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 pays for care in a skilled nursing facility (SNF) when all of the following four factors are met:1. The patient requires skilled nursing or skilled rehabilitation services;2. The patient requires these services on a daily basis;3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and4. The services are reasonable and necessary for the treatment of the patient's illness or injury or the services must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from getting worse. You can find these rules at 42 CFR Section 409.31 and in the Medicare Benefit Policy Manual, Chapter 8, Section 30.  The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoingcare from trained medical or paramedical staff. Custodial care serves to help with the activities of daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also custodial care services. You can find this rule in the Medicare Benefit Policy Manual, Chapter 16, Section 110.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 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 beneficiaryon the basis of BGM or CGM testing results.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.
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 SSA, Section 1862(a)(12) and 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 health plan contract says limitations/restrictions: services must be performed by a participating general dentist. You can find this information in Chapter 4 on page 64 of the plan's 2020 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 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 state that impotence is a failure of a body part for which the diagnosis, and frequently the treatment, 
require medical expertise. Depending on the cause of the condition, treatment may be surgical; e.g., 
implantation of a penile prosthesis, or nonsurgical; e.g., medical or psychotherapeutic treatment. 
 
Program payment may be made for diagnosis and treatment of sexual impotence.  Since causes and, therefore, 
appropriate treatment vary, if abuse is suspected it may be necessary to request documentation of 
appropriateness in individual cases. 
 
You can find these rules in National Coverage Determination (NCD) for Diagnosis and Treatment of 
Impotence (230.4). 
 
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 that Because many radiological oncologists believe that proton beam therapy is a legitimate 
treatment option in certain circumstances where 3-dimensional conformal or intensity modulated radiation 
therapy (IMRT) is deemed medically necessary, proton beam therapy will be considered as medically 
reasonable and necessary for certain other conditions (i.e., Group #2 of ICD-10-CM Codes that Support 
Medical Necessity) not listed above, as long as the following criteria are met: 
 
Either #1, #2, or #3 must be present and 
 
Either #4 or #5 must be present and 
 
#6 must always be present. 
 
1.  When dose constraints to normal tissues limit the total dose of radiation safely deliverable to the tumor with 
other indicated methods 
 
2.  When there is a reason to believe that doses generally thought to be above the level otherwise attainable 
with other methods might improve control rates 
 
3.  In circumstances when the higher levels of precision associated with proton beam therapy as compared to 
other radiation methods are necessary, i.e., clinically relevant 
 
4.  For the treatment of primary lesions, the intent of treatment must be curative 
 
5.  For the treatment of metastatic lesions, there must be 
 
    the expectation of a long-term benefit (> 2y) that could not have been attained with conventional therapy 
    the expectation of a complete eradication of the metastatic lesion that could not have been safely 
accomplished with conventional therapy, as evidenced by a dosimetric advantage for proton beam radiotherapy 
over other forms of radiation therapy 
 
6.  The patient?s record demonstrates why Proton beam radiotherapy is considered the treatment of choice for 
the individual patient. Specifically, the record must address the lower risk to normal tissue, the lower risk of 
disease recurrence, and the advantages of the treatment over IMRT or 3-dimensional conformal Dosimetric 
evidence of reduced normal tissue toxicity and/or improved tumor control must be maintained. 
 
If the above provisions are met and the patient is treated in a protocol that is designed for evidence 
development and for future publication, it is expected that future published data will support an outcome 
advantage for patients for continued coverage of the specific diagnosis. The protocol in and by itself does not 
constitute criteria for coverage. The presence of an Institutional Review Board review, when appropriate, and 
patient informed consent are also expected. 
 
 
 
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 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 also says that your PCP can also coordinate the rest of the covered services you get as a plan member. 
For example, in order to see a network specialist, you usually need to get your PCP's approval first (this is 
called getting a "referral" to a specialist). You can find this information on pages 39-40 of the Plan's 2020 
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 effective for services performed on or after January 9, 2014, Percutaneous Image-Guided Lumbar 
Decompression (PILD) for Lumbar Spinal Stenosis (LSS) may only be covered under the context of a clinical 
trial as described in section B above according to section 1862(a)(1)(E) of the Social Security Act. CMS has 
determined that PILD for LSS is not reasonable and necessary under section 1862(a)(1)(A) of the Act. You can 
find this information in Medicare's National Coverage Determination (NCD) for Percutaneous Image-Guided 
Lumbar Decompression for Lumbar Spinal Stenosis (150.13). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

We decided that the Plan does not have to pre-approve Musculoskeletal Surgery (CPT Code(s): 22869, 22612, 22867, 22870) for the enrollee.

