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 a repeat polysomnography (PSG) should not be routinely indicated for the assessment of 
treatment results in patients whose symptoms continue to be resolved with PAP treatment. Repeat PSG or PSG 
with continuous positive airway pressure (CPAP) titration may be indicated in the following circumstances: 
 
    1. After surgical treatment of patients with obstructive sleep apnea (OSA), to ensure satisfactory response; or 
    2. After surgical treatment of patients with OSA whose symptoms return despite a good initial response to 
treatment. 
    3. After substantial weight loss has occurred in patients on positive airway pressure (PAP) for treatment of 
OSA to ascertain whether PAP is still needed at the previously titrated pressure; 
    4. After substantial weight gain has occurred in patients previously treated with PAP successfully, who are 
again symptomatic despite the continued use of PAP, to ascertain whether pressure adjustments are needed; or 
    5. When clinical response is insufficient or when symptoms return despite a good initial response to 
treatment with PAP 
    6. Initial CPAP was not tolerated and bilevel positive airway pressure (BPAP) is to be used in lieu of CPAP 
 
You can find this information in the Local Coverage Determination (LCD) for Polysomnography and Sleep 
Testing (L33405). 
 
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 a power standing feature (E2301) is non-covered because it is not primarily medical in 
nature. You can find this rule in the Local Coverage Article for Wheelchair Options/Accessories - Policy 
Article (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 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. The Plan has a Point-of-Service (POS) option to cover out-of-
network services. Prior authorization rules apply. You can find this information on page 64-66 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. The Plan has a Point-of-Service (POS) option to cover certain 
out-of-network services. You can find this information on page 38 of the Plan's 2023 Evidence of Coverage 
(EOC).  
 
The Plan contract also says that out-of-network virtual care services are not covered. You can find this 
information on pages 117-118 of the Plans 2023 EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that percutaneous vertebral augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients with osteoporotic vertebral compression fracture (VCF) when both 
of the following: 
1. Inclusion criteria (all are required): 
a. Acute (less than 6 weeks) or subacute (6 to 12 weeks) osteoporotic VCF (T1  L5), based on 
symptom onset, and documented by advanced imaging 
b. Symptomatic (one of the following): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score of 8 or more) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS of 5 or more) despite 
optimal non-surgical management (NSM): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still  or more 5) (with 2 or more of the 
following): 
A. Progression of vertebral body height loss 
B. More than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) more than 17 
c. Continuum of care (Both are required) 
i. All patients presenting with VCF should be referred for evaluation of bone mineral 
density (BMD) and osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program. 
2. Exclusion criteria (Can have none of the following): 
a. Absolute contraindication 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
ii. Osteomyelitis, discitis or active systemic or surgical site infection iii. Pregnancy 
b. Relative contraindication 
i. Greater than three vertebral fractures per procedure 
ii. Allergy to bone cement or opacification agents 
iii. Uncorrected coagulopathy 
iv. Spinal instability 
v. Myelopathy from the fracture 
vi. Neurologic deficit 
vii. Neural impingement 
viii. Fracture retropulsion/canal compromise 
 
You can find these rules in Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L38201). 
 
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 $325 copayment for in-network outpatient surgery. You can find this 
information on pages 96-97 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. The Plan has a Point-of-Service (POS) option to cover certain 
out-of-network services. You can find this information on page 38 of the Plan's 2023 Evidence of Coverage 
(EOC). 
 
The Plan contract also says that out-of-network virtual care services are not covered. You can find this 
information on pages 117-118 of the Plan's 2023 EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that TENS therapy for Chronic Low Back Pain (CLBP) will be denied as not reasonable and 
necessary. You can find this rule in the Local Coverage Determination (LCD) for Transcutaneous Electrical 
Nerve Stimulators (TENS), L33802. 
 
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 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 
2. Pain that has been present for a minimum of 3 months with documented failure to respond to 
noninvasive conservative care management 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
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 thermal radiofrequency ablation (RFA) of cervical, thoracic, or lumbar paravertebral facet joint 
(medial branch) nerves is considered medically reasonable and necessary for patients who have had at least two 
(2) medically reasonable and necessary diagnostic medial branch blocks (MBBs), with each one providing a 
consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being 
consistent with the agent used). You can find these rules 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay 20% coinsurance for in-network Medicare-covered prosthetic devices, 
supplies related to prosthetic devices, and orthotics. You can find this information on page 96 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 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 40% coinsurance for a home based sleep study. You can find this 
information on page 78 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 say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that CWF shall revise the current line level edits from once every 30 days to only allow a 
frequency of one every 14 days for the following codes when billed with the GT or GQ modifier or Place of 
Service (POS) code 02, effective for claims with dates of service on or after January 1, 2021, that are processed 
on or after July 6, 2021: 
99307 
99308 
99309 
99310 
You can find this rule in the Centers for Medicare & Medicaid Services, Pub 100-04, Medicare Claims 
Processing, Transmittal 10716. 
 
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 a percutaneous kyphoplasty is covered in patients with both the following: 
 
a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (T1  L5) by recent 
(within 30 days) advanced imaging (bone marrow edema on magnetic resonance imaging (MRI) or bone-
scan/single photon emission computed tomography (SPECT)/computed tomography (CT) uptake) and 
b. Symptomatic (ONE): 
     i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score  8 
     ii. Non-hospitalized with moderate-to-severe pain (NRS or VAS 5) despite optimal non-surgical 
management: 
     1. Worsening pain; 
     2. Stable-to-improved pain (but NRS or VAS still 5) (with  2 of the following): 
         A. Progression of vertebral body height loss 
         B. > 25% vertebral body height reduction 
         C. Kyphotic deformity 
         D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire. 
 
You can find this information in the Local Coverage Determination (LCD) Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38737). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
  The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Transcutaneous Electrical Nerve Stimulator (TENS) therapy for Chronic Low Back Pain 
(CLBP) will be denied as not reasonable and necessary. You can find this rule in the Local Coverage 
Determination (LCD) for Transcutaneous Electrical Nerve Stimulators (TENS), L33802. 
 
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 Group 3 power wheelchair (PWC) with multiple power options (such as code K0861) is 
covered if: 
     A. All of the coverage criteria for a PWC are met; and 
     B. The beneficiarys mobility limitation is due to a neurological condition, myopathy, or congenital 
deformity; and 
     C. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical 
professional, such as a physical therapist (PT) or occupational therapist (OT), or practitioner who has specific 
training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for 
the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or practitioner 
may have no financial relationship with the supplier; and 
     D. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and Assistive 
Technology Society of North America (RESNA) certified Assistive Technology Professional (ATP) who 
specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the 
beneficiary. 
     E. Criterion 1 or 2 is met; and 
          1. The beneficiary meets coverage criteria for a power tilt and recline seating system (see Wheelchair 
Options and Accessories policy) and the system is being used on the wheelchair. 
          2. The beneficiary uses a ventilator which is mounted on the wheelchair. 
 
If the PWC base is not covered, then related accessories will be denied. 
 
If the PWC base is not covered, then related accessories will be denied. You can find this information in the 
Local Coverage Determination (LCD) for Power Mobility Devices (L33789). 
 
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 a $1000 
allowance every year for non-Medicare covered preventive dental services and non-Medicare covered 
comprehensive dental services combined. The enrollee is responsible for any amount above the dental coverage 
limit. You can find this information on pages 74-74 of the Plan's 2023 Evidence of Coverage (EOC).