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 417.414.
The rules say that radionuclide imaging may be employed in the assessment of a variety of conditions
associated with primary coronary artery disease. Some of these conditions include:
1. Assessment of the functional and prognostic importance of angina, chest pain, or angina equivalent
symptoms.
2. Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG/EKG changes
occurring naturally or caused by drugs, bundle branch block, or left ventricular hypertrophy.
3. Risk assessment of re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with
known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a
revascularization procedure within the past two years or greater than 2 years since last imaging study.
4. Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed
heart failure or left ventricular systolic dysfunction.
5. Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization/coronary
angiography is not planned.
6. Evaluation of myocardial perfusion viability or function before and more than or equal to 5 years after
coronary artery bypass surgery or greater than or equal to 2 years after percutaneous perfusion procedures,
unless new clinical signs or symptoms necessitate reevaluation.
7. Quantification and surveillance of myocardial infarction and prognostication in patient with infarction.
8. Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery or perioperative
management
9. Evaluation of ventricular function in patients with non-ischemic myocardial disease
10. Evaluation of patients in whom an accurate measure of the ejection fraction is needed to make a
determination of whether to implant a defibrillator or biventricular pacemaker.
11. Evaluation of patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., Adriamycin,
Herceptin).
You can find this rule in Local Coverage Determination (LCD): Cardiovascular Nuclear Medicine (L35083) -
Effective October 17, 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 contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The benefit includes dentures (partial, full, immediate) are limited to one set every 5 years. The contract also says replacement of lost, stolen, or broken dentures less than 5 years of age does not meet criteria for pre-authorization of a new denture. 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.
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 290(3). Depth-inlay or custom molded shoes for diabetics and related inserts and modifications are billed using A codes whether or not the shoe is an integral part of a brace. See the medical policy on Therapeutic Shoes for Persons with Diabetes for coverage, documentation, and additional coding guidelines. You can find this information at Local Coverage Article: Orthopedic Footwear- Policy Article (A52481).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that effective January 18, 2017, the Centers for Medicare & Medicaid Services (CMS) covers leadless pacemakers through Coverage with Evidence Development (CED). CMS covers leadless pacemakers when procedures are performed in Food and Drug Administration (FDA) approved studies. CMS also covers, in prospectivelongitudinal studies, leadless pacemakers that are used in accordance with the FDA approved label for devices that have either:-an associated ongoing FDA approved post-approval study; or-completed an FDA post-approval study.You can find this rule in National Coverage Determination (NCD) for Leadless Pacemakers (20.8.4) -Effective January 18, 2017.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that incontinence supplies are not covered because they are hygienic items that are non-reusable. You can find this rule inthe Medicare National Coverage Determinations Manual, Section 280.1.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on pages 46 and 49 of the Plan's 2020 Evidence of Coverag
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 repeat or serial test or diagnostic injections without documented response are not considered reasonable and necessary. Response to each epidural injection should be determined prior to determining the value of a repeat injection and the specific methods used for subsequent epidurals. You can find this rule in Local Coverage Determination (LCD): Epidural Injections for Pain Management (L36920) - Effective July 1, 2020. The rules say that if a prior epidural injection procedure provided limited or no relief (i.e., NPRS less than 3, less than 50% symptom improvement, insignificant or indiscernible relief), a second epidural injection utilizing the same method, technique or medication to the same level will be considered not medically reasonable and necessary. A second injection involving a change in technique or medication will be considered following re-evaluation of the patient. If a patient does not obtain significant relief with a diagnostic selective nerve root block (DSNRB), therapeutic injections (EI) in that same area will be considered not medically necessary. You can find this rule in Local Coverage Determination (LCD): Epidural Injections for Pain Management (L36920) - Effective July 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 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 websitewww.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. The contract says 1 bridge or crown is covered per quarter. The contract also says prior authorization may be required. You can find this information on pages 80 and 81 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 if medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan to determine the initial level of cancer treatment needed for an enrollee. After the completion of the initial anti-cancer therapy, additional FDG PET scans may be covered at the discretion of Medicare. You can find this rule in the National Coverage Determinations Manual, Section 220.6.17.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% coinsurance  for  Medicare  Part B prescription  drugs.  You can find this  information  on pages 81-82 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  Medicare  will  pay for an  IRF admission  when  the  services  are reasonable  and medically necessary.  The  patient  must  require  an intensive  and coordinated  interdisciplinary  approach to providing rehabilitation.  The  patient  must  need active  and ongoing  treatment  by more  than  one therapy  discipline.  One of the  therapies  must  be physical  therapy  or occupational  therapy.  The  patient  must  need and be expected  to actively  participate  in  and to benefit  from  an intensive  rehabilitation  therapy  program.  This  intensive rehabilitation  therapy  program  generally  consists  of at least  three  hours  of therapy  per day  at least  five  days per week. The  patient  does not need to be expected  to achieve  complete  independence  in  self-care  nor  be expected to return  to his  or her  prior  level  of functioning.  The  patient  must  need supervision  by a rehabilitation physician.  The  physician  must  see the patient  at least  three  days  per week throughout  the  stay. You  can find these  rules  in  the  Medicare  Benefit  Policy  Manual,  Chapter  1, Sections  110.2 and 110.2.5 and  at 42 CFR Section  412.622.If  you  want  to read these  Medicare  rules,  you  can go to this  website www.medicareappeal.com.The  Plan  contract  says that  the  Plan  covers  items  and services  in  accordance  with  Medicare  rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $250 copayment per day for days 1-5 for each admission for inpatient hospital care. You can find this information on page 84 of the Plan's 2017 EOC.