You asked the Plan to pre-approve this surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the distraction device requested is  experimental as more research is needed to show safety and efficacy. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Musculoskeletal Surgery (CPT Code(s): 22869, 22612, 22867, 22870) for the enrollee.
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.Intravenous immune globulin (IVIG) may be indicated for:Myasthenia gravis (MG). Routine use is not indicated. IVIG may be considered in patients with severe MG to treat acute severe decompensation when other treatments have been unsuccessful or are contraindicated. You can find this rule and further indication in Local Coverage Determination (LCD): Immune Globulins (L34771).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 The Centers for Medicare & Medicaid Services (CMS) covers percutaneous LAAC for non-valvular atrial fibrillation (NVAF) through Coverage with Evidence Development (CED) with the following conditions:

LAAC devices are covered when the device has received Food and Drug Administration (FDA) Premarket Approval (PMA) for that device's FDA-approved indication and meet all of the conditions specified below:The patient must have:

A CHADS2 score = 2 (Congestive heart failure, Hypertension, Age > 75, Diabetes, Stroke/transient ischemia attack/thromboembolism) or CHA2DS2-VASc score = 3 (Congestive heart failure, Hypertension, Age = 65, Diabetes, Stroke/transient ischemia attack/thromboembolism, Vascular disease, Sex category)A formal shared decision making interaction with an independent non-interventional physician using an evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. Additionally, the shared decision making interaction must be documented in the medical record.A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following the conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral anticoagulants. The patient (preoperatively and postoperatively) is under the careof a cohesive, multidisciplinary team (MDT) of medical professionals. The procedure must be furnished in a hospital with an established structural heart disease (SHD) and/or electrophysiology (EP) program.The procedure must be performed by an interventional cardiologist(s), electrophysiologist(s), or cardiovascular surgeon (s) that meet the following criteria:Has received training prescribed by the manufacturer on the safe and effective use of the device prior to performing LAAC; and,

Has performed = 25 interventional cardiac procedures that involve transeptal puncture through an intact septum; and,Continues to perform = 25 interventional cardiac procedures that involve transeptal puncture through an intact septum, of which at least 12 are LAAC, over a 2-year period.T
he patient is enrolled in, and the MDT and hospital must participate in, a prospective, national, audited registry that: 1) consecutively enrolls LAAC patients
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 screening tests are excluded from coverage. The only exceptions are for the following services: 1. screening mammography, 2. colorectal cancer screening tests, 3. screening pelvic exams, 4. prostate cancer screening tests, 5. glaucoma screening exams, 6. ultrasound screening for abdominal aortic aneurysms (AAA), 7. cardiovascular disease screening tests, 8. diabetes screening tests, and 9. screening electrocardiograms 10. certain other testing recommended by the United States Preventive Services Task Force and approved by CMS You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. The rules say that the following HCPCS codes are to be billed for Cardiovascular Disease Screening: 80061 - Lipid Panel 82465 - Cholesterol, serum or whole blood, total 83718 - Lipoprotein, direct measurement, high density cholesterol 84478 - Triglycerides You can find this information in the Medicare Claims Processing Manual, Chapter 18, 100.1
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 itin this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that plans must pay for ambulance services when an emergency exists or when other means of transport would endanger the patient's health. An emergency is defined as when a prudent layperson would believe that without immediate medical attention there would be serious jeopardy to his or her health. You can find these rules in the Medicare Managed Care Manual, Chapter 4, Sections 20.1 and 20.2.The plan contract says that covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care, only if they are furnished to a member whosemedical condition is such that other means of transportation could endanger the person's health, or if authorized by the plan. You can find this information on page 65 of the plan's 2020 Evidence of Coverage.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 Medicarewill pay for durable medical equipment that is mainly used to serve a medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly used for medical purposes. Medicare will not pay for:1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners;2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1. No provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. Medicare Program Integrity Manual, Chapter 15, 15.1.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 the provider must be eligible to participate in Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. Check with your provider before receiving services to confirm that they are eligible to participate in Medicare. You can find this information on page 3-3 of the Plan's 2020 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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
 
2. The services require the skills or direct supervision of a therapist,  
 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 220.2. 
 
Therapy services should be provided in a manner that meets the patient?s needs. The treatment plan should 
strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome 
with the appropriate resources. This LCD provides recommendations intended to assist qualified 
professionals/auxiliary personnel in documenting to support both the medical necessity and the skilled nature 
of the therapy services provided. In addition, any numerical guidelines related to individual codes in this 
section of the LCD, are based on contractor medical review experience. These are provided to remind qualified 
professionals/auxiliary personnel of the importance of justifying therapy services in the documentation as the 
patient progresses through an episode of care. Documentation must be sufficient to demonstrate the specifics of 
the therapy provided so that it may be determined that the treatment was medically necessary. You can find 
these rules and further guidelines in Local Coverage Determination (LCD): Outpatient Physical and 
Occupational Therapy Services (L33631). 
 
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 providers must report services correctly. Procedures should be reported with the CPT code
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative
Manual, Chapter I(A).
The rules say that critical care is a time- based service, and for each date and encounter entry, the physician's
progress note(s) shall document the total time that critical care services were provided. You can find this rule in
the Medicare Claims Processing Manual, Chapter 12, 30.6.12
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.