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 provisions in this LCD and related coding article only address Vertebral Augmentation for 
Osteoporotic Vertebral Compression Fracture (VCF). Coverage will remain available for medically necessary 
procedures for other conditions not included in this LCD. 
 
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 VCF (T1  L5), based on symptom 
onset, and documented by advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake)  
        Symptomatic (ONE): 
            Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score = 
8) 
            Non-hospitalized with moderate to severe pain (NRS or VAS =5) despite optimal non-surgical 
management (NSM) (10) (ONE): 
                Worsening pain 
                Stable to improved pain (but NRS or VAS still =5) (with = 2 of the following): 
                    Progression of vertebral body height loss 
                    Greater than 25% vertebral body height reduction 
                    Kyphotic deformity 
                    Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
greater than 17 
        Continuum of care (10) (Both)  
            All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis education 
for subsequent treatment as indicated. 
            All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment 
program. 
 
    Exclusion criteria (Can have NONE of the following):           Absolute contraindication 
            Current back pain is not primarily due to the identified acute or subacute VCF(s). 
            Osteomyelitis, discitis, active systemic or surgical site infection 
            Pregnancy 
        Relative contraindication 
            Greater than three vertebral fractures per procedure 
            Allergy to bone cement or opacification agents 
            Uncorrected coagulopathy 
            Spinal instability 
            Myelopathy from the fracture 
            Neurologic deficit 
            Neural impingement 
            Fracture retropulsion/canal compromise 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L33569). 
 
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 a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1843, L1845, L1851, L1852) is covered if the beneficiary has had recent injury to 
or a surgical procedure on the knee(s). They are also also covered for a beneficiary who is ambulatory and has 
knee instability. Knee instability must be documented by examination of the beneficiary and objective 
description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). Claims will be denied 
as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For 
example, they will be denied if only pain or a subjective description of joint instability is documented. You can 
find this information in the 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 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 only the 
items and services listed in the dental rider. An endosteal implant (D6010), a bone replacement graft (D4263), 
and guided tissue regeneration (D4266) are not covered by the Plan's dental benefits. You can find this 
information on pages 99-105 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 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 only the 
items and services listed in the covered dental services code chart. A partial maxillary denture with a flexible 
base (D5225) is not covered by the Plan's dental benefits. You can find this information on pages 103-115 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 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 specific 
dental items/services stated in the Plans contract. Dental implants are not a covered benefit. You can find this 
information on pages 59-60 and 103-115 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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers routine transportation to plan approved health-related locations up to 30 one-way trips per calendar year. 
Each one-way trip must not exceed 60 miles based on the most efficient route. You can find this information on 
pages 74 to 75 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 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 specific 
items/services stated in the Plans contract. A complete lower denture, lower immediate denture, or lower 
partial denture is covered once every 60 months. The Plan contract also states that replacement of removable 
and fixed prostheses is covered only if the existing prostheses were inserted at least 60 months prior to the 
replacement and satisfactory evidence is presented that the existing prostheses are not and cannot be made 
serviceable. You can find this information on pages 59-60 and 103-115 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 payment may be made for a one-time ultrasound screening for abdominal aortic aneurysm 
(AAA) for beneficiaries who are in at least one of the following risk categories: 
 
1. has a family history of AAA; 
2. is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; 
3. is a beneficiary who manifests other risk factors in a beneficiary category recommended for screening by the 
United States Preventive Services Task Force regarding AAA, as specified by the Secretary of Health and 
Human Services, through the national coverage determination process. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 110.2. 
 
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 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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
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 7-8 of the 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 specific 
dental procedure codes included in a dental benefits chart with a list of exclusions. Dental implants are 
excluded from coverage. You can find this information on page 124 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 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 specific 
dental items/services stated in the Plans contract. Services are only covered when received by a participating 
provider. You can find this information on pages 59-60 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 proton beam therapy will be considered medically reasonable and necessary for the 
following conditions: 
 
Group #2 Conditions 
 
    Malignant lesions of the prostate 
    Malignant advanced stage, non-metastatic tumors of the bladder 
    Skin cancer with perineural/cranial nerve invasion 
    Unresectable retroperitoneal sarcoma and extremity sarcoma 
    Cancers of the lung and upper abdominal/peri-diaphragmatic cancers 
    Malignant lesions of the liver, biliary tract, anal canal and rectum  
 
Limitations 
 
In general, proton beam radiotherapy is not indicated for cancers that are widely disseminated, such as 
leukemias, have hematogenous metastases or as a short-term palliative procedure. The intent of treatment 
should be curative. If proton beam radiotherapy is used for a patient with metastatic disease, evidence should 
be provided to justify the expectation of a long-term benefit (> 2y), as well as evidence of a dosimetric 
advantage for proton beam radiotherapy over other forms of radiation therapy. 
 
All other indications are not considered reasonable and necessary and will be denied. 
 
As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 
13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the 
Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under 
which the item or service is considered reasonable and necessary. You can find this information in Medicare's 
Local Coverage Determination (LCD): Proton Beam Radiotherapy (L33937). 
 
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 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 
coverage for the requested items or services, but only when they are received from an in-network provider. You 
can find this information on page 66 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 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 page(s) 29 and 30 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 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 specific 
dental procedures included in a dental benefits chart. Fixed partial denture sectioning is not listed as a covered 
dental benefit. You can find this information on pages 103-109 of the Plans 2023 Evidence of Coverage 
(EOC).