whose functional level is 3 or above. 
 
L5859 (ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, 
POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY 
TYPE MOTOR(S)) is only covered when the beneficiary meets all of the criteria below: 
 
    Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee 
 
    K3 functional level only 
 
    Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps 
function that impairs K-3 level function with the use of a microprocessor-controlled knee alone 
 
    Is able to make use of a product that requires daily charging 
 
    Is able to understand and respond to error alerts and alarms indicating problems with the function of the unit 
 
If these coverage criteria for the knee component are not met, L5859 will be denied as not reasonable and 
necessary. You can find these rules in the Local Coverage Determination (LCD) Lower Limb Prostheses 
L33787. 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 Intensity Modulated Radiation Therapy (IMRT) is a technology in radiation oncology that 
delivers radiation more precisely to the tumor while relatively sparing the surrounding normal tissues. It is an 
advanced form of three-dimensional conformal radiation therapy (3D CRT) that allows for varying intensities 
of radiation to produce dose distributions that are more conformal than those possible with standard 3D CRT. It 
introduces inverse planning and computer-controlled radiation deposition, and normal tissue avoidance in 
contrast to the conventional trial-and-error approach. 
 
The clinical objectives are defined mathematically and the IMRT optimization process determines the beam 
parameters that will lead to the desired solution while sparing normal tissues. 
 
Examples of situations where IMRT is covered include tumors of the prostate, head and neck, brain, and 
paraspinal regions when needed to reduce the incidence and severity of the side effects of radiation, including 
compromise of visual function, mucositis, and xerostomia. 
 
An IMRT candidate includes a patient who has already received a maximum amount of radiation delivered by 
conventional means. IMRT allows these patients to receive additional radiation safely, which can result in a 
prolonged survival and an improved quality of life. 
 
 
The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) 
may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence 
over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations 
prior to billing Medicare. 
 
Services billed should be consistent with CPT code descriptors and Medicare valuation. You can find these 
rules in the Local Coverage Article Billing and Coding Billing and Coding: Intensity Modulated Radiation 
Therapy (IMRT) A58236. 
 
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. Covered dental services are 
listed on pages 52-53 of the Plan's 2023 Evidence of Coverage. Any service not listed is not covered.
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 for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
  
  test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement 
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following 
requirements are met: 
 
   a. Patient has: 
 
   i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
   ii not been previously tested with the same test using NGS for the same cancer genetic content, and 
   iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
   b. The diagnostic laboratory test using NGS must have: 
 
   i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
   ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
   iii. results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
You can find this rule in the National Coverage Determination (NCD) for Next Generation Sequencing (NGS) 
(90.2). 
 
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 state that no payment may be made for the implantation of dorsal column or depth brain stimulators 
or services and supplies related to such implantation, unless all of the conditions listed below have been met: 
- The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with 
chronic intractable pain; 
- With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or 
contraindicated for the given patient; 
- Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
- All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be 
available; and 
- Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
Generally the physician should be able to determine whether the patient is likely to derive a significant 
therapeutic benefit from continuing use of an implanted nerve stimulator within a trial period of 1 month. In a 
few cases, this determination may take longer to make. The medical necessity for such diagnostic services 
which are furnished beyond the first month must be documented. You can find these rules in National 
Coverage Determination (NCD) Electrical Nerve Stimulators (160.7) and National Coverage Determination 
(NCD) Assessing Patient's Suitability for Electrical Nerve Stimulation Therapy (160.7.1). 
 
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 facet joint interventions are considered medically reasonable and necessary for the 
diagnosis and treatment of chronic pain in patients who meet all the following criteria: 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant 
deformity. 
 
Repeat thermal facet joint radiofrequency ablation (RFA) at the same anatomic site is considered medically 
reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at 
least six (6) months or at least 50% consistent improvement in the ability to perform previously painful 
movements and activities of daily living (ADLs) as compared to baseline measurement using the same scale. 
You can find these rules in Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management (L38801). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that whole gland HIFU is considered medically necessary as a local treatment for recurrent 
prostate cancer following radiation therapy (RT). You can find this rule at Local Coverage Determination 
(LCD) L38262: Salvage High-intensity Focused Ultrasound (HIFU) Treatment in Prostate Cancer (PCa) (eff. 
4/1/20). 
 
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 codes with a professional component (PC)/technical component (TC) indicator of 5 means 
these are incident to codes: This indicator identifies codes that describe services covered incident to a 
physicians service when they are provided by auxiliary personnel employed by the physician and working 
under his or her direct supervision. 
 
Payment may not be made by carriers for these services when they are provided to hospital inpatients or 
patients in a hospital outpatient department. Modifiers 26 and TC cannot be used with these codes. 
 
You can find this rule in the You can find this information in the Centers for Medicare and Medicaid Services 
(CMS), Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual Chapter 23, Section 
50.6. 
 
The rules say that codes with status indicator of P are bundled/excluded codes. There are no Relative Value 
Units (RVUs) and no payment amounts for these services. No separate payment is 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 
(an example is an elastic bandage furnished by a physician incident to a physician service). If the item or service is covered as other than incident to a physician service, it is excluded from the fee 
schedule (for example, colostomy supplies) and is paid under the other payment provision of the Act. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 23, 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 state that a group 3 power wheelchair with a single power option is covered if the beneficiary 
requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples 
include but are not limited to head control, sip and puff, switch control) or the beneficiary meets coverage 
criteria for a power tilt or a power recline seating system and the system is being used on the wheelchair.  
 
