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 no payment may be made for the implantation of dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the conditions listed below have been met:

- The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic intractable pain;
- With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for the given patient;
- Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. (Such screening must include psychological, as well as physical evaluation);
- All the facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment training, and follow up of the patient (including that required to satisfy item c) must be available; and
- Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation.

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 160.7.

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 program reimbursement for hyperbaric oxygen (HBO) therapy will be limited to that which is administered in a chamber (including the one man unit) and is limited to the following conditions:
1. Acute carbon monoxide intoxication,
2. Decompression illness,
3. Gas embolism,
4. Gas gangrene,
5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened.
6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened.
7. Progressive necrotizing infections (necrotizing fasciitis),
8. Acute peripheral arterial insufficiency,
9. Preparation and preservation of compromised skin grafts (not for primary management of wounds),
10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management,
11. Osteoradionecrosis as an adjunct to conventional treatment,
12. Soft tissue radionecrosis as an adjunct to conventional treatment,
13. Cyanide poisoning,
14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment,
15. Diabetic wounds of the lower extremities in patients who meet the following three criteria:
a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
b. Patient has a wound classified as Wagner grade III or higher; and
c. Patient has failed an adequate course of standard wound therapy.
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determination for Hyperbaric Oxygen Therapy, 20.29.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). 

The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $10 copayment for outpatient diagnostic tests. You can find this information in Chapter 4 on page 96 of the Plan's 2021 Evidence of Coverage (EOC). 

The Plan contract also says that enrollees must pay a $45 copayment for specialist visits. You can find this information in Chapter 4 on page 103 of the Plan's 2021 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 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). Local Coverage Determination (LCD) Chest X-Ray Policy L37547: In general, preprocedural chest X-rays in the absence of symptomatic pulmonary or cardiac diseases, chest X-rays in the absence of signs or symptoms, and chest X-rays for minor trauma of the head, lower back or extremities are not reasonable and necessary. If a patient with known, but stable, asymptomatic cardiac or pulmonary disease requires a chest x-ray, the reason(s) for the chest radiograph(s) must be clearly documented in the clinical chart with an explanation of how the results of the X-ray will be used for the patient's care. If a patient with known but stable, asymptomatic cardiac or pulmonary disease requires a pre-procedural chest X-ray, the reason(s) must be documented in the clinical chart with an explanation of how the results of the X-ray would be used for the patient's care. Patients with symptomatic cardiac or pulmonary conditions (e.g., adverse change in cough, orthopnea, dyspnea on exertion, recent decrement in SaO2), planning surgery performed in ASC or outpatient facilities, the chart must document how the x-ray results will be used to make treatment decisions. Radiographs of the chest are commonly performed in outpatient offices (radiology and many others), clinics, outpatient hospital departments, inpatient hospital episodes, skilled nursing facilities, homes, and other settings. They are used to diagnose and aid in treatment decisions for pulmonary diseases, cardiac diseases, infections
and inflammatory diseases, chest and upper abdominal trauma situations, malignant and metastatic diseases, allergic and drug related diseases. In general, preprocedural chest X-rays in the absence of pulmonary or cardiac diseases, chest X-rays in the absence of signs or symptoms, and chest X-rays for minor trauma of the head, lower back or extremities are not the current accepted medical practice.
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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that 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 47
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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 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 Sections 422.2 and 422.136.

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 89 of the 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 when completing the 1500 claim form, providers must enter the correct Place of Service
(POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. You
can find this rule at Medicare Claims Processing Manual Ch. 26 Section 10.6.
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.
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 Plan will consider total hip replacement surgery medically necessary in the following circumstances: 
 
Advanced joint disease demonstrated by: 
 - Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance 
imaging (MRI) and/or computed tomography (CT) (in situations when MRI is non-diagnostic or not able to be 
performed) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint 
subluxation, severe joint space narrowing, avascular necrosis); AND 
 - Pain that cannot be adequately controlled despite optimal conservative treatment or functional disability from 
injury due to trauma or arthritis of the joint; AND 
 - If appropriate, history of unsuccessful conservative therapy (non-surgical medical management) that is 
clearly addressed in the pre-procedure medical record. (If conservative therapy is not appropriate, the medical 
record must clearly document the rationale for why such approach is not reasonable). 
 
Non-surgical medical management is usually but not always implemented prior to scheduling total joint 
surgery. Non-surgical treatment as clinically appropriate for the patient's current episode of care typically 
includes one or more of the following: 
- anti-inflammatory medications or analgesics, or 
- flexibility and muscle strengthening exercises, or 
- supervised physical therapy [Activities of daily living (ADLs) diminished despite completing a plan of care],
- weight reduction as appropriate, or 
- therapeutic injections into the hip as appropriate. 
 
You can find this information in the Local Coverage Determination (LCD) Total Hip Arthroplasty (L34163). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). 

The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $20 copayment for non-radiological diagnostic services. You can find this information in Chapter 4 on page 31 of the Plan's 2020 Evidence of Coverage (EOC). 

The Plan contract also says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs. You can find this information in Chapter 4 on page 26 of the Plan's 2020 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 a Medicare plan may not pay for services given by a physician or other practitioner who has 
opted out of Medicare. This rule does not apply to emergency or urgently needed services. A Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 6, Section 60.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. For a full list of covered dental services and the coverage requirements, please refer to the additional Dental Benefits Chart following this Medical Benefits Chart. Some dental services require prior authorization to be covered. Other dental services may be subject to limitations. Please contact Member Services for further details. You can find this information on pages 54 and 91 to 110 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 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 maximum plan payment for covered dental services is $1,000 per year. You can
find this information on page 67 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 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. 
 
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 magnetic resonance imaging scans (MRIs) are covered when medically necessary and reasonable for the diagnosis or treatment of the specific patient involved. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 220.2(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.
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 Part B pays for outpatient physical therapy services only if they are furnished by, 
or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a 
nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy 
services under State law. You can find this information in Title 42 CFR Section 410.60. 
 
The rules say that beginning in July 2015, claims for compounded drugs shall be submitted using a 
compounded drug, not otherwise classified (NOC) code. You can find this information in the Centers for 
Medicare and Medicaid Service, Internet-Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 17, Section 20.1.2. 
 
The rules say that Modifier 25 is defined as a significant, separately identifiable Evaluation and Management 
(EM) service by the same physician or other qualified health care professional on the same day of a procedure 
or other service. You can find this in the article Modifier 25 Fact Sheet on the Novitas Solutions website at 
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00097341. 
 
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.