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 in order to support additional research on the use of TENS for CLBP, we will cover this item under section 1862(a)(1)(E) of the Social Security Act (the Act) subject to all of the following conditions: 1. Coverage under this section expires three years after the publication of this decision on the CMS website. 2. The beneficiary is enrolled in an approved clinical study meeting all of the requirements below. The study must address one or more aspects of the following questions in a randomized, controlled design using validated and reliable instruments. This can include randomized crossover designs when the impact of prior TENS use is appropriately accounted for in the study protocol. Does the use of TENS provide clinically meaningful reduction in pain in Medicare beneficiaries with CLBP? Does the use of TENS provide a clinically meaningful improvement of function in Medicare beneficiaries with CLBP? Does the use of TENS impact the utilization of other medical treatments or services used in the medical management of CLBP? You can find this information in Medicare's National Coverage Determination (NCD): Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP) (160.27).
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 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 Plan covers items and services in accordance with Medicare rules. The Plan contract also says that there is a $150 deductible which applies to certain items and services. The Plan deductible applies to periodontal maintenance. You can find this information on pages 119 to 123 of the Plan's 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 local Medicare coverage of biomarkers for oncology must be predicated upon four fundamental principles: 1. First, the biomarkers must have proven clinical validity/utility (CVU). 2. Second, to support the medical necessity of the service, there must be acceptance/uptake of specific testing into patient management. It is essential that physicians be familiar enough with all specific biomarkers, which they order, such that all test results may become clinically actionable. 3. Providers managing oncological conditions must demonstrate that the use of biomarkers will be used to assist in the management/treatment of the beneficiary. 4. Peer-reviewed full manuscript evidence is required to support combination panels for multiple biomarkers, particularly regarding their alleged composite clinical validity/utility. For example; such potential billing for multiple, diverse biomarkers (e.g., diagnostic/monitoring/prognostic/predictive) can only achieve medical necessity when it is clearly evident how each requested biomarker can be individually contributory. You can find this rule in the Local Coverage Determination (LCD) - Biomarkers for Oncology (L35396) - Effective December 13, 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.
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 doctor's 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 up to 24 one-way trips to Plan approved locations every year. You can find this information on page 96 of the Plan's 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 state that an extra wide/heavy duty commode chair (E0168) is covered for a beneficiary who weighs
300 pounds or more. If an E0168 commode is ordered and the beneficiary does not weigh more than 300
pounds, it will be denied as not reasonable and necessary. You can find this in the Local Coverage
Determination (LCD): Commodes (L33736).
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 fluid circulating cold pad with pump (E0218) will be denied as not reasonable and
necessary. You can find this information in Medicare's Local Coverage Determination (LCD): Cold Therapy
(L33735).
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 Appeal Number is:
1-10502427666
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 a Medicare plan may restrict enrollees 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 an enrollee's medical needs. You can find this rule at 42 CFR Section 422.112.
The rules say that plans must ensure continuity of care for enrollees. You can find this rule in the Centers for
Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 4, Section
110.6.
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The
rules say plans may require prior authorization for most in-network services if the plan ensures that all covered
services are available and accessible under the plan. The plan must arrange for specialty care outside of the
plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through
arrangements with contracted providers. This includes services available through contracting or noncontracting
providers in the area serviced by the health plan including nursing home and community based
services. You can find this rule at 42 CFR Section 422.112.
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 molecular pathology procedures (Tier 1 and Tier 2) may be eligible for coverage when ALL of the following criteria are met: 1. Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are unavailable or results are clearly equivocal; AND 2. Availability of a clinically valid test, based on published peer reviewed medical literature; AND 3. Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed test) or LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) analytical validity and clinical utility; AND 4. Results of the testing must directly impact treatment or management of the beneficiary; AND 5. For testing panels, including but not limited to, multiple genes or multiple conditions, and in cases where a tiered approach/method is clinically available, testing would be covered ONLY for the number of genes or test that are reasonable and necessary to establish a diagnosis; AND 6. Individual has not previously received genetic testing for the disease/condition. (In general, diagnostic genetic testing for a disease should be performed once in a lifetime. You can find this rule in the Local Coverage Determination (LCD) - Molecular Pathology Procedures (L35000) - Effective October 1, 2019.
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 pays for outpatient rehabilitation therapy services only when they are provided by
those trained specifically in physical therapy, occupational therapy or speech-language pathology. This means
that the services of massage therapists may not be billed as covered therapy services. You can find these rules
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare
Benefit Policy Manual, Chapter 15, Section 230.5.
The rules say that Medicare plans may not offer a massage therapy benefit. 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 30.4.
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 state that therapeutic continuous glucose monitors (CGMs) and related supplies are covered by Medicare when all of the following coverage criteria are met:
1. The beneficiary has diabetes mellitus, 2. The beneficiary has been using a blood glucose monitor (BGM) and performing frequent (four or more times a day) testing, 3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump, 4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results. 5. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822).
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 manual wheelchair with tilt in space (E1161) is covered if the beneficiary meets the general coverage criteria for a manual wheelchair above, and if criteria (1) and (2) are met:
1. The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician 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 LCMP may have no financial relationship with the supplier.
2. The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient.
You can find this rule at Local Coverage Determination (LCD) L33788: Manual Wheelchair Bases (eff. 1/1/20).
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 seat lift mechanism is covered if all of the following criteria are met:
1. The beneficiary must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
2. The seat lift mechanism must be a part of the treating practitioner's course of treatment and be prescribed
to effect improvement, or arrest or retard deterioration in the beneficiary's condition.
3. The beneficiary must be completely incapable of standing up from a regular armchair or any chair in their
home. (The fact that a beneficiary has difficulty or is even incapable of getting up from a chair, particularly a
low chair, is not sufficient justification for a seat lift mechanism. Almost all beneficiaries who are capable of
ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.)
4. Once standing, the beneficiary must have the ability to ambulate.
Coverage of seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the
beneficiary, and effectively assist a beneficiary in standing up and sitting down without other assistance.
Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden, catapultlike
motion and jolts the beneficiary from a seated to a standing position.
The practitioner ordering the seat lift mechanism must be the treating practitioner or a consulting practitioner
for the disease or condition resulting in the need for a seat lift. The practitioner's record must document that all
appropriate therapeutic modalities (e.g., medication, physical therapy) have been tried and failed to enable the
beneficiary to transfer from a chair to a standing position.
When providing a seat lift mechanism that is incorporated into a chair as a complete unit at the time of
purchase, suppliers must bill the item using the established HCPCS code for the seat-lift mechanism. In this
situation, the supplier may bill the seat lift mechanism using E0627 or E0629, and bill A9270 for the chair.
You can find this information in Medicare's Local Coverage Article: Seat Lift Mechanisms - Policy Article
(A52518) and Local Coverage Determination (LCD): Seat Lift Mechanisms (L33801).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
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 providers 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).
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 guidance says that the upgraded electronics (expandable controller, harness and electronic connector
to 2 power options) are not medically necessary. They cannot be covered. You can find this guidance in the
Local Coverage Article Wheelchair Options/Accessories - Policy Article (A52504).
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 the quantity of ostomy supplies needed by a beneficiary is determined primarily by the type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will be variation according to individual beneficiary need and their needs may vary over time. The table below lists the maximum number of items/units of service that are usually reasonable and necessary. The actual quantity needed for a particular beneficiary may be more or less than the amount listed depending on the factors that affect the frequency of barrier and pouch change. The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the beneficiary's medical record. If adequate documentation is not provided when requested, the excess quantities will be denied as not reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD) - Ostomy Supplies (L33828) - Effective January 1, 2020. The rules say that the usual maximum quantity of supplies for A4424 is 20 per month. You can find this rule in the Local Coverage Determination (LCD) - Ostomy Supplies (L33828) - Effective January 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.

