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 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. Core buildup (D2950) is not listed as a covered dental 
benefit. You can find this information on pages 75-78 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 for claims with dates of service on or after January 1, 2023, a non-adjunctive continuous glucose monitor (CGM) must be billed with code E2103. Code E2103 describes a non-adjunctive CGM that meets the requirements of the durable medical equipment (DME) benefit. To be eligible for Medicare reimbursement, all CGM devices billed as E2103 must have received coding verification review by the Pricing, Data Analysis and Coding (PDAC) contractor and be listed on the Product Classification List (PCL) for Healthcare Common Procedure Coding System (HCPCS) code E2103. You can find this information in the Local Coverage Article: Glucose Monitor - Policy Article (A52464). The rules say that a Freestyle Libre 3 is not specified as a product that may be billed using code E2103. You can find this information in the Product Classification List (PCL) on the Pricing Data Analysis, and Coding (PDAC) contractor website.
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 $375 copayment for in-network diagnostic radiology and a 20% coinsurance for Medicare Part B prescription drugs. You can find this information on pages 99 and 104-105 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 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 certain dental services as a supplemental (extra) benefit with limitations and exclusions. You can review the dental benefits on pages 125 to137 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 
coverage for only those items and services specifically listed in your Plan contract. Debridement of a peri-
implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, 
including flap entry and closure (D6101) is not listed as covered. You can find this information page 38 of the 
Plan's 2023 Evidence of Coverage (EOC) and in the Plan's 2023 Patient Charge Schedule booklet.
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 based on information in the scientific literature, intra-operative testing may be considered 
reasonable and necessary for the following: 

 Surgery of the aortic arch, its branch vessels, or thoracic aorta, including carotid artery surgery, when 
there is risk of cerebral or spinal cord ischemia 
 Resection of epileptogenic brain tissue or tumor 
 Resection of brain tissue close to the primary motor cortex and requiring brain mapping 
 Protection of cranial nerves:  
 Resection of tumors involving the cranial nerves 
 Cavernous sinus tumors 
 Microvascular decompression of cranial nerves 
 Skull base surgery in the vicinity of the cranial nerves and surgeries of the foramen magnum 
 Oval or round window graft 
 Endolymphatic shunt for Meniere's disease 
 Vestibular section for vertigo 
 Correction of scoliosis or deformity of spinal cord involving traction of the cord  Protection of spinal cord where work is performed in close proximity to cord as in the placement or 
removal of old hardware or where there have been numerous interventions 
 Spinal instrumentation requiring pedicle screws or distraction 
 Decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or 
claudication where function of spinal cord or spinal nerves is at risk 
 Spinal cord tumors and spinal fractures (with the risk of cord compression) 
 Neuromas of peripheral nerves of brachial plexus, when there is risk to major sensory or motor nerves 
 Surgery or embolization for intracranial AV malformations 
 Surgery for arteriovenous malformation of spinal cord 
 Embolization of bronchial artery AVMs or tumors 
 Cerebral vascular aneurysms 
 Surgery for intractable movement disorders 
 Arteriography, during which there is a test occlusion of the carotid artery 
 Circulatory arrest with hypothermia (does not include surgeries performed under circulatory bypass) 
 Distal aortic procedures, where there is risk of ischemia to spinal cord 
 Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks 
 Basal ganglia movement disorders 
 Surgery as a result of traumatic injury to spinal cord/brain 
 Deep brain stimulation, and 
 Certain thyroid surgeries  

You can find this information in the Local Coverage Determination (LCD) for Intraoperative 
Neurophysiological Testing (L35003). 

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that The Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations 
Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 stipulates that ventilators (E0465, E0466, and 
E0467) are covered for the following conditions: 
 
"[N]euromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic 
obstructive pulmonary disease." 
 
Each of these disease categories are comprised of conditions that can vary from severe and life-threatening to 
less serious forms. These ventilator-related disease groups overlap conditions described in this Respiratory 
Assist Devices LCD used to determine coverage for bi-level PAP devices. Each of these disease categories are 
conditions where the specific presentation of the disease can vary from beneficiary to beneficiary. For 
conditions such as these, the specific treatment plan for any individual beneficiary will vary as well. Choice of 
an appropriate treatment plan, including the determination to use a ventilator vs. a bi-level PAP device, is made 
based upon the specifics of each individual beneficiary's medical condition. In the event of a claim review, 
there must be sufficient detailed information in the medical record to justify the treatment selected. 
 
Ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and payment policy 
requirements preclude FSS payment for devices used to deliver continuous and/or intermittent positive airway 
pressure, regardless of the illness treated by the device. (Social Security Act 1834(a)(3)(A)) This means that 
products currently classified as HCPCS code E0465, E0466, or E0467 when used to provide CPAP or bi-level 
PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in 
the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions described in 
this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP 
(E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions 
described in this RAD policy will be denied as not reasonable and necessary. 
 
You can find this rule in the Local Coverage Determination (LCD) for Respiratory Assist Devices (L33800). 
 
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 home health services under a plan of care are paid based on a 30-day period of care. Home Health Agencies (HHAs) submit a Notice of Admission (NOA) at the beginning of an admission and then submit one claim for each 30-day period of care. Claims submitted before an NOA has been received for the enrollee will be returned to the provider You can find this in the Medicare Claims Processing Manual Chapter 10, Section 40.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that 4 months (including the time NPWT was applied in an inpatient setting prior to discharge to 
the home) have elapsed using a NPWT pump in the treatment of the most recent wound. 
 
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 in all wound management, the ulcer must be free of infection and underlying osteomyelitis 
with documentation of the conditions that have been treated and resolved prior to the institution of skin 
substitute therapy. 
 
You can find these rules in Local Coverage Determination (LCD) Application of Bioengineered Skin 
Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041). 
 
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. 
 
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. 
 
When a patient has a bilateral condition and each side is treated during separate encounters, assign the 
"bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. 
For the second encounter for treatment after one side has previously been treated and the condition no longer 
exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., 
cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for 
the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the 
treatment on the first side did not completely resolve the condition, then the bilateral code would still be 
appropriate. 
 
When laterality is not documented by the patients provider, code assignment for the affected side may be 
based on medical record documentation from other clinicians. If there is conflicting medical record 
documentation regarding the affected side, the patients attending provider should be queried for clarification. 
Codes for unspecified side should rarely be used, such as when the documentation in the record is 
insufficient to determine the affected side and it is not possible to obtain clarification. 
 
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 say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that Medicare pays for up to 100 days of skilled care in a SNF in each benefit period. A benefit 
period begins upon admission to a hospital or SNF and ends after 60 days in a row without the patient receiving 
hospital or skilled SNF services. You can find this rule in the Social Security Act, Section 1862(a)(18), at 42 
CFR Sections 409.60(a) and (b) and Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, Section 
10.4. 
 
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). If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the enrollee has a $300 Benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). The Plan contract also says the enrollee must pay any amount over the $300 retail price. You can find this information on page 81 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 say that PVA (Percutaneous Vertebroplasty (PVP) or Kyphoplasty (PKP)) is covered in patients with 
BOTH the following: 
1. Inclusion criteria (ALL are required):  
a. Acute (< 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) 
1-3,10,25,27
 
b. Symptomatic (ONE):  
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score  8) 
4-7
 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS 5) despite optimal non-
surgical management (NSM)
10
 (ONE):  
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 (RDQ) >17 
c. Continuum of care
10
 (Both)  
i. All patients presenting with VCF should be referred for evaluation of 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 
2,5,8-10
 (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 this rule at Local Coverage Determination (LCD) L34228: Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (eff. 1/10/21). 
 
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.
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 there are some services that will not be covered. Dental care services from any dentist other than the assigned contract dentist will not be covered. You can see this on page 98 of the Plans 2023 Evidence of Coverage.
The Plan contract says that for dental services. Prior authorization may be required from our plan. Referral may be required from your network dentist. You can see this on page 69 of the Plans 2023 Evidence of Coverage.
The Plan contract defines a contract dentist as a dentist who provides services in general dentistry, and who has agreed to provide benefits to enrollees. You can see this on page 209 of the Plans 2023 Evidence of Coverage.