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 parenteral nutrition is covered for a beneficiary with permanent, severe pathology of the
alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength
commensurate with the beneficiary's general condition. The beneficiary must have a permanent impairment.
Permanence does not require a determination that there is no possibility that the beneficiary's condition may
improve sometime in the future. If the judgment of the attending physician, substantiated in the medical record,
is that the condition is of long and indefinite duration (ordinarily at least 3 months), the test of permanence is
considered met. Parenteral nutrition will be denied as non-covered in situations involving temporary
impairments. The beneficiary must have (a) a condition involving the small intestine and/or its exocrine glands
which significantly impairs the absorption of nutrients or (b) disease of the stomach and/or intestine which is a
motility disorder and impairs the ability of nutrients to be transported through the GI system. There must be
objective evidence supporting the clinical diagnosis. Parenteral nutrition is noncovered for the beneficiary with
a functioning gastrointestinal tract whose need for Parenteral nutrition is only due to any of the following
conditions:
-Swallowing disorder
-Temporary defect in gastric emptying such as a metabolic or electrolyte disorder
-Psychological disorder impairing food intake such as depression
-Metabolic disorder inducing anorexia such as cancer
-Physical disorder impairing food intake such as the dyspnea of severe pulmonary or cardiac disease
-Side effect of a medication
-Renal failure and/or dialysis
You can find this rule in Local Coverage Article: Parenteral Nutrition - Policy Article (A52515) - Effective
January 1, 2017.
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 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 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by CMS 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64.

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 30% coinsurance for out-of-network Medicare preventative services. You can find this information in the Plan's 2020 Benefit Chart.
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 CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A). Many of the diagnostic services, including radiology services, provided by physicians/practitioners contain both a technical component (TC) and a professional component (PC). Often, the PC and TC of diagnostic services are furnished in different settings. As a general policy, the Place of Service (POS) code assigned by the physician/practitioner for the PC of a diagnostic service shall be the setting in which the beneficiary received the TC service. Medicare Claims Processing Manual Chapter 13 - Radiology Services and Other Diagnostic Procedures 150 - Place of Service (POS) Instructions for the Professional Component (PC or Interpretation) and the Technical Component (TC) of Diagnostic Tests.
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 1-7 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 state that if an independent lab bills for services, the place where the sample was taken is reported as
the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of
service. You can find this information in the Medicare Claims Processing Manual, Chapter 26, Section 10.6.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than the close of the period ending 1 calendar year after the date of service. You can find this rule at 42 CFR Section 424.44(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 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 $15 copayment for a visit to a primary care provider. You can find this information on page 75 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 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 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.
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 non-coverage has been reaffirmed for CPT codes 0012M and 0013M for CxBladder. You
can find this rule in Local Coverage Determination (LCD): Biomarkers for Oncology (L35396).
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 this is a non-coverage policy for genetic testing for thrombophilia testing for the Factor V
Leiden (FVL) variant in the F5 gene, the G20210G>A (G20210A) variant in the F2 gene, and the MTHFR
gene which encodes the 5,10-methylenetetrahydrofolate reductase enzyme. Genetic testing for these genes for
all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are noncovered
except for pregnant patients. You can find this information in Medicare's Local Coverage
Determination (LCD): MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden,
Factor II Prothrombin, and MTHFR) (L36089).
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 does not pay for hearing aids or examinations for the purpose of prescribing,
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d).

