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 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 20% coinsurance for Medicare Part B prescription drugs. You can find 
this information on page(s) 63 to 64 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 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 procedure code E2311 describes the electronic components that allow the beneficiary to 
control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or 
non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power 
leg elevation, power seat elevation, power standing. 
 
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the 
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting 
hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and 
with complete replacement of the expandable controller. Code K0108 must not be used for any component or 
feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete 
expandable controller is included in the allowance for codes E2377/E2376 plus E2313. You can find this 
information in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). 
 
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 state that modifier 77 indicates that a procedure had to be repeated by a different physician on the 
same day. You can find this information on the website for the Wisconsin Medicare Administrative Contractor 
(MAC), National Government Services at 
https://www.ngsmedicare.com/hu/modifiers?lob=96664&state=97178&rgion=93623&selectedArticleId=19732
88 
 
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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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 any service other than manual manipulation for the treatment of a subluxation is 
excluded from Medicare coverage. You can find this information on page 4-11 of the Plan's 2022 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 home health services under a plan of care are paid based on a 30-day period of care. Home 
Health Agencies (HHAs) submit a Notice of Admission (NOA) at the beginning of an admission and then 
submit one claim for each 30-day period of care. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
10, Section 40.2. 
 
The rules say that when periods of care are created from a notice of admission, the common working file 
(CWF) calculates a period end date that does not exceed the start date plus 29 days. CWF will assure no period 
exceeds the maximum length under any circumstance and will auto-adjust the period end date to shorten the 
period if needed. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 30.6. 
 
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 lower limb prosthesis is covered when the beneficiary: 
1. Will reach or maintain a defined functional state within a reasonable period of time; and 
2. Is motivated to ambulate. 
 
A determination of the medical necessity for certain components/additions to the prosthesis is based on the 
beneficiarys potential functional abilities. Potential functional ability is based on the reasonable expectations 
of the prosthetist, and treating practitioner, considering factors including, but not limited to: 
1. The beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other 
medical problems; and 
3. The beneficiarys desire to ambulate. 
 
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. You can find this information in the Local Coverage 
Determination (LCD): Lower Limb Prostheses (L33787). 
 
The rules say that L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, L5859 are additional features 
and/or functions that do not describe a complete endoskeletal knee-shin system and must be used in 
combination with an L-code for a knee-shin system (L5610, L5611, L5613, L5616, L5810, L5811, L5812, 
L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840). The use of additional feature L-codes 
may also depend on the assigned K-Level modifier (K0-K4), as referenced in the LCD. You can find this 
information 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 state that Nationally Non-Covered Conditions for Sterilization include: 
 
Elective hysterectomy, tubal ligation, and vasectomy, if the primary indication for these procedures is 
sterilization; 
 
A sterilization that is performed because a physician believes another pregnancy would endanger the overall 
general health of the woman is not considered to be reasonable and necessary for the diagnosis or treatment of 
illness or injury within the meaning of 1862(a)(1) of the Social Security Act. The same conclusion would 
apply where the sterilization is performed only as a measure to prevent the possible development of, or effect 
on, a mental condition should the individual become pregnant; and sterilization of a mentally retarded person 
where the purpose is to prevent conception, rather than the treatment of an illness or injury. 
 
You can find this information in the National Coverage Determination (NCD) Sterilization 230.3. 
 
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 the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet 
joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet ALL the 
following criteria: 
 
       a. Initial thermal radiofrequency ablation (RFA): 
           i. After the patient has had at least two (2) medically reasonable and necessary diagnostic medial branch 
blocks (MBBs), with each one providing a consistent minimum of 80 percent sustained relief of primary 
(index) pain (with the duration of relief being consistent with the agent used) AND 
           ii. Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and 
necessary provided the patient had a minimum of consistent 50 percent improvement in pain for at least six (6) 
months or at least 50 percent consistent improvement in the ability to perform previously painful movements 
and ADLs as compared to baseline measurement using the same scale; 
 
Frequency Limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be 
reimbursed per rolling 12 months. You can find this information in Local Coverage Determination (LCD): 
Facet Joint Interventions for Pain Management (L35936). 
 
