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 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 412.622.
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 Original Medicare pays physicians, providers and suppliers for Medicare-covered services furnished to enrollees who have elected hospice. The Plan is responsible for non-hospice services that are not Medicare-covered, but that are offered as supplemental benefits under the Plan. You can find this rule in the Medicare Managed Care Manual, Chapter 8, Section 70.3.1. The rules also say that the Medicare hospice pays claims for services related to the terminal illness. Original Medicare pays claims for Medicare-covered non-hospice services provided by physicians, providers or suppliers. Original Medicare continues to pay for services furnished after the revocation or expiration of the enrollee's hospice election until the first day of the month after the hospice election has been revoked or terminated. You can find this rule in the Medicare Claims Processing Manual, Chapter 11, Section 30.4.
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) 422.101. 
 
The rules say that Medicare generally does not cover screening services, which are defined as examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury. However, limited coverage is allowed for screening for prostate cancer. You can find this information in the Medicare Benefit Policy Manual, Chapter 15, Section 90. 
 
The rules also say that prostate screenings are covered when ordered by a provider who is fully knowledgeable about the beneficiary, and who would be responsible for explaining the results of the screening examination or test. You can find this information in 42 CFR Section 410.39.
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) 422.101.
The rules say that posterior tibial nerve stimulation (PTNS) should not be performed as first line therapy for patients with OAB. It may be considered medically necessary and covered to treat patients with overactive bladder and associated symptoms of urinary urgency, urinary frequency, and urge incontinence when ALL of the following criteria have been met: - The patient has experienced OAB with associated symptoms of urinary urgency, urinary frequency, and urge incontinence for at least 12 months and the condition has resulted in significant disability [the symptoms are limiting the patient's ability to participate in activities of daily living (ADLs);] and - The patient has tried at least two different anti-cholinergic drugs, or a combination of an anti-cholinergic and a tricyclic drug for a period of four to six weeks without improvement, or the documentation shows the patient is unable to tolerate these type drugs; and - The patient has tried behavioral treatments (e.g., pelvic floor exercise, biofeedback, timed voids, or fluid management (not an all-inclusive list) without improvement in the symptoms. You can find this rule in the Local Coverage Determination for Posterior Tibial Nerve Stimulation (PTNS), L33406 (eff 01/08/19).
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) 422.101.
The rules state that echocardiography is indicated in the evaluation of derangements of valvular, myocardial and pericardial structure and function. The general applications for coverage include: A. TRANSTHORACIC Echocardiogram INDICATIONS: 1. Ventricular Function, Cardiomyopathies and Heart Failure 2. Hypertensive Cardiovascular Disease 3. Acute Myocardial Infarction and Coronary Insufficiency 4. Exposure to Cardiotoxic Agents (chemotherapeutic and external) 5. Cardiac Transplant and Rejection Monitoring 6. Native Valvular Heart Disease 7. Prosthetic Heart Valves (Mechanical & Bio-prostheses) 8. Acute Endocarditis 9. Pericardial Disease 10. Abnormalities of the Great Vessels 11. Congenital Heart Disease 12. Suspected Cardiac Thrombi and Embolic Sources 13. Cardiac Tumors and Masses 14. Critically Ill and Trauma Patients 15. Arrhythmias and Palpitations 16. Syncope 17. Pulmonary 18. Contrast Echocardiography Echocardiography performed for screening purposes is not covered. Screening includes testing performed on patients who present with risk factors (including the risk factor as having a positive family history, e.g., familial history of Marfan's disease). A screening service for high-risk patients is considered good medical practice but is not covered by Medicare. When the result of the test is abnormal, subsequent services may be billed with the test-result diagnosis; however, the initial screening test must be listed as screening, even though the result of the screening test may be a covered condition. You can find this rule and explanations of the covered indications in Local Coverage Determination (LCD): TRANSTHORACIC Echocardiography (TTE) (L34338).
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) 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) 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).
The rules say that if medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan to when determined to be medically reasonable and necessary. 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) 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 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 $45 copay for each Medicare-covered office visit to other providers for urgently needed services. You can find this information on page 95 of the Plan's 2019 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) 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 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 Section 423.578(b)(5)(ii).
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. You can find this information on page 98 of the 2020 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) 422.101.
The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. You can find this rule in the Medicare National Coverage Determinations Manual, Section 240.2(E). The rules state that only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered. You can find this rule in Local Coverage Article: Oxygen and Oxygen Equipment - Policy Article (A52514).
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) 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).
The rules say that the applicable payments made under the prospective payment systems are payment in full for all facility or hospital services, as defined in 42 CFR 409.10. CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements (as defined in 42 CFR 409.3). You can see this in 42 CFR 412.50.
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) 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 Plan contract includes a list of covered supplemental dental services. Extraction is not included on this list and is not a covered supplemental benefit. You can find this information on pages 89 to 90 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 Code of Federal Regulations (CFR) 422.101.
The rules say that payment for inpatient psychiatric hospital services is to be made only for active treatment.
For services to be designated as active treatment they must:
1. be provided under an individualized treatment or diagnostic plan;
2. reasonably be expected to improve the patient's condition, or for the purpose of diagnosis; and
3. be supervised and evaluated by a physician.
You can find these rules in the Medicare Benefit Policy Manual, Chapter 2, Sections 30.2.2 and 30.2.2.1.
The rules say that Medicare will not pay any expenses for items or services which are not medically necessary
and reasonable for the diagnosis or treatment of illness or injury. This exclusion extends to claims for services
which are provided in inappropriate settings. You can find this rule in the Social Security Act, Section
1862(a)(1).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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) 422.101.
The rules say that for definitive drug testing, limitations apply when denials are likely, whether based on medical necessity or other coverage reasons. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. For code 80307, diagnosis codes and physician documentation must be coded to the highest level of specificity. You can find this in the Local Coverage Article: Billing and Coding: Drug Testing (A56818).
The rules say that Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare policies. You can find this in the Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, Section 3.3.2.4 entitled Signature Requirements.
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) 422.101. 
 
The rules state that low back pain may also be produced by "Myofascial Pain Syndrome" in which case there is not nerve root pathology and epidural injections are not reasonable and necessary. If there is a doubt in the differential diagnosis, the diagnosis of radiculopathy can be confirmed by an EMG/nerve conduction/small fiber testing or appropriate radiological study. Degenerative Disk Disease without root compression has been shown to be a significant cause of low back and/or radicular pain; some patients will respond to Epidural Steroid Injection in this situation.  
 
It is not expected that a patient would undergo an epidural injection at more than two (2) levels (unilateral or bilateral) on any given date of service. (A level is defined as the articulation between two vertebrae i.e., C4-5; or L2- 3).
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) 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). Medicare rules say that Psychotherapy is defined as the treatment for mental illness and behavioral disturbances in which the clinician establishes a professional contract with the patient and through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior and encourage personality growth and development or support current evaluation of functioning. Psychotherapy services include ongoing assessment and adjustment of psychotherapeutic interventions and may include involvement of family member(s) or others in the treatment process. Although maintenance per se is not covered, helping a patient maintain his/her highest level of functioning, such as a patient with borderline personality disorder, may be covered on a case-by-case basis. These case-by-case considerations must be supported by the evaluation and a plan with clearly identified goal(s). This information can be found in Local Coverage Determination (LCD): Psychiatry and Psychology Services (L34616).
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) 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).
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) 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). The rules say that payment for an initial observation care code is for all the care rendered by the ordering physician on the date the patient's observation services began. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes. You can find this rule in the Medicare Claims Processing Manual, Chapter 12, 30.6.8.
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.