If the power wheelchair base is not covered, then related accessories will be denied. 
 
You can find these rule in Per Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
A power seating system  tilt only, recline only, or combination tilt and recline  with or without power 
elevating legrests will be covered if the beneficiary is at high risk for development of a pressure ulcer and is 
unable to perform a functional weight shift; or the beneficiary utilizes intermittent catheterization for bladder 
management and is unable to independently transfer from the wheelchair to bed; or the power seating system is 
needed to manage increased tone or spasticity. You can find this rule in Local Coverage Determination (LCD): 
Wheelchair Options/Accessories (L33792). 
 
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 FDA-approved hypoglossal nerve neurostimulation (HGNS) is considered medically 
reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea when all of the 
following criteria are met: 
 
1. Beneficiary is 22 years of age or older; and 
2. Body mass index (BMI) is less than 35 kg/m2; and 
3. A polysomnography (PSG) is performed within 24 months of first consultation for HGNS implant; and 
4. Beneficiary has predominantly obstructive events (defined as central and mixed apneas less than 25% of the 
total AHI); and 
5. AHI is 15 to 65 events per hour; and 
6. Beneficiary has documentation that demonstrates Continuous Positive Air Pressure (CPAP) failure (defined 
as AHI greater than 15 despite CPAP usage) or CPAP intolerance (defined as less than 4 hours per night, 5 
nights per week or the CPAP has been returned) including shared decision making that the patient was 
intolerant of CPAP despite consultation with a sleep expert: and 
7. Absence of complete concentric collapse at the soft palate level as seen on a drug-induced sleep endoscopy 
(DISE) procedure; and 
8. No other anatomical findings that would compromise performance of device (e.g., tonsil size 3 or 4 per 
standardized tonsillar hypertrophy grading scale). 
 
These rules are found in Local Coverage Determination (LCD): Hypoglossal Nerve Stimulation for the 
Treatment of Obstructive Sleep Apnea (L38528). 
 
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 code L5781 describes a complete device that is an addition to a lower limb prosthesis. The 
primary function of the vacuum pump is to suspend the prosthetic limb. Additionally, products coded L5781 
provide residual limb volume management and moisture evacuation. The pump mechanism evacuates air and 
accumulated moisture between the limb and socket walls. The pump mechanism can be actuated by either 
external power and/or mechanical system(s). 
 
L5782 describes a complete device that is an addition to a lower limb prosthesis. The primary function of the 
vacuum pump is to suspend the prosthetic limb. It also provides residual limb volume management and 
moisture evacuation. The pump mechanism evacuates air and accumulated moisture between the limb and 
socket walls. The pump mechanism can be actuated by either external power and/or mechanical system(s). 
Products described by this code would have components built to withstand higher prosthetic limb forces than 
L5781. 
 
L5988 describes an endoskeletal pylon device that allows vertical shock reduction between the foot and pelvis 
during ambulation. The vertical shock reducing pylon feature of L5988 is a separate function from other 
products which use a piston/telescoping mechanism such as products described by L5781 or L5782.  
 
You can find these rules in the Local Coverage Article Lower Limb Prostheses - Policy Article A52496. 
 
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 in the case where the point of origin is not a provider, Part A coverage is not available 
because, at the time the beneficiary is being transported, the beneficiary is not an inpatient of any provider paid 
under Part A of the program and ambulance services are excluded from the 3-day preadmission payment 
window. The transfer, i.e., the discharge of a beneficiary from one provider with a subsequent admission to 
another provider, is also payable as a Part B ambulance transport, provided all program coverage criteria are 
met, because, at the time that the beneficiary is in transit, the beneficiary is not a patient of either provider and 
not subject to either the inpatient preadmission payment window or outpatient payment packaging 
requirements. This includes an outpatient transfer from a remote, off-campus emergency department (ER) to 
becoming an inpatient or outpatient at the main campus hospital, even if the ER is owned and operated by the 
hospital. Once a beneficiary is admitted to a hospital, CAH, or SNF, it may be necessary to transport the 
beneficiary to another hospital or other site temporarily for specialized care while the beneficiary maintains 
inpatient status with the original provider. This movement of the patient is considered "patient transportation" 
and is covered as an inpatient hospital or CAH service and as a SNF service when the SNF is furnishing it as a 
covered SNF service and payment is made under Part A for that service. (If the beneficiary is a resident of a 
SNF and must be transported by ambulance to receive dialysis or certain other high-end outpatient hospital 
services, the ambulance transport may be separately payable under Part B. Also, if the beneficiary is a SNF 
resident and not in a Part A covered stay and must be transported by ambulance to the nearest supplier of 
medically necessary services not available at the SNF, the ambulance transport, including the return trip, may 
be covered under Part B.) Because the service is covered and payable as a beneficiary transportation service 
under Part A, the service cannot be classified and paid for as an ambulance service under Part B. This includes 
intra-campus transfers between different departments of the same hospital, even where the departments are 
located in separate buildings. Such intra-campus transfers are not separately payable under the Part B 
ambulance benefit. Such costs are accounted for in the same manner as the costs of such a transfer within a 
single building. You can find this information in the Medicare Benefit Policy Manual Chapter 10 - Ambulance 
Services, 10.3.3 - Separately Payable Ambulance Transport Under Part B versus Patient Transportation that is 
Covered Under a Packaged Institutional Service. 
 If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.