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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with 
BOTH the following: 
 
1. Inclusion criteria (ALL are required): 
a. Acute (less than 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 imaing (MRI) 
or bone-scan/Single-Photon Emission Computerized Tomography (SPECT)/computed tomography (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) (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% 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 (BOTH): 
i. All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis education for 
subsequent treatment as indicated.  
ii. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program. 
 
   
2. Exclusion criteria (Can have NONE of the following): 
 
a. Absolute contraindication 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s) 
ii. Osteomyelitis, discitis or active systemic or surgical site infection 
iii. Pregnancy 
 
b. Relative contraindication 
i. Allergy to bone cement or opacification agents 
ii. Uncorrected coagulopathy 
iii. Spinal instability 
iv. Myelopathy from the fracture 
v. Neurologic deficit 
vi. Neural impingement 
vii. Fracture retropulsion/canal compromise 
viii. Greater than three vertebral fractures 
 
Vertebral augmentation and kyphoplasty for vertebral compression fractures 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 this information 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 state that with limited exceptions, items and services furnished outside the United States are excluded 
from coverage. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 60. 
 
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 states that the Plan covers emergency care worldwide. The Plan may not reimburse all out-of-
pocket expenses. The Plan will only reimburse up to the Medicare allowable rates. You can find this 
information on page 55 of the Plan's 2023 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 provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
The rules also state that all diagnostic X-Ray tests, diagnostic laboratory tests, and other diagnostic tests must 
be ordered by the physician who is treating the beneficiary and tests not ordered by the physician who is 
treating the beneficiary are not reasonable and necessary. While a physician order is not required to be signed, 
the physician must clearly document, in the medical record, the intent that the test be performed. Contractors 
shall consider order requirements for diagnostic laboratory tests met if there is: 
 
A signed order or signed requisition listing the specific test; or 
An unsigned order or unsigned laboratory requisition listing the specific tests to be performed and an 
authenticated medical record that supports the physician/practitioners intent to order the tests; or 
An authenticated medical record that supports the physician/practitioners intent to order the specific tests. 
 
You can find these rules in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.9.1. 
 
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 state that physicians bill for the anesthesia services associated with multiple bilateral surgeries by 
reporting the anesthesia procedure with the highest base unit value with the multiple procedure modifier -51. 
They report the total time for all procedures in the line item with the highest base unit value. If the same 
anesthesia CPT code applies to two or more of the surgical procedures, billers enter the anesthesia code with 
the -51 modifier and the number of surgeries to which the modified CPT code applies. You can find this rule in 
the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-104, Chapter 12, 
Section 50. 
 
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 modifier -25 is used to facilitate billing of evaluation and management services on the day 
of a procedure for which separate payment is made. You can find this information in the Centers for Medicare 
and Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, 
Chapter 12, 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 Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL of 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; AND 
2. Pain that has been present for a minimum of 3 months with documented failure to respond to 
noninvasive conservative care management (as tolerated); AND 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst); AND 
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. 
 
Diagnostic procedures should be performed with the intent that if successful, a radiofrequency ablation (RFA) 
procedure would be considered the primary treatment goal at the diagnosed level(s). A second diagnostic facet 
procedure is considered medically reasonable and necessary to confirm validity of the initial diagnostic facet 
procedure when administered at the same level. The second diagnostic procedure may only be performed a 
minimum of 2 weeks after the initial diagnostic procedure. 
1. An initial diagnostic facet joint procedure will be considered medically reasonable and necessary when 
the patient meets the criteria outlined under the indications for facet joint interventions. 
2. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and 
necessary in patients who meet BOTH of the following criteria: 
? The patient meets the criteria for the first diagnostic procedure; AND 
? After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 
80% relief of primary (index) pain (with the duration of relief being consistent with the agent used). 
 
You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L34892). 
 
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.