Appeal type: unknown
Decision: unknown

The  rules  say that  plans  must  pay for  a medical  service  oritem  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 (suchas 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  percentageof  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 $50 copayment  for services  obtained  by a specialist.  You can find  this information  in  Chapter  4 on pages 52 -53 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 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 $395 copayment for days 1-4 for inpatient hospital care. You can find this information in Chapter 4 on page 83 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 cellular therapy involves the practice of injecting humans with foreign proteins like the placenta or lungs of unborn lambs. Cellular therapy is without scientific or statistical evidence to document its therapeutic efficacy and, in fact, is considered a potentially dangerous practice. Accordingly, cellular therapy is not considered reasonable and necessary. You can find this rule in the National Coverage Determination Manual, Section 30.8.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 fora medical service or item if regular Medicare would pay for it in this case. You can find this rule at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that an inpatient admission is generally appropriate when the admittingphysician expects the patient to need hospital care that crosses at least two midnights. The expectation should be based on such complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and medical risk. The factors must be documented in the medical record. The order for inpatient admission must be present in the medical record. If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as "inpatient only" is generally appropriate, regardless of the length of stay. An inpatient admission may be appropriate if the admitting physician expects a patient to require hospital care for only a limited period of time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be supported by the medical record. You can find this rule at 42 CFR Section 412.3.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules
Appeal type: unknown
Decision: unknown

The  rules  say that  plans  must  pay for  a medical  service  or item  if  regular  Medicare  would  pay for it  in  this case. You  can find  this  rule  at 42 Code of Federal  Regulations  (CFR) Section  422.101.The  rules  say that  Medicare  will  pay for an  IRF admission  when  the  services  are reasonable  and medically necessary.  The  patient  must  require  an intensive  and coordinatedinterdisciplinary  approach to providing rehabilitation.  The  patient  must  need active  and ongoing  treatment  by more  than  one therapy  discipline.  One of the  therapies  must  be physical  therapy  or occupational  therapy.  The  patient  must  need and be expected  toactively  participate  in  and to benefit  from  an intensive  rehabilitation  therapy  program.  This  intensive rehabilitation  therapy  program  generally  consists  of at least  three  hours  of therapy  per day  at least  five  days per week. The  patient  does not need to be expected  to achieve  complete  independence  in  self-care  nor  be expected to return  to his  or her  prior  level  of functioning.  The  patient  must  need supervision  by a rehabilitation physician.  The  physician  must  see the  patient  at least  three  days  per week throughout  the  stay. You  can find these  rules  in  the  Medicare  Benefit  Policy  Manual,  Chapter  1, Sections  110.2 and 110.2.5 and  at 42 CFR Section  412.622.If  you  want  to read these  Medicare  rules,  you  can go to this  website www.medicareappeal.com.The  Plan  contract  says that  the  Plan  covers  items  and services  in  accordance  with  Medicare  rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that the indications for facet joint injections are: -At least 3 months of moderate to severe pain with functional impairment inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical therapy (if tolerated). -Predominant axial pain that is not associated with radiculopathy or neurogenic claudication. -Absence of non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor, infection, or significant deformity. -Clinical assessment that implicates the facet joint as the putative source of pain. You can find this rule in Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L34995) - Effective December 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.