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

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that Medicare pays for an assistant at surgery only when the procedure is authorized for an assistant. The assistant must be a physician, physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS). Medicare does not pay for assistant at surgery services performed by a person who bears any title or license other than those listed. You can find this rule in the Medicare Claims Processing Manual, Chapter 4, Section 250.9.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item ifregular Medicare would pay for it in this case. You can find this rule at 42 CFR 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:-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-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-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.)-The patient has failed at least three months ofconservative therapy. Conservative therapy is defined as:-Non-pharmacologic therapy (such as but not limited to home exercise program, education, weight loss, physical therapy if indicated); and-If not contraindicated, simple analgesics and NSAIDS.-The patient has failed to respond to aspiration of the knee 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 for Viscosupplementation Therapy For Knee, L33767 (eff 10/01/19).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A). Providers or suppliers shall use anatomic modifiers (e.g. RT, LT, FA, F1-F9, TA, T1-T9, E1-E4) and report procedures with differing modifiers on individual claim lines when appropriate. Many MUEs are based on the assumption that correct modifiers are used. You can find this information in the Medicare Claims Processing Manual, Chapter 23 - Fee Schedule Administration and Coding Requirements 20.9.3.2- Medically Unlikely Edits
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rule
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR 422.2.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay 20% coinsurance for chemotherapy drugs from an in-network provider. You can find this information on page 73 of the Plan's 2019 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information in Chapter 3 on pages 34 to 35 of the Plan's 2019 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that immunizations are not covered unless they are directly related to the treatment of an injury or direct exposure to a disease or condition. In the absence of injury or direct exposure, vaccination or inoculation is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule. You can find this rule at 42 CFR 411.15(e).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that covered Medicare Part B services include:
&#61623; Pneumonia vaccine
&#61623; A different, second pneumonia vaccine if received one year (or later) after the first vaccine is given
&#61623; Flu shots, once each flu season in the fall and winter, with additional flu shots if medically necessary
&#61623; Hepatitis B vaccine if you are at high or intermediate risk of getting Hepatitis B
&#61623; Other vaccines if you are at risk and they meet Medicare Part B coverage rules
We also cover some vaccines under our Part D prescription drug benefit. You can find this information on page 61 of the 2019 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for amedical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information in Chapter 3 on pages 3-3 to 3-4 of the Plan's 2019 Evidence of Coverage
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that an expandable controller is capable of accommodating one or more of the following additional functions: -Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) -Non-proportional input devices (e.g., sip and puff, head array, etc.) -Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) You can find this rule in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504) - Effective January 1, 2020. The rules say that an expandable controller may also be able to operate one or more of the following: -A separate display (i.e., for alternate control devices) -Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control) -An attendant control You can find this rule in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504) - Effective January 1, 2020. The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly used for medical purposes. Medicare will not pay for: 1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners; 2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules 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 when a preparatory below knee prosthesis (L5510-L5530, L5540) is provided, prosthetic substitutions and/or additions of procedures and components are covered in accordance with the functional level assessment except for codes L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962, and L5980 which will be denied as not reasonable and necessary. You can find this rule in the Local Coverage Determination for Lower Limb Prostheses, L33787 (eff 11/01/18).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that 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 Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1.
The rules say that a contract plan provider is an agent of the plan. Services and referrals obtained from a plan provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or item is never covered, the plan does not have to hold the enrollee harmless.
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 160.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that facet injections are indicated for:&#61623;Patient must have a history of at least 3 months of moderate to severe pain with functional impairment and the pain is inadequately responsive to conservative care such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen and/or physical therapy (as tolerated).&#61623;The pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with radiculopathy or neurogenic claudication. &#61623;There is no non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor, infection or significant deformity.&#61623;Clinical assessment implicates the facet joint as the putative source of pain.You can find this rule at Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L36471) (eff. 10/10/19).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at42 CFR 422.101The 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 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 web site www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. This rule does not apply to: 1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed; 2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL; and 3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with an IOL. You can find this rule at 42 CFR 411.15(b). Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR 411.15(c).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts. You can find this information on page 80 of the plan's 2019 Evidence of Coverage. The Plan contract also says that all eyeglasses and contact lenses, including eye refractions to determine changes in your vision and/or the need for eyeglasses or contact lenses, even if you have a cataract surgery, must be obtained through an EyeQuest vision care provider. The refraction will not be covered, even after cataract surgery, if performed or provided by the specialist, who is found in the Specialist section of the Provider/Pharmacy Directory. You can find this information on page 81 of the plan's 2019 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that Medicare pays for therapeutic continuous glucose monitors (CGMs) when they are medically reasonable and necessary. Therapeutic CGMs are defined in CMS Ruling 1682R. You can find these rules in Local Coverage Article A52464, effective on and after January 12, 2017.CGMs consist of three components: a glucose sensor, a transmitter, and a receiver. CGMs are considered therapeutic CGMs if they are:-approved by the FDA for use in place of a blood glucose monitor for making diabetes treatment decisions (for example, changes in diet and insulin dosage);-generally not useful to the individual in the absence of an illness or injury;-appropriate for use in the home; and-those which include a durable component that can withstand repeated use, are expected to last at least three years, and arecapable of displaying the trending of the continuous glucose measurements.The rules also say that a CGM which does not replace a blood glucose monitor for making diabetes treatment decisions is not covered. You can find these rules in CMS Ruling 1682R.The rules say therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria (1-6) are met:1.The beneficiary has diabetes mellitus (Refer to the "ICD-10 Codes that are Covered" section of the LCD-related PolicyArticle for applicable diagnoses); and,2.The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and,3.The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and,4.The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,5.Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and,6.Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.When a therapeutic CGM (code K0554) is covered, the related supply allowance (code K0553) is also covered. If any of coverage criteria (1-6) are not met, the CGM and related supply allowance will be denied as not reasonable and necessary.You can find this rule in the Local Coverage Determination (LCD): Glucose Monitors (L33822) effective January 1, 2019.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR 422.111(a) and (b).The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR 422.2.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says thatif you are having surgery in a hospital facility, you should check with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an "outpatient." You can find this information on page 72 of the Plan's 2019 Evidence of Coverage.The Plan contract says that enrollees must pay 20% coinsurance for each outpatient hospital and observation service. You can find this information on page 70 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 ifregular Medicare would pay for it in this case. You can find this rule at42 CFR 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).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on pages 30-37 of the plan's 2019 Evidence of Coverage.