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 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 website www.medicareappeal.com.
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 at 42 CFR 422.101.The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are:1. blood-clotting factors; 2. drugs used in immunosuppressive therapy;3. erythropoietin for dialysis patients; 4. osteoporosis drugs for certain homebound patients;5. certain oral cancer drugs; 6. oral anti-emetics used in certain situations; 7. drugs treated as supplies during an outpatient hospital procedure; and 8. drugs required for the effective use of durable medical equipment.You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.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 ifregular Medicare would pay for it in this case. You can find this rule at 42 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 Plancovers 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 pages 72 to 73 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 findthis 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:1.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.2.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.3.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).4.The patient has failed at least three months of conservative therapy. Conservative therapy is definedas:-Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss, physical therapy if indicated); and-If not contraindicated, simple analgesics and (e.g., acetaminophen) or NSAIDS per hyaluronan product prescribing information.5.The patient has failed to respond to aspiration of the knee when effusion is present and intra-articular corticosteroid injection therapy when inflammation is a significant component of the patient's symptoms and intra-articular corticosteroids are not contraindicated.A repeat series* of hyaluronan knee injection(s) for patients who have responded to a prior series is considered to be reasonable and necessary under the following circumstances:-Symptoms have recurred And,-At least six months have elapsed since the prior series of injections And,-There was significant improvement in pain and functional capacity achieved with the prior series of injections using a standardized assessment tool Or,-There is significant reduction in the doses of NSAID medications taken or reduction in the number of intra-articular steroid injections to the knees during the six-month period following the injection(s).*Note: A series is defined as a set of injections for each joint and each treatment (initial or repeat).You can find this rule in the Local Coverage Determination (LCD): Hyaluronan Acid Therapies for Osteoarthritis of the Knee (L35427) effective October 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.
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 CFR 422.101.The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are:1. blood-clotting factors; 2. drugs used in immunosuppressive therapy;3. erythropoietin for dialysis patients; 4. osteoporosis drugs for certain homebound patients;5. certain oral cancer drugs; 6. oral anti-emetics used in certain situations; 7. drugs treated as supplies during an outpatient hospital procedure; and 8. drugs required for the effective use of durable medical equipment.You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that there is $180.83 for Vision services. You can find this information on page 56 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 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. This benefit includes adjustments, relines, rebase and repairs of removable dentures. You can find this information on page 65 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 at42 CFR 422.101.The rules say that treatment for Symptomatic Chronic Venous Insufficiency or Varicose Veins (VV), in the absence of bleeding, phlebitis or skin necrosis, may be covered as medically necessary with:  1. A documented 3-month trial of conservative therapy including graduated compression stockings with a minimum of (12-18 mmHg), weight reduction to BMI less than 35, therapeutic leg elevation, and an exercise program of calf muscle pumping activity with compression of the involved veins, which results in limited alteration/improvement of symptoms or findings without satisfactory endpoint, and2. Duplex venous studies of the involved lower extremity(s), mapping size and course of the greater and lesser saphenous vein and prominent tributaries and demonstrating the:-Presence and Patency of the Deep Venous System.-Absence of Deep Venous Thrombosis, and-Documented Incompetence (reflux greater than 500msec) of the Valves of the Saphenous, Perforator or Deep venous systems consistent with the patient's symptoms and findings.You can find this rule in Local Coverage Determination (LCD): Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities (L34924) -Effective November 14, 2019.The rules say that to be considered for coverage of endovenous ablation therapy, all of the following criteria must be met:-Patient's anatomy is amenable to laser or radiofrequency catheter with the absence of tortuosity that would impair catheter passage and distance separation from skin as to preclude thermal injury. Unless documented by the supplier of the RFA or LA device, maximal vein diameter may not exceed 20mm as there is insufficient data to suggest devices presently marketed for this purpose are effective for occlusion of veins above this diameter.-Non-Aneurysmal Saphenous vein or portion of vein at risk of rupture, hemorrhage or adjacent skin injury. Large veins adjacent to aneurysm formation (fusion of skin and vein wall) are optimal candidates for ERFA or EVLT in that adjacent aneurysm and preclude further need for treatment.-Maximal vein diameter is clinically appropriate for catheter or sheath employed.-No planned treatment of incompetent valves or risk of direct injury to perforator veins of the calf that may induce thrombus propagation into the deep vein system.-Absence of clinically significant or symptomatic peripheral arterial disease.You can find this rule in Local Coverage Determination (LCD): Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities (L34924) -Effective November 14, 2019.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 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 $200 copayment for ambulance services. You can find this information in Chapter 4 on page 6 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 state that tinted lenses (V2745), including photochromatic lenses (V2744), used as sunglasses, which are prescribed in addition to regular prosthetic lenses to a pseudophakic beneficiary, will be denied as non-covered.You can find this information in the Local Coverage Article: Refractive LENSES -Policy Article (A52499).Anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses (V2780) are covered only when they are medically necessary for the individual beneficiary and the medical necessity is documented by the treating practitioner. When these features are provided as a beneficiary preference item and are billed with an EY modifier (see LCD-related Standard Documentation Requirements Article), they will be denied as not reasonable and necessary.You can find this information in the Local Coverage Determination (LCD): Refractive Lenses (L33793).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.ThePlan 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 the supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) must have an order from the treating physician before giving any DMEPOS item to an enrollee. The supplier must keep the order and proof of delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. You can find this rule in the Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1 and 5.8.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 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 Coverage is available for an AWV that meets the following requirements:It is performed by a health professional; and,It is furnished to an eligible beneficiary who is no longer within 12 months after the effective date of his/her      first Medicare Part B coverage   period, and he/she has not received either an IPPE or an AWV providing   PPPS within the past 12 months.You can find this rule in the Medicare Benefit Policy Manual Chapter 15, 280.5If you want to read these Medicare rules, youcan 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 42CFR 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 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 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 a physician shall not unbundle services that are integral to a more comprehensive procedure. A physician shall not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT codedescribes these services. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I.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 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 $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You can find this information on page 83 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 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 therapeutic facet joint injections are considered medically reasonable and necessary if the patient has had two medically reasonable and necessary diagnostic MBBs with each one providing a minimum of 80% relief of primary pain. You can find this rule in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892). The rules say that services that are not medically necessary are not covered.The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR 411.15 and 411.15(o).
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 MRIs are covered when medically necessary and reasonable for the diagnosis or treatment of the specific patient involved. You can find this rule in the Medicare National Coverage Determinations Manual, Section 220.2(B)
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 state that no Medicare payment can be made to a provider that is not enrolled in the Medicare program. You can find this in the Medicare Program Integrity Manual, Chapter 15. The rules say that Medicare pays for inpatient hospital services under the Inpatient Prospective Payment System (PPS). These amounts are, with certain exceptions, payment in full to the hospital for inpatient operating costs. All items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. This provision applies to all hospitals, regardless of whether they are subject to PPS. You can find this information in the Medicare Claims Processing Manual, Chapter 3, Sections 10.1 and 20.
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 CFR 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 programgenerally 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.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.