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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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 pages 38 and 39 of the Plan's 
2022 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 covers application of CTPS to Ulcers or Wounds with Failed Response that are: 
 Partial- or full-thickness ulcers, not involving tendon, muscle, joint capsule or exhibiting exposed bone 
or sinus tracts, with a clean granular base unless the CTP package label indicates the CTP is approved 
for use involving tendon, muscle, joint capsule or exhibiting exposed bone or sinus tracts, with a clean 
granular base ; 
 Skin deficit at least 1.0 cm2 in size; 
 Clean and free of necrotic debris or exudate; 
 Have adequate circulation/oxygenation to support tissue growth/wound healing as evidenced by 
physical examination (e.g., Ankle-Brachial Index (ABI) of no less than 0.60, toe pressure > 30mm Hg); 
 For diabetic foot ulcers, the patients medical record reflects a diagnosis of Type 1 or Type 2 Diabetes 
and also reflects medical management for this condition. 
  
You can find this in the Local Coverage Determination (LCD): Wound Application of Cellular and/or Tissue 
Based Products (CTPs), Lower Extremities (L36690). 
 
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. 
 
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. 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 rule in the Local Coverage Determination for Facet Joint Interventions for Pain Management, 
L33930.  
 
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 Pneumatic Compression Device (PCD) that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a 
preventative service or function are excluded from coverage under the Medicare DME benefit. A PCD coded as 
E0675 to treat peripheral arterial disease is not eligible for reimbursement. There is insufficient evidence to 
demonstrate that reimbursement is justified. Claims for E0675 will be denied as not reasonable and necessary. 
You can find this information in the Local Coverage Article: Pneumatic Compression Devices - Policy Article 
(A52488) and in the Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829). 
 
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. 
 
You can find this in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management 
(L33930). 
 
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 following indications are covered nationally unless otherwise indicated: 
1. Computer analysis of EKGs when furnished in a setting and under the circumstances required for 
coverage of other EKG services. 
2. EKG services rendered by an IDTF, including physician review and interpretation. Separate physician 
services are not covered unless he/she is the patients attending or consulting physician. 
3. Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed 
as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance 
at the time the service is performed or immediately thereafter. 
4. Home EKG services with documentation of medical necessity. 
5. Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications 
described below, when performed with equipment meeting the standards described below, subject to the 
limitations and conditions specified below. Coverage is further limited to the amounts payable with 
respect to the physicians service in interpreting the results of such transmissions, including charges for 
rental of the equipment. The device used by the beneficiary is part of a total diagnostic system and is 
not considered DME separately. Covered uses are to: 
a. Detect, characterize, and document symptomatic transient arrhythmias; 
b. Initiate, revise, or discontinue arrhythmic drug therapy; or, 
c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); 
(only if 24-hour coverage is provided, see C.5. below). 
 
Certain uses other than those specified above may be covered if, in the judgment of the local Medicare 
Administrative Contractor (MAC), such use is medically necessary. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determination for Electrocardiographic Services, 20.15.  
 
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 if Field 21 contains an indicator of 3, and multiple endoscopies are billed, the special 
rules for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the 
difference between the next highest and the base endoscopy. You can find this rule in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 12, Section 40.6. 
 
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 abdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the 
abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally, 
chronic pain, ulceration created by the abdominal skin fold, or intertrigo dermatitis, such surgery is considered 
reconstructive. Preoperative photographs may be required to support justification and should be supplied upon 
request. 
 
Palmetto GBA considers panniculectomy medically necessary when the panniculus hangs below the level of 
the pubis, and the medical records document that the panniculus causes chronic intertrigo (dermatitis occurring 
on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over 3 months 
while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period 
of 3 months. 
 
Palmetto GBA considers panniculectomy experimental and investigational for minimizing the risk of hernia 
formation or recurrence. There is no adequate evidence that pannus contributes to hernia formation. The 
primary cause of hernia formation is an abdominal wall defect or weakness, not a pulling effect from a large or 
redundant pannus. 
 
Note: If the procedure is being performed following significant weight loss, in addition to meeting the criteria 
noted above, there should be evidence that the individual has maintained a stable weight for at least 3 to 6 
months. If the weight loss is the result of bariatric surgery, abdominoplasty/panniculectomy should generally 
not be performed until at least 18 months after bariatric surgery and only when weight has been stable for at 
least the most recent 3 to 6 months. 
 
You can find this in the Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery 
(L33428). 
 
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 because the available language in the current HIPAA compliant code sets used to describe 
the pathology and laboratory categories and the tests included in those categories are not specific to the actual 
test results provided, all MDT services must include an identifier as additional claim documentation. Test 
providers must receive an identifier specific to the applicable test and submit the test assigned identifier with 
the claim for reimbursement. The assigned identifier will provide a crosswalk between the tests associated 
detail information on file and the submitted claim detail line(s) required to adjudicate each tests claim. The 
unique identifier limits the need to submit the required additional information about the test on each claim. You 
can find this information in Local Coverage Determination (LCD): MolDX: Molecular Diagnostic Tests 
(MDT) (L35025). 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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 pages 3-3 through 3-6 of the 
Plan's 2021 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 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 $45 copayment for Vision Care. You can find this information on page 
140 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 a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints 
(L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury 
to or a surgical procedure on the knee(s) or when knee instability is documented by examination of the 
beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer 
test). This information is found in Local Coverage Determination (LCD): Knee Orthoses (L33318). 
 
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). You can find this rule at 42 CFR Section 422.111.  
 
The rules say that a copayment is a fixed amount 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 $305 copayment for each ambulance trip. You can find this information 
on page 64 of the Plans 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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). You can find this rule in the Local Coverage Article (LCA) - 
Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020. 
 
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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(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 Plan covers other eyewear with $150 allowance every 24 months that you can use to 
pay for eyewear. You can find this information on page 75 of the Plan's 2022 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 percutaneous vertebroplasty (PVP) or kyphoplasty is covered in patients with acute or 
subacute osteoporotic vertebral compression fracture, confirmed by recent advanced imaging. You can find this 
rule in the Local Coverage Determination (LCD) - Percutaneous Vertebral Augmentation (PVA) for Vertebral 
Compression Fracture (VCF) (L38737) - Effective November 28, 2021. 
 
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.