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 Viscosupplementation therapy for the knee via intra-articular injections of hyaluronic
preparations will be considered medically reasonable and necessary when ALL of the following conditions are
met:
1. The patient is symptomatic. Such symptoms may include pain which interferes with the activities of daily
living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness.
2. The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space
narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts.
3. If appropriate, other diagnoses have been excluded by appropriate evaluation and management services,
laboratory and imaging studies (i.e., the pain and functional disability is not considered likely to be due to a
diagnosis other than osteoarthritis of the knee).
4. The patient has failed at least three months of conservative therapy. Conservative therapy is defined as:
- Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss,
physical therapy if indicated); and
- If not contraindicated, simple analgesics and (e.g., acetaminophen) or NSAIDS per hyaluronan product
prescribing information.
5. The patient has failed to respond to aspiration of the knee when effusion is present and intra-articular
corticosteroid injection therapy when inflammation is a significant component of the patient's symptoms and
intra-articular corticosteroids are not contraindicated.
You can find this rule in the Local Coverage Determination (LCD): Hyaluronan Acid Therapies for
Osteoarthritis of the Knee (L35427) effective October 1, 2019.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare 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 limited exam to evaluate a problem (D0140) is covered one (1) procedure per plan year. You can find this information in Chapter 4 on pages 4-73 to 4-87 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 state that transthoracic echocardiography is useful in defining cardiac function in which arrhythmias
occur, and may be useful in the management of cardiac arrhythmias. Some arrhythmias are frequently
associated with underlying organic heart disease or may predispose the patient to hemodynamic deterioration.
Atrial fibrillation and atrial flutter are examples of arrhythmias in which echocardiography may be appropriate
to assess the underlying disorder. Echocardiographic studies are appropriate only when there is evidence of
heart disease.
Routine (yearly) re-evaluation of mitral valve prolapse in patients with no or mild mitral regurgitation and no
change in clinical status and routine (yearly) re-evaluation of patients with heart failure (systolic or diastolic) in
whom there is no change in clinical status are deemed to be not medically necessary and are therefore not
reimbursable.
You can find these rules and full coverage criteria in Local Coverage Determination (LCD): Transthoracic
Echocardiography (TTE) (L33577).
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 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 Section 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 website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that a PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone even if the criteria in this section are met. Claims will be denied as not reasonable and necessary. You can find this rule at Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) (eff. 1/1/20).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for selfinjection.
The only exceptions are:
1. blood-clotting factors;
2. drugs used in immunosuppressive therapy;
3. erythropoietin for dialysis patients;
4. osteoporosis drugs for certain homebound patients;
5. certain oral cancer drugs;
6. oral anti-emetics used in certain situations;
7. drugs treated as supplies during an outpatient hospital procedure; and
8. drugs required for the effective use of durable medical equipment.
You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.
AVONEX, Q3027, injection, interferon Beta-aA, for intramuscular use is on the Local Coverage Article: Self-
Administered Drug Exclusion List: (A53033).
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 generally does not pay for drugs that are usually self-administered by the
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for selfinjection.
The only exceptions are:
1. blood-clotting factors;
2. drugs used in immunosuppressive therapy;
3. erythropoietin for dialysis patients;
4. osteoporosis drugs for certain homebound patients;
5. certain oral cancer drugs;
6. oral anti-emetics used in certain situations;
7. drugs treated as supplies during an outpatient hospital procedure; and
8. drugs required for the effective use of durable medical equipment.
You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.
Immunosuppressive drugs are covered under the immunosuppressive therapy benefit following a transplant.
Immunosuppressive drugs are denied as noncovered when used for the treatment of beneficiaries with nontransplant
related diagnoses.
You can find this information in Local Coverage Article: Immunosuppressive Drugs - Policy Article (A52474).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
Medicare rules state that two radiofrequency neurotomies per year involving 2 joints per region per session
may be performed 2 times a year with appropriate documentation of relief with dual medial branch blocks and
5 to 6 months of pain relief and functional improvement after a session. These rules may be found in Local
Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency
Neurotomy (L34832).
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 page 1-8 of the 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 state that in this policy, the term PAP (positive airway pressure) device will refer to both a singlelevel
continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without backup
rate (E0470) when it is used in the treatment of obstructive sleep apnea.
I. An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A - C are met:
A. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to
assess the beneficiary for obstructive sleep apnea.
B. The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2):
1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15
events per hour with a minimum of 30 events; or,
2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of
10 events and documentation of:
a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,
b. Hypertension, ischemic heart disease, or history of stroke.
C. The beneficiary and/or their caregiver has received instruction from the supplier of the device in the proper
use and care of the equipment.
If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not
reasonable and necessary.
II. An E0470 device is covered for those beneficiaries with OSA who meet criteria A-C above, in addition to
criterion D:
D. An E0601 has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or
in a home setting.
Ineffective is defined as documented failure to meet therapeutic goals using an E0601 during the titration
portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and
fitting and appropriate pressure settings).
If E0470 is billed for a beneficiary with OSA and criteria A-D are not met, it will be denied as not reasonable
and necessary.
You can find this information in the Local Coverage Determination (LCD): Positive Airway Pressure (PAP)
Devices for the Treatment of Obstructive Sleep Apnea (L33718).
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 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 31 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 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 an ultra-lightweight manual wheelchair (K0005) is covered for a beneficiary if criteria (1) or
(2) is met and (3) and (4) are met:
1. The beneficiary must be a full-time manual wheelchair user.
2. The beneficiary must require individualized fitting and adjustments for one or more features such as, but not
limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a
K0001 through K0004 manual wheelchair.
3. The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical
professional (LCMP), such as a PT or OT, or physician who has specific training and experience in
rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its
special features (see Documentation Requirements section). The LCMP may have no financial relationship
with the supplier.
4. The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified
Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person
involvement in the wheelchair selection for the patient.
You can find this information in the
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). 
 
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 enrollees pay the 2020 Original Medicare Part B deductible amount in-network. The 2020 Medicare Deductible amount is $198. You must pay the deductible amount out of your own pocket before the plan will begin coverage for the following Medicare-covered services: specialists. You can find this information on pages 4-29 to 4-30 of the Plan's 2020 Evidence of Coverage (EOC). 
 
The Plan contract also says that enrollees must pay 20% coinsurance for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other no-physicians health care professionals in a specialist's office. You can find this information on pages 4-43 to 4-48 of the Plan's 2020 Evidence of Coverage (EOC).  
 
The Plan contract also says that a Specified Low-Income Medicare Beneficiary (SLMB) is when Medicaid pays your Part B premium only. The state Medicaid Office does not pay your cost-share. You do not have full Medicaid benefits. There may be some services that do not have a member cost share amount. You can find this information on page 1-6 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 state that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and hospital and outside vendors. If the physician furnishes services to beneficiaries in providers, the carrier pays on a fee schedule basis provided the following requirements are met: 
 
(1) The services are personally furnished for an individual beneficiary by a physician. (2) The services contribute directly to the diagnosis or treatment of an individual beneficiary. (3) The services ordinarily require performance by a physician. (4) In the case of radiology or laboratory services, the additional requirements in ? 415.120 or ? 415.130, respectively, are met. 
 
You can find this rule at 42 CFR, Sections 412.50 and 415.102. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that an inversion table is covered if you have an impairment (being unable) that prevents ambulation (walking) during the period of use. National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1).
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.
The rules say that Medicare Advantage Plans may not make payment directly or indirectly for Medicare covered services furnished to a Medicare beneficiary by a physician or practitioner who has opted out of Medicare except in cases involving emergency or urgent care services furnished to a beneficiary who has not previously entered into a private contract with the physician or practitioner. You can find this rule at 42 CFR Section 422.220 and in the Medicare Benefit Policy Manual, Chapter 15, Section 40.37.
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 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 13 of the Plan's 2020 Evidence of Coverage.