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 thermal destruction of the intraosseous basivertebral nerve BVN will be considered 
medically reasonable and necessary for the treatment of cLBP in patients who meet ALL the following criteria: 
1. Chronic lumbar back pain of greater than or equal to 6 months duration that causes functional deficit 
measured on a pain or disability scale, AND 
2. Documented failure to respond to greater than or equal to 6 months of non-surgical management, AND 
3. Absence of non-vertebrogenic pathology per clinical assessment or radiology studies that could explain 
the source of the patients pain, including but not limited to fracture, tumor, infection, or significant 
deformity, AND 
4. Evidence of Type 1 or Type 2 Modic changes on MRI, such as inflammation, edema, vertebral endplate 
changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent 
marrow, hypotensive signals (Type 1 Modic change), and changes to the vertebral body marrow 
including replacement of normal bone marrow by fat, and hypertensive signals (Type 2 Modic change), 
in 1 or more vertebrae from L3-S1. 
You can find this rule in the Local Coverage Determination (LCD) for Thermal Destruction of the Intraosseous 
Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain, L39420. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 89-90 in the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare 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 CGM's are limited to Freestyle Libre products manufactured by Abbot. You can find this 
information in pages 69 to 71 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. Crowns are covered by the Plan's dental benefits. You can find this information on pages 61 to 68 
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 say that no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2.  
 
The rules say that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 27 of the Plans 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 also say that the patient must be referred to the clinic by the attending/treating physician. The 
referring physician's order for the testing must be kept in the medical record. Sleep testing must be conducted 
by an entity that qualifies as a Medicare provider of sleep testing and is in compliance with all applicable state 
regulatory requirements. The patient who undergoes HST must receive, prior to the test, adequate instruction 
on how to properly apply a portable sleep monitoring device. This instruction must be provided by the provider 
conducting the HST. You can find this rule in the Local Coverage Article (LCA) for Polysomnography and 
Sleep Studies  Medical Policy Article (A53019). 
 
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 proton beam therapy (PBT) is considered reasonable in instances where sparing the 
surrounding normal tissue cannot be adequately achieved with photon-based radiotherapy and is of added 
clinical benefit to the patient. Examples of such an advantage might be: 
 
1. The target volume is in close proximity to one or more critical structures and a steep dose gradient 
outside the target must be achieved to avoid exceeding the tolerance dose to the critical structure(s). 
2. A decrease in the amount of dose inhomogeneity in a large treatment volume is required to avoid an 
excessive dose "hotspot" within the treated volume to lessen the risk of excessive early or late normal 
tissue toxicity. 
3. A photon-based technique would increase the probability of clinically meaningful normal tissue toxicity 
by exceeding an integral dose-based metric associated with toxicity. 
4. The same or an immediately adjacent area has been previously irradiated, and the dose distribution 
within the patient must be sculpted to avoid exceeding the cumulative tolerance dose of nearby normal 
tissue. 
 
PBT may offer dosimetric advantages as well as added complexity over conventional radiotherapy, 3D 
Conformal Radiation Therapy (3-D CRT) or Intensity Modulated Radiation Therapy (IMRT). Before applying 
PBT techniques, a comprehensive understanding of the benefits and consequences is required. In addition to 
satisfying at least one of the four selection criteria noted above, the radiation oncologist's decision to employ 
PBT requires an informed assessment of the benefits and risks. You can find this rule in the Local Coverage 
Determination for Proton Beam Therapy, L35075.  
 
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 the only covered chiropractic service is manual manipulation of the spine to correct a 
subluxation. You can find this information on page 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 state that a seat lift mechanism is covered if all of the following criteria are met: 
 
    The beneficiary must have severe arthritis of the hip or knee or have a severe neuromuscular disease. 
    The seat lift mechanism must be a part of the treating practitioners course of treatment and be prescribed to 
effect improvement, or arrest or retard deterioration in the beneficiary's condition. 
    The beneficiary must be completely incapable of standing up from a regular armchair or any chair in their 
home. (The fact that a beneficiary has difficulty or is even incapable of getting up from a chair, particularly a 
low chair, is not sufficient justification for a seat lift mechanism. Almost all beneficiaries who are capable of 
ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.) 
    Once standing, the beneficiary must have the ability to ambulate. 
 
Coverage of seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the 
beneficiary, and effectively assist a beneficiary in standing up and sitting down without other assistance. 
Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden, catapult-
like motion and jolts the beneficiary from a seated to a standing position. 
 
You can find this information in the Local Coverage Determination (LCD) Seat Lift Mechanisms L33801. 
 
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. 
 
Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is 
bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left 
and right side. If the side is not identified in the medical record, assign the code for the unspecified side. 
 
You can find this information in the Centers for Medicare and Medicaid Services, ICD-10-CM Official 
Guidelines for Coding and Reporting FY 2023, Section 1.B.13. 
 
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 wireless capsule endoscopy of the small bowel is considered medically reasonable and 
necessary when the following conditions have been met:  
 documented continuous blood loss and anemia secondary to obscure bleeding of the small bowel; 
 the site of bleeding could not be previously identified by colonoscopy, or endoscopy, or;  
 radiographic exams of the small bowel have failed to reveal a source, or; 
 intraoperative enteroscopy is being considered, or; 
 initial diagnosis of suspected Crohns Disease when there is no evidence provided by conventional 
diagnostic tests such as small bowel follow-through (SBFT), and upper and lower endoscopy. 
Wireless capsule endoscopy of the esophagus is considered medically reasonable and necessary for the 
following condition, if the criteria have been met: 
 Patient diagnosed with portal hypertension who requires immediate evaluation of esophageal varices  
 AND the esophageal capsule endoscopy is performed in lieu of conventional endoscopy because the 
provider who would perform the endoscopy has determined that the patients current medical condition 
prohibits a conventional endoscopy.  
 AND the medical record clearly reflects why the patient was not a candidate for conventional 
endoscopy and how the capsule endoscopy would contribute to the patients care. 
Limitations 
 Wireless capsule endoscopy of the esophagus will be considered medically necessary only as specified 
under Covered Indications. Performance of wireless capsule endoscopy for any other reason will be 
considered not medically necessary. 
 Wireless capsule endoscopy is not reimbursable for colorectal cancer screening. 
 This test is covered only for services using Food and Drug Administration (FDA) approved devices.  Wireless capsule endoscopy is not indicated for the confirmation of lesions of pathology normally 
within the reach of upper and lower endoscopes (proximal to the ligament of Treitz, or distal to the 
ileum). 
 The use of wireless capsule endoscopy should not be used in patients with a cardiac pacemaker, or other 
implanted electromagnetic device. 
 This test is not indicated for patients in whom a radiological exam of the small bowel has confirmed an 
intestinal blockage, a significantly narrow small bowel, or an abnormal connection between the bowel 
and another organ.  
 An x-ray exam of the small bowel should be done if there is concern that it may be too narrow for the 
camera. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L33774: Wireless Capsule 
Endoscopy. 
 
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
 
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 50 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. Health Plans may specify the networks of providers from whom enrollees may obtain services and may 
require prior authorization for most in-network services if the health plan ensures that all covered services are 
available and accessible under the plan. The Health Plan must arrange for specialty care outside of the plan 
provider network when network providers are unavailable or inadequate to meet an enrollees medical needs. 
You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information in Chapter 3 on page 42 of the 
Plan's 2023 Evidence of Coverage.