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 indications for lumbar fusion include any of the following. A patient must have at least 1 of 
the following: 
1. Radiographic or clinical evidence of instability due to any 1 of the following: 
a. Congenital deformities, 
b. Trauma, 
c. Fractures, 
d. Chronic degenerative conditions, 
e. Tumor, 
f. Infection, 
g. Erosive conditions, 
h. Space-occupying lesions, or 
i. Iatrogenic causes, including expected instability as a consequence of another medically 
necessary spine procedure. 
If more than 1 level is fused under this indication, the record must reflect that each fused level is 
affected by 1 of the above conditions. 
2. Symptomatic spinal deformity (in the absence of instability or neural compression) which meets the 
following criteria. 
- Both of the first 2 criteria must be met: 
a. Functional limitation in daily activities due to back pain or discomfort and 
b. Nonresponse to at least 1 year of non-operative treatment 
- Any 1 of these 3 criteria must be met: 
c. Sagittal or coronal imbalance by at least 5 cm as measured on radiographic imaging of 
the entire spine, or 
d. Progression of deformity by at least 10 degrees, or 
e. Scoliotic curvature of greater than 30 degrees 
3. Revision surgery for pseudarthrosis following an initial spine surgery if the following conditions are all 
met. 
a. The patient had a period of reduced pain initially following surgery and b. The time since the prior surgery has been at least 1 year and 
c. There is clear radiographic evidence of pseudarthrosis  and 
d. The patient has exhausted available conservative treatment measures 
 
The medical record must clearly reflect which conservative treatments the patient has tried or is not a candidate 
for and why, including medical therapies, physical and exercise therapies and injections. Outcomes for fusion 
in revision surgery, usually do not lead to pain relief and as such fusion is considered a last resort treatment 
option only when all other treatment options have failed. This information must be communicated to the patient 
prior to surgery to allow for appropriate shared decision making with a well-informed patient. The medical 
record must reflect that this counseling was done and that the patient wished to undergo surgery with the 
appropriately informed consent. 
 
4. Symptomatic compression of neural elements for which disc excision is necessary for decompression. 
The record must reflect disc compression of neural elements for each level fused based on this 
indication. 
 
You can find these rules in Local Coverage Determination (LCD) Lumbar Spinal Fusion (L37848). 
 
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 Present on admission (POA) is defined as being present at the time the order for inpatient 
admission occurs. Claims for inpatient admission to acute care inpatient prospective payment system hospitals 
must include the appropriate POA indicator for the principal and all secondary diagnoses, unless the code is 
exempt. Exempt POA diagnoses should not be reported. You can find this rule at Centers for Medicare and 
Medicaid Services (CMS), CMS POA Indicator Options and Definitions bulletin located here: 
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding. 
 
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 20% coinsurance for in-network outpatient hospital diagnostic testing 
services, diagnostic radiological services, and x-ray services. You can find this information on page 90 of the 
Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a 20% coinsurance for each in-network outpatient hospital 
facility visit, including physician or surgical charges. You can find this information on page 95 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 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. 
 
You can find this information in 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.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare covers services in an emergency department only if the emergency clinic is 
affiliated with a hospital. You can find this rule at SSA 1861, 42 CFR 489.24, and 42 CFR 413.65. 
 
The rules say that CMS is creating additional flexibilities to allow licensed independent freestanding 
emergency departments (EDs) to participate in Medicare and Medicaid to help address the urgent need to 
increase hospital capacity to provide care to patients. The following ways to participate include: 
Becoming affiliated with a Medicare/Medicaid-certified hospital under the temporary expansion 1135 
emergency waiver. Participating in Medicaid under the clinic benefit if permitted by the State, or 
Enrolling temporarily as a Medicare/Medicaid-certified hospital to provide hospital services. You can find this 
information in The Centers for Medicare and Medicaid Services (CMS) Guidance for Licensed Independent 
Freestanding Emergency Departments (EDs) to Participate in Medicare and Medicaid during the COVID-19 
Public Health Emergency.  
 
