Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that the following are criteria for BRCA testing: -Individual with breast, ovarian, pancreatic, or prostate cancer from a family with a known deleterious BRCA1 or BRCA2 gene mutation.
-Individual with a personal history of ovarian cancer
-Individual with a breast cancer diagnosis meeting any of the following criteria:
&#9642; Diagnosed &#8804;45 y
&#9642; Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR) negative, and human epidermal growth factor receptor 2 (HER2) negative) breast cancer diagnosed &#8804; 60 y
&#9642; Diagnosed at &#8804; 50 y with:
o An additional breast cancer primary
o &#8805;1 first, second, or third degree relative5 with breast cancer at any age, or
o &#8805;1 first, second, or third degree relative5 with prostate cancer (Gleason score &#8805;7), or
o An unknown or limited family history
&#9642; Breast cancer diagnosed at any age, and
o &#8805;1 first, second, or third degree relative5 with breast cancer &#8804;50 y, or
o &#8805;1 first, second, or third degree relative5 with ovarian cancer at any age, or
o &#8805;1 first, second, or third degree relative5 with metastatic prostate cancer or pancreatic cancer at any age
o &#8805;2 additional diagnoses of breast cancer at any age in patient and/or in close blood relative5, o
o A first, second, or third degree male relative with breast cancer
o For an individual of ethnicity associated with higher mutation frequency (e.g. Ashkenazi Jewish4) no additional family history may be required.
&#9642; Male breast cancer
-Personal history of prostate cancer (Gleason score&#8805;7) at any age with
&#9642; &#8805;1 first, second, or third degree relative5 with ovarian cancer at any age, or
&#9642; &#8805;1 first, second, or third degree relative5 with breast cancer &#8804;50 y, or
&#9642; &#8805;1 first, second, or third degree relative5 with pancreatic cancer at any age, or
&#9642; &#8805;1 first, second, or third degree relative5 with metastatic prostate cancer at any age, or
&#9642; &#8805;2 first, second, or third degree relatives5 with breast cancer and/or pancreatic cancer and/or prostate cancer (Gleason score &#8805;7 or metastatic) at any age, or
&#9642; Ashkenazi Jewish ancestry
-Personal history of pancreatic cancer at any age
-Personal history of metastatic prostate cancer (radiographic evidence of or biopsy-proven disease)
-BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of germline mutation analysis.
You can find these rules in the Local Coverage Determination (LCD) for MolDX: BRCA1 and BRCA2 Genetic Testing, L3616. This LCD is effective for services provided on or after December 4, 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 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 Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on pages 39-40 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 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 contract says that the Plan covers certain dental services as a supplemental benefit. Coverage includes exams, cleanings, x-rays, restorations, endodontics, implants, periodontics, prosthodontics, oral surgery, and adjunctive general services. You can find this information on pages 91-103 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $250 copayment for advanced imaging services provided in an outpatient hospital facility. You can find this information in Chapter 4 on pages 71 - 72 of the Plan's 2019 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 may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Section 423.578(b)(5)(ii).
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You can find this information on page 74-75 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 ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive pulmonary disease (COPD). You can find this rule in the Medicare National Coverage Determinations Manual, Chapter 1, Section 280.1.The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device is made based upon the specifics of each person's medical condition. There must be enough detailed information in the medical record to justify the treatment selected. You can find this rule in the Local Coverage Determination (LCD): Respiratory Assist Devices (L33800), effective for services performed on or after January 1, 2017.
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 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 1-6 of the 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 CT scans are covered if there is literature to support its use for the patient's condition and the scan is reasonable and necessary for the patient. You can find this rule in the Medicare National Coverage Determinations Manual, Section 220.1(A).

The rules say that for purposes of Medicare coverage of lung cancer screening with LDCT, beneficiaries must meet all of the following eligibility criteria:

 -Age 55 - 77 years;
 -Asymptomatic (no signs or symptoms of lung cancer);
 -Tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes);
 -Current smoker or one who has quit smoking within the last 15 years; and
 -Receive a written order for lung cancer screening with LDCT. Written orders for lung cancer LDCT screenings must be appropriately documented in the beneficiary's medical records, and must contain the following information:
 
1. Beneficiary date of birth;
2. Actual pack - year smoking history (number);
3. Current smoking status, and for former smokers, the number of years since quitting smoking;
4. Statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer); and
5. National Provider Identifier (NPI) of the ordering practitioner.

You can find this rule in National Coverage Determination (NCD) for Lung Cancer Screening With Low Dose Computed Tomography (LDCT) (210.14).
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. 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 website www.medicareappeal.com. The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2. If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on pages 50-61 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 Code of Federal Regulations (CFR) Section 422.101.The rules state that A skin protection seat cushion is covered for a beneficiary who meets both of the following criteria:1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and2. The beneficiary has either of the following (a or b):a. Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface; orb. Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift positioning back cushion (E2620) is covered for a beneficiary who meets both of the following criteria:1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and2. The beneficiary has any significant postural asymmetries that are due to one of the following (a or b):a. A diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article; orb. A diagnosis code listed in Group 3 of the ICD-10 code list in the LCD-related Policy Article.A combination skin protection and positioning seat cushion (E2624) is covered for a beneficiary who meets the criteria for both a skin protection seat cushion and a positioning seat cushion.If a skin protection seat cushion, positioning seat cushion, or combination skin protection and positioning seat cushion is provided and if the stated coverage criteria are not met, it will be denied as not reasonable and necessary. You can find this rule in the Local Coverage Determination for Wheelchair Seating, L33312 (eff 01/01/20).The rules say that a harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting hardware. Code K0108 must not be used for any component or feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313.You can find this rule in the Local Coverage Article for Wheelchair Options/Accessories, A52504 (eff 01/01/20).The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your home may be a dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, an institution may not be considered your home if it is an acute hospital or a skilled nursing facility (SNF). You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D).
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).
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 grab bars are not covered because they are considered self-help items that are 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 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 pay for an IRF admission when the services are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week. The patient does not need to be expected to achieve complete independence in self-care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. You can find these rules in the Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622.
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 at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that functional electrical stimulation is covered only to treat muscle atrophy and spinal cord injury. You can find this rule in National Coverage Determination (NCD) for Neuromuscular Electrical Stimulation (NMES) (160.12) -Effective October 1, 2006.If you want to read these Medicare rules, you can go to this website 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 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare does not pay for nutritional supplements. You can find this rule in the Medicare National Coverage Determination Manual, Chapter 1, Section 180.2.Local Coverage Article: Enteral Nutrition -Policy Article (A52493) -Enteral nutrition products that are administered orally and related supplies are non-covered, no benefit.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.