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 offers hearing aids as a supplemental (extra) benefit. This benefit includes a $500 maximum
plan benefit allowance every year for hearing aids. Hearing aids must be obtained from an in-network provider.
You can find this information on page 67 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 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 50-52 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 payment for oxygen and oxygen equipment is made on a monthly fee schedule amount per
beneficiary. Payment is not made for purchases of this type of equipment.
You can find this rule in the Medicare Claims Processing Manual, Chapter 20, Section 30.6.
The rules say that payment cannot be made for oxygen equipment that is purchased on or after June 1, 1989.
You can find this rule in the Medicare Claims Processing Manual, Chapter 20, Section 30.6.2.
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 Durable medical equipment (DME) includes items such as oxygen equipment and supplies,
wheelchairs, walkers, powered mattress systems, crutches, diabetic supplies, speech generating devices, IV
infusion pumps, nebulizers, and hospital beds ordered by a provider for use in the home. The member always
owns certain items, such as prosthetics. In this section, we discuss other types of DME that you must rent.
In Original Medicare, people who rent certain types of DME own the equipment after paying copayments for
the item for thirteen months. As a member of our plan, however, you usually will not acquire ownership of
rented DME items no matter how many copayments you make for the item while a member of our plan. Under
certain limited circumstances we will transfer ownership of the DME item to you.
You can find this information on page 35 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 a NPWT pump and supplies will be denied at any time as not reasonable and necessary if one
or more of the following are present:
-The presence in the wound of necrotic tissue with eschar, if debridement is not attempted;
-Osteomyelitis within the vicinity of the wound that is not concurrently being treated with intent to cure;
-Cancer present in the wound;
-The presence of an open fistula to an organ or body cavity within the vicinity of the wound.
You can find this rule in Local Coverage Determination (LCD): Negative Pressure Wound Therapy Pumps
(L33821) - 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 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 $50 copayment for emergency care. Your copayment will be waived if you are admitted to the hospital within 24 hours. If you are in an observation status the copayment still applies You can find this information in Chapter 4 on page 64 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 the Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations
Manual (Internet-Only Manual, Publ. 100-03) in Chapter 1, Part 4, Section 280.1 stipulates that ventilators
(E0465, E0466) are covered for the following conditions:
"Neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic
obstructive pulmonary disease."
Each of these disease categories are comprised of conditions that can vary from severe and life-threatening to
less serious forms. These ventilator-related disease groups overlap conditions described in this Respiratory
Assist Devices LCD used to determine coverage for bi-level PAP devices. Each of these disease categories are
conditions where the specific presentation of the disease can vary from patient to patient. For conditions such
as these, the specific treatment plan for any individual patient will vary as well. Choice of an appropriate
treatment plan, including the determination to use a ventilator vs. a bi-level PAP device, is made based upon
the specifics of each individual beneficiary's medical condition. In the event of a claim review, there must be
sufficient detailed information in the medical record to justify the treatment selected.
Ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and payment policy
requirements preclude FSS payment for devices used to deliver continuous and/or intermittent positive airway
pressure, regardless of the illness treated by the device. (Social Security Act 1834(a)(3)(A)) This means that
products currently classified as HCPCS code E0465 or E0466 when used to provide CPAP or bi-level PAP
(with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the
FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions described in this
RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP
(E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions
described in this RAD policy will be denied as not reasonable and necessary.
General principles of correct coding require that products assigned to a specific HCPCS code only be billed
using the assigned code. Thus, using the HCPCS codes for CPAP (E0601) or bi-level PAP (E0470, E0471)
devices for a ventilator (E0465, E0466) used to provide CPAP or bi-level PAP therapy is incorrect coding.
Claims for ventilators billed using the CPAP or bi-level PAP device HCPCS codes will be denied as incorrect
coding.
You can find this information in Medicare's Local Coverage Determination (LCD): Respiratory Assist Devices
(L33800).
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 an ankle foot orthosis (AFO) (L1970) is covered for ambulatory beneficiaries with weakness
or deformity of the foot and ankle, who:
1. Require stabilization for medical reasons, and
2. Have the potential to benefit functionally

You can find this rule in Local Coverage Determination (LCD): Ankle-Foot/Knee-Ankle-Foot Orthosis
(L33686) - Effective January 1, 2020.

The rules say that AFOs and KAFOs that are custom-fabricated are covered for ambulatory beneficiaries when
the basic coverage criteria listed above and one of the following criteria are met:
1. The beneficiary could not be fit with a prefabricated AFO; or,
2. The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than
6 months); or,
3. There is a need to control the knee, ankle or foot in more than one plane; or,
4. The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom
fabricating over a model to prevent tissue injury; or,
5. The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric
proportions.

You can find this rule in Local Coverage Determination (LCD): Ankle-Foot/Knee-Ankle-Foot Orthosis
(L33686) - Effective January 1, 2020.

The rules say that L-coded additions to AFOs will be denied as not reasonable and necessary if either the base
orthosis is not reasonable and necessary or the specific addition is not reasonable and necessary. You can find
this rule in Local Coverage Determination (LCD): Ankle-Foot/Knee-Ankle-Foot Orthosis (L33686) - 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.