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 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 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 Sections 411.15 and 411.15(o).
National Coverage Determination (NCD) Colorectal Cancer Screening Tests 210.3: Nationally Non-Covered Indications: All other indications for colorectal cancer screening not otherwise specified in the Act and regulations, or otherwise specified above remain nationally non-covered. Non-coverage specifically includes:
(1) All screening DNA tests, effective April 28, 2008, through October 8, 2014. Effective for dates of service on or after October 9, 2014, all other screening DNA tests not otherwise specified above remain nationally non-covered.
(2) Screening computed tomographic colonography (CTC), effective May 12, 2009.
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 for patients enrolled in a Medicare Advantage (MA) Plan in 2020 and 2021, you must submit COVID-19 vaccine administration claims to Original Medicare through your Medicare Administrative Contractor (MAC). Use your patients' Medicare Beneficiary Identifiers (MBIs) (not their Medicare Advantage Plan Member IDs) to bill Original Medicare. You can find this rule at https://www.cms.gov/medicare/covid-19/medicare-billing-covid-19-vaccineshot-administration.
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 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 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 Sections 411.15 and
411.15(o).
Local Coverage Determination (LCD) Negative Pressure Wound Therapy Pumps L33821: For wounds and
ulcers described under A or B above, a NPWT pump and supplies will be denied as not reasonable and
necessary with any of the following, whichever occurs earliest:
1. Criteria C1-C2 cease to occur,
2. In the judgment of the treating practitioner, adequate wound healing has occurred to the degree that
NPWT may be discontinued,
3. Any measurable degree of wound healing has failed to occur over the prior month. Wound healing is
defined as improvement occurring in either surface area (length times width) or depth of the wound
4. 4 months (including the time NPWT was applied in an inpatient setting prior to discharge to the
home) have elapsed using a NPWT pump in the treatment of the most recent wound
5. Once equipment or supplies are no longer being used for the beneficiary, whether or not by the
treating practitioner's order
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.
Medicare does not pay for the services of a naturopath. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-06, Medicare Financial Management Manual, Chapter 3, Section 90.1(L).
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 primary indication of a diagnostic facet joint procedure is to diagnose whether the patient has facet syndrome. Diagnostic procedures should be performed with the intent that if successful, radiofrequency ablation (RFA) procedure would be considered the primary treatment goal at the diagnosed level(s). A second diagnostic facet procedure is considered medically necessary to confirm validity of the initial diagnostic facet procedure when administered at the same level. The second diagnostic procedure may only be performed a minimum of 2 weeks after the initial diagnostic procedure. Clinical circumstances that necessitate an exception to the two-week duration may be considered on an individual basis and must be clearly documented in the medical record. For each covered spinal region, no more than four (4) diagnostic joint sessions will be reimbursed per rolling 12 months, in recognition that the pain generator cannot always be identified with the initial and confirmatory diagnostic procedure. You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L35936).
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.
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. This rule does not apply to: 1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed; 2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL; and 3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with an IOL. You can find this rule at 42 CFR Section 411.15(b). Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR Section 411.15(c).
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 does not list low vision aids as a covered benefit. You can find this information on pages 105-108 of the 2021 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 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 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. The contract specifically says that any procedure not listed is not covered. Oral hygiene instructions (D1330) is not included on this list and is not a covered supplemental benefit. You can find this information on pages 4-56 to 4-59 of the Plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that the following indications for BRCA 1 and BRCA 2 testing are covered by Medicare: - Individual with breast, ovarian1, pancreatic, or prostate cancer from a family with a known deleterious BRCA1 or BRCA2 gene mutation. - Individual with a personal history of ovarian1 cancer - Individual with a breast cancer diagnosis meeting any of the following criteria: -- Diagnosed =45 y2 -- Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR) negative, and human epidermal growth factor receptor 2 (HER2) negative) breast cancer diagnosed = 60 y -- Diagnosed at = 50 y with: - An additional breast cancer primary - =1 first, second, or third degree relative5 with breast cancer at any age, or - =1 first, second, or third degree relative5 with prostate cancer (Gleason score =7), or - An unknown or limited family history3 -- Breast cancer diagnosed at any age, and - =1 first, second, or third degree relative5 with breast cancer =50 y, or - =1 first, second, or third degree relative5 with ovarian cancer at any age, or - =1 first, second, or third degree relative5 with metastatic prostate cancer or pancreatic cancer at any age - =2 additional diagnoses of breast cancer at any age in patient and/or in close blood relative5, or - A first, second, or third degree male relative with breast cancer - For an individual of ethnicity associated with higher mutation frequency (e.g. Ashkenazi Jewish4) no additional family history may be required. -- Male breast cancer - Personal history of prostate cancer (Gleason score=7) at any age with: -- =1 first, second, or third degree relative5 with ovarian cancer at any age, or -- =1 first, second, or third degree relative5 with breast cancer =50 y, or -- =1 first, second, or third degree relative5 with pancreatic cancer at any age, or -- =1 first, second, or third degree relative5 with metastatic prostate cancer at any age, or -- =2 first, second, or third degree relatives5 with breast cancer and/or pancreatic cancer and/or prostate cancer (Gleason score =7 or metastatic) at any age, or -- Ashkenazi Jewish ancestry
- Personal history of pancreatic cancer at any age - Personal history of metastatic prostate cancer (radiographic evidence of or biopsy-proven disease) - BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of germline mutation analysis You can find this rule in the Local Coverage Determination (LCD) for MolDX: BRCA1 and BRCA2 Genetic Testing (L36163).
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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 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 does not include an implant supported crowns. You can find this information on pages 76-79 of the Plan's 2021 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 providers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A). The rules also say that Modifier "-24" reports an unrelated evaluation and management service by same physician during a postoperative period. The physician may need to indicate that an evaluation and management service was performed during the postoperative period of an unrelated procedure. This circumstance is reported by adding the modifier "-24" to the appropriate level of evaluation and management service. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 12, Section 40.2.
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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, 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 in Chapter 3 on pages 3-3 to 3-4
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 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 Centers for Medicare and Medicaid Services, Internet
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 220.2(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.
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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.6. The rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You can find this information in the Medicare Learning Network (MLN) Matters article number MM7631, "Revised and Clarified Place of Service (POS) Coding Instructions."
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 elastic stockings are not covered because they are non-reusable supply items. Elastic
stockings are not durable medical equipment. You can find this rule in the Centers for Medicare and Medicaid
Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual,
Chapter 1, Section 280.1.
The rules say that gradient pressure garments may be covered when used as dressings following burn injuries.
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication
100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 270.5.
The rules also say that compression bandages, multi-layer systems, and gradient compression wraps are
covered only when they are used as dressings over a qualifying wound. A qualifying wound is either a wound
caused or treated by surgery or a wound that must be debrided. A gradient compression stocking or wrap
described by codes A6531, A6532, or A6545 is only covered when it is used in the treatment of an open
venous stasis ulcer. Gradient compression stockings and wraps identified with codes A6531, A6532, and
A6545 are not covered when they are used to treat the following conditions:
- Venous insufficiency without stasis ulcers;
- Prevention of stasis ulcers;
- Prevention of the reoccurrence of stasis ulcers that have healed;
- Treatment of lymphedema in the absence of ulcers.
You can find these rules in Local Coverage Determination (LCD): Surgical Dressings L33831 and Local
Coverage Article: Surgical Dressings-Policy Article A54563