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. You can find this information 
on pages 68 to 69 of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that an Excludes1 note indicates that the code excluded should never be used at the same time as 
the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a 
congenital form versus an acquired form of the same condition. You can find this rule at Centers for Medicare 
and Medicaid Services, ICD-10-CM Official Guidelines for Coding and Reporting, Section I.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 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). 
 
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 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/B Administrative Contractors (MACs) (B) may not pay for the technical component (TC) 
of radiology services furnished to hospital patients. Payment for physicians radiological services to the 
hospital, e.g., administrative or supervisory services, and for provider services needed to produce the radiology 
service, is made by the A/B MAC (A) to the hospital as a provider service. A/B MACs (A) include the TC of 
radiology services for hospital inpatients, except Critical Access Hospitals (CAHs), in the prospective payment 
system (PPS) payment to hospitals. Hospital bundling rules exclude payment to suppliers of the TC of a 
radiology service for beneficiaries in a hospital inpatient stay. The TC of radiology and other diagnostic 
services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to 
the hospital. 
 
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 13, Section 20.2.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the indications for cardiac computed tomography and coronary computed tomography 
angiography are: 
  
  a. Patient presenting with chest pain syndrome 
b. To facilitate the management decision of a patient with an equivocal stress test 
c. When the recurrence of symptoms in patients with known coronary artery disease may be related to 
progression/exacerbation of underlying disease 
d. When patients with prior bypass surgery or intracoronary artery stent placement present with chest pain 
or dyspnea 
e. Suspected congenital anomalies of the coronary circulation 
f. The assessment of coronary or pulmonary venous anatomy 
g. The patient undergoing non-coronary cardiac surgery 
h. The test may be medically necessary in patients presenting to the emergency room with complains 
consistent with cardiac ischemia, but without diagnostic electrocardiography or enzymes 
i. The test may be considered medically necessary in patients status post revascularization procedures 
who present with recurrent symptoms not clearly identifiable as ischemic 
 
You can find these rules in Local Coverage Determination (LCD) Cardiac Computed Tomography (CCT) and 
Coronary Computed Tomography Angiography (CCTA) (L33559). 
 
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 An extra heavy duty wheelchair (K0007) is covered if the beneficiary weighs more than 
300 pounds. 
 
A manual wheelchair for use inside the home is covered if: 
 Criteria A, B, C, D, and E are met; and 
 Criterion F or G is met. 
A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, 
grooming, and bathing in customary locations in the home. A mobility limitation is one that: 
  1.  Prevents the beneficiary from accomplishing an MRADL entirely, or 
  2.  Places the beneficiary at reasonably determined heightened risk of morbidity or mortality 
secondary to the attempts to perform an MRADL; or 
  3.  Prevents the beneficiary from completing an MRADL within a reasonable time frame; and 
B. The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately 
fitted cane or walker; and 
C. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for 
use of the manual wheelchair that is provided; and 
D. Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in 
MRADLs and the beneficiary will use it on a regular basis in the home; and 
E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the 
home; and 
F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities 
needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. 
Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or 
absence of one or both upper extremities are relevant to the assessment of upper extremity function; or 
G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the 
wheelchair. 
 
You can find this information in Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788). 
 
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 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 National Coverage Determination (NCD) 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 when calf pads (E0995) are requested simultaneously with a wheelchair accessory, addition 
to power seating system, center mount power elevating leg rest/platform, complete system, any type, each 
(E1012), the E0995 allowance is included in the allowance of the E1012 since it is being requested at the same 
time. The request for E0995 will be denied as not reasonable and necessary because it is included in the 
allowance for the replacement power seating system (E1012). You can find this information in Local Coverage 
Article: Wheelchair Options/Accessories (A52504). 
 
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 $295 copayment per day, for days 1 to 7 and a $0 copayment per day, 
for days 8 to 90 for each Medicare-covered hospital stay. You can find this information on pages 51 to 52 of 
the Plan's 2022 Evidence of Coverage (EOC).