The rules say that effective June 8, 2012, the Centers for Medicare & Medicaid Services (CMS) will allow
coverage for Transcutaneous Electrical Nerve Stimulation (TENS) for CLBP only when the beneficiary is
enrolled in an approved clinical study meeting specific criteria. You can find this rule in the Centers for
Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-03, Medicare National
Coverage Determinations (NCD) Manual, Section 160.27.

The rules say that a PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in
beneficiaries with chronic and severe lymphedema when all the following three requirements are met:
1. The beneficiary has a diagnosis of lymphedema as defined above, and
2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented
presence of at least one of the following clinical findings:
a. Marked hyperkeratosis with hyperplasia and hyperpigmentation,
b. Papillomatosis cutis lymphostatica,
c. Deformity of elephantiasis,
d. Skin breakdown with persisting lymphorrhea,
e. Detailed measurements over time confirming the persistence of the lymphedema with a history
evidencing a likely etiology, and
3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to
other clinical treatment over the course of a required four-week trial.

A PCD coded as E0650 or E0651 used to treat lymphedema that does not meet all the requirements above is
not eligible for reimbursement. Claims will be denied as not reasonable and necessary. You can find this rule at
Local Coverage Determination (LCD) L33829: Pneumatic Compression Devices (eff. 1/1/20).

The rules say that Vitamin B12 injections to strengthen tendons, ligaments, etc., of the foot are not covered
under Medicare because (1) there is no evidence the Vitamin B12 injections are effective for the purpose of
strengthening weakened tendons and ligaments, and (2) this is nonsurgical treatment under the subluxation
exclusion. Accordingly, Vitamin B12 injections are not considered reasonable and necessary within the
meaning of 1862(a)(1) of the Act. You can find this rule in the Centers for Medicare and Medicaid Services
(CMS), Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD)
Manual, Section 150.6.

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.