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 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 $200 copayment for services at an ambulatory surgery center. You can find this information on page 75 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 that physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable
and necessary when:

1. The services are specific and effective treatment for the patient's condition,
2. The services require the skills or direct supervision of a therapist,
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver,
or carry out a maintenance program.

Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for
skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2.

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 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. The health plan contract says that Hymovis is subject to step therapy. There must be a trial and failure, or contraindication to, Euflexxa. You can find this information in the plan's step therapy policy.
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 for patients with arterial partial pressure off oxygen (PO2) at or above 60 millimeters of mercury (mm Hg) or arterial oxygen (O2) saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. 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 240.2(D)(3)(c).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that providers must report services correctly. Procedures should be reported with the Current
Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the
Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for
Medicare Services, Chapter I(A).

The rules say that all providers are required to furnish necessary information to the health plan when requested.
You can find this information in the Medicare Managed Care Manual, Chapter 4 Benefits and Beneficiary
Protections, 20.3 (MAO Responsibility), 110.1 (Access and Availability Rule), Medicare Benefit Policy
Manual, Chapter 15 - Covered Medical and Other Health Services 20.0-40.4 Physician Services and
Physician/Practitioner.

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 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 Centers for Medicare and
Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations
Manual, Section 220.1(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 a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843) are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). It is also covered for a beneficiary who is ambulatory and has knee instability. The knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). Claims for L1843 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented. You can find this rule in the Local Coverage Determination (LCD) - Knee Orthoses (L33318) - Effective January 1, 2020.

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 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 pages 46 to 47 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 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. This benefit includes routine preventative dental care, periodic and comprehensive oral exams, prophylaxis (cleanings), fluoride treatment, dental x-rays, one extraction, one filling or restoration, full mouth debridement, scaling and root planing and periodontal maintenance services. You can find this information on pages 69-70 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 that screening tests are excluded from coverage. The only exceptions are for the following
services:

1. screening mammography,
2. colorectal cancer screening tests,
3. screening pelvic exams,
4. prostate cancer screening tests,
5. glaucoma screening exams,
6. ultrasound screening for abdominal aortic aneurysms (AAA),
7. cardiovascular disease screening tests,
8. diabetes screening tests, and
9. screening electrocardiograms, and
10. certain other testing recommended by the United States Preventive Services Task Force and approved by
the Centers for Medicare and Medicaid Service.

You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64.

The rules say that Medicare denies coverage for all cardiovascular risk assessment panels." You can find this in
the Medicare Local Coverage Determination (LCD): MolDX: Biomarkers in Cardiovascular Risk Assessment
(L36139; DL36139), LCD: MolDX: Biomarkers in Cardiovascular Risk (L36129; DL36129), LCD: MolDX:
Biomarkers in Cardiovascular Risk Assessment (L36362), Local Coverage Article: Billing and Coding:
MolDX: Biomarkers in Cardiovascular Risk Assessment (A57559), Local Coverage Article: Billing and
Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57055), LCD: MolDX: Biomarkers in
Cardiovascular Risk Assessment (L36523; DL36523).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare pays for care in a skilled nursing facility (SNF) when all of the following four
factors are met:

1. The patient requires skilled nursing or skilled rehabilitation services;
2. The patient requires these services on a daily basis;
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and
4. The services are reasonable and necessary for the treatment of the patient's illness or injury, or the services
must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from
getting worse.

You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare and Medicaid Services,
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30.
The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding,
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also
custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

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 the Plan covers acupuncture for chronic low back pain. Prior authorization is required. You can find this information on page 61 of the Plan's 2021 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 screening tests are excluded from coverage. The only exceptions are for the following services: 

1. screening mammography, 
2. colorectal cancer screening tests, 
3. screening pelvic exams, 
4. prostate cancer screening tests, 
5. glaucoma screening exams, 
6. ultrasound screening for abdominal aortic aneurysms (AAA), 
7. cardiovascular disease screening tests, 
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by the Centers for Medicare and Medicaid Service. 

You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 

The rules state that a claim that is submitted for Cardiovascular Disease Screening shall be submitted in the following manner: 

The line item shall contain 80061, 82465, 83718 or 84478. 

You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04 Medicare Claims Processing Manual, Chapter 18, 100.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that Medicare recognizes these Part B providers as eligible to provide diagnostic and BHI or SBIRT services, as permitted under state law: 
&#9679; Physicians (Medical Doctors [MDs] and Doctors of Osteopathy [DOs]), particularly Psychiatrists 
&#9679; Clinical Psychologists (CPs) 
&#9679; Clinical Social Workers (CSWs) 
&#9679; Clinical Nurse Specialists (CNSs) 
&#9679; Nurse Practitioners (NPs) 
&#9679; Physician Assistants (PAs) 
&#9679; Certified Nurse-Midwives (CNMs)
&#9679; Independently Practicing Psychologists (IPPs). 

You can find this information in the Centers for Medicare and Medicaid Services MLN Booklet: Medicare Mental Health.

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 that you must receive your care from a provider who is eligible to provide services under Original Medicare. You can receive your care from either a network or an out of network provider. If you go to a provider who is not eligible to participate in Medicare and/or receive non-Medicare covered services, you will be responsible for the full cost of the services you receive. You can find this information on page 3-3 of the Plan's 2021 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.

Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise
reasonable and necessary for the patient. Food and Drug Administration (FDA) approved drugs used for
indications other than what is indicated on the official label may be covered if the use is determined to be
medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or
accepted standards of medical practice. 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, Sections
50.4.1 and 50.4.2.

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 plans must pay for ambulance services when an emergency exists or when other means of transport would endanger the patient's health. An emergency is defined as when a prudent layperson would believe that without immediate medical attention there would be serious jeopardy to his or her health. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Sections 20.1 and 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 also says that you pay $0 for covered ambulance services. Your condition must be serious enough that other ways of getting to a place of care could risk your life or health. You can find this information on page 58 of the Plan's 2021 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 pays for care in a SNF when all of the following four factors are met: 

1. The patient requires skilled nursing or skilled rehabilitation services; 
2. The patient requires these services on a daily basis; 
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and 
4. The services are reasonable and necessary for the treatment of the patient's illness or injury or the services must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from getting worse. 

You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30. 

The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

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 one face mask interface described by procedure code A7035 is approved every six months.
You can find this rule at Local Coverage Determination (LCD) L33718: Positive Airway Pressure (PAP)
Devices for the Treatment of Obstructive Sleep Apnea (eff. 8/8/21).

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.