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 CFR 422.101.The rules state that the Medicare Physician Fee Schedule database status code of "N" indicates a non-covered service. A code with status indicator "N" is carried in the database as a non-covered service. You can find this rule in Medicare Claims Processing Manual Chapter 23, Section 30.2.2.The rules state that procedure code 80050 --general health panel --has a status code of "N", indicating that this is a non-covered service. This service is not covered by Medicare. You can find this rule in the 2019 National Physician Fee Schedule Relative Value File.If you want to read these Medicare rules, you can go to this web site 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 CFR 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 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 41 of the 2019 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 CFR 422.101.The rules state that coverage and payment for Medicare telehealth services includes consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system. Eligible geographic areas include rural health professional shortage areas (HPSA) and counties not classified as a metropolitan statistical area (MSA). The originating site for telehealth services(location to which the enrollee presents) must be a practitioner's office, hospital, rural health clinic (RHC), federally qualified health center (FQHC), skilled nursing facility or community mental health center. You can find this rule in the Medicare Claims Processing Manual, Chapter 12, Sections 190.1 and 190.2.The rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. You can find this in the CMS MLN document entitled "Telehealth Services."If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.The rules say that payment for inpatient psychiatric hospital services is to be made only for active treatment. For services to be designated as active treatment they must: 1. be provided under an individualized treatment or diagnostic plan;2. reasonably be expected to improve the patient's condition, or for the purpose of diagnosis; and3. be supervised and evaluated by a physician.You can find these rules in the Medicare Benefit Policy Manual, Chapter 2, Sections 30.2.2 and 30.2.2.1.The rules say that Medicare will not pay any expenses for items or services which are not medically necessary and reasonable for the diagnosis or treatment of illness or injury. This exclusion extends to claims for services which are provided in inappropriate settings. You can find this rule in the Social Security Act, Section 1862(a)(1).If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.The rules state that a pneumatic compression device (PCD) coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when all of the following are met:- The beneficiary has lymphedema of an extremity.- The coverage criteria for an E0650 or E0651 PCD are met.- The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial. A four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651 PCD is required. The four-week trial of conservative therapy must include all of the following:- At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 PCD after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided - Compliant use of an appropriate compression bandage system or compression garment to provide adequate graduated compression - Elevation where appropriate - Manual lymphatic drainage (where available) and self-manual lymphatic drainage (MLD) for at least 30 minutes per day - Evaluation of diet and implementation of any necessary change - Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.) - Correction (where possible) of anemia and/or hypoproteinemia You can find this information at Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829). If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that thePlan 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 CFR 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 422.112. The rules say that the plan must pay for emergency and urgently needed services. This rule applies whether the services are obtained in or out of the plan's network. This rule applies whether or not there is prior authorization for the services. The rules say that 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. The rules say that urgently needed services are those needed because of an unforeseen illness or condition and it is not reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside of the service area. You can find this rule at 42 CFR 422.113.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that when an enrollee is outside of the Plan's service area and cannot get care from a network provider, the Plan will cover urgently needed services received from any provider. You can find this information in Chapter 3 on page 32 of the Plan's 2019 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 CFR 422.101.The rules say that shower and bath chairs are not covered because they are considered hygienic equipment that is not primarily medical in nature. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.1.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plancovers 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 CFR 422.101.
Medicare considers equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment already available to an enrollee. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1(C).
The rules say that Medicare pays for therapeutic continuous glucose monitors (CGMs) when they are medically reasonable and necessary. Therapeutic CGMs are defined in CMS Ruling 1682R. You can find these rules in Local Coverage Article A52464, effective on and after January 12, 2017. The rules say that the reasonable useful lifetime (RUL) of durable medical equipment is determined through program instructions. In the absence of program instructions, carriers may determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the beneficiary, not the age of the equipment. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary. Cases suggesting malicious damage, culpable neglect, or wrongful disposition of equipment should be investigated and denied where the DME MACs determines that it is unreasonable to make program payment under the circumstances. The rules can be found in the Medicare Benefit Policy Manual Chapter 15 under Covered Medical and Other Services Section 110.2. for Repairs, Maintenance, Replacement, and Delivery.
If you want to read these Medicare rules, you can go to this web site 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 ifregular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that indications for Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy include:-At least 3 months of moderateto severe pain with functional impairment inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical therapy (if tolerated).-Predominant axial pain that is not associated with radiculopathy or neurogenic claudication.-Absenceof non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor, infection, or significant deformity.-Clinical assessment that implicates the facet joint as the putative source of pain.You can find this rule in the Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L34832) effective December 26, 2019.If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101. The rules state that the definition of "new patient" -- for purposes of selection of evaluation and management visit codes -- is a patient who has not received any professional services (i.e. evaluation and management service or other face-to-face service) from the physician or physician group practice (same physician specialty) within the previous 3 years. You can find this information in Medicare Claims Processing Manual Chapter 12, Section 30.6.7.
If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.
The rules say that elastic stockings are not covered because they are non-reusable supply items. Elastic stockings are not durable medical equipment. You can find this rule in the Medicare National Coverage Determinations Manual, Chapter 1, Section 280.1. The rules say that gradient pressure garments may be covered when used as dressings following burn injuries. You can find this rule in the Medicare National Coverage Determinations Manual, Chapter 1, Section 270.5. The rules state that compression bandages, multi-layer systems, and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. A qualifying wound is either a wound caused or treated by surgery or a wound that must be debrided. A gradient compression stocking or wrap described by codes A6531, A6532, or A6545 is only covered when it is used in the treatment of an open venous stasis ulcer. Gradient compression stockings and wraps identified with codes A6531, A6532, and A6545 are not covered when they are used to treat the following conditions: - Venous insufficiency without stasis ulcers; - Prevention of stasis ulcers; - Prevention of the reoccurrence of stasis ulcers that have healed; - Treatment of lymphedema in the absence of ulcers. You can find these rules in Local Coverage Determination (LCD): Surgical Dressings L33831 and Local Coverage Article: Surgical Dressings-Policy Article A54563, effective for services performed on or after July 24, 2017.
If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101. The rules say that the provider must notify the enrollee in writing before a Medicare plan ends coverage of skilled nursing facility services. A Notice of Medicare Non-Coverage (NOMNC) must be issued no later than two days before the last covered day. The notice must state: 1. The date that coverage of services ends, 2. The date that the enrollee must begin to pay for the services, and 3. A description of the enrollee's right to a fast-track appeal and other appeal procedures. The Medicare plan must continue to cover services until two days after valid notice is delivered. You can find this rule at 42 CFR 422.624. The rules say that notification of changes for an enrollee who is incapable of receiving or incompetent to receive the notice must be made to a representative of the enrollee. You can find these rules in the Medicare Claims Processing Manual, Chapter 30, Section 260.3.8.
If you want to read these Medicare rules, you can go to this web site 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 CFR 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 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 422.2.If you want to read these Medicare rules, you can go to this web site 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 $10 copayment for laboratory tests. You can find this information in Chapter 4 on page 84 of the Plan's 2019 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 CFR 422.101.
The rules state that a pneumatic compression device (PCD) coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when all of the following three requirements are met: 1. The enrollee has a diagnosis of lymphedema as defined above, and 2. The enrollee has persistence of chronic and severe lymphedema as identified by the documented presence of at least one of the following clinical findings: marked hyperkeratosis with hyperplasia and hyperpigmentation, papillomatosis cutis lymphostatica, deformity of elephantiasis, skin breakdown with persisting lymphorrhea, 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 four-week trial of conservative therapy demonstrating failed response to treatment is required. The four-week trial of conservative therapy must include all of the following: regular and compliant use of an appropriate compression bandage system or compression garment to provide adequate graduated compression, adequate compression is defined as (1) sufficient pressure at the lowest pressure point to cause fluid movement and (2) sufficient pressure across the gradient (from highest to lowest pressure point) to move fluid from distal to proximal. (the compression used must not create a tourniquet effect at any point. The garment may be prefabricated or custom-fabricated but must provide adequate graduated compression starting with a minimum of 30 mmHg distally), regular exercise and elevation of the limb. A pneumatic compression device coded as E0652, is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when all of the following are met: the enrollee has lymphedema of an extremity as defined above, the coverage criteria for an E0650 or E0651 are met, the enrollee has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial. A PCD coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen that does not meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable and necessary. These rules can be found in the Local Coverage Determination (LCD) L33829 for Pneumatic Compression Devices.
If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.
The rules say that therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria (1-6) are met:
1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses); and,
2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and,
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; and,
4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and,
6. 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.
If any of coverage criteria (1-6) are not met, the CGM and related supply allowance will be denied as not reasonable and necessary. You can find this rule at Local Coverage Determination (LCD): Glucose Monitors (L33822) (eff. 1/1/20).
If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.The medical necessity for the additional features of a custom fabricated prosthesis (L8035) compared to a prefabricated silicone breast prosthesis has not been established, and therefore, if an L8035 breast prosthesis is billed, it will be denied as not reasonable and necessary. You can find this rule in Local Coverage Determination (LCD): External Breast Prostheses (L33317.If you want to read these Medicare rules, you can go to this web site 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 CFR 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 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 422.2.
If you want to read these Medicare rules, you can go to this web site 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 $75 copayment for each visit for the following Medicare-covered diagnostic radiology procedures: computed tomography (CT), magnetic resonance (MRI's and MRA's), and nuclear medicine studies, which includes PET scans. You can find this information on page 73 of the Plan's 2019 Evidence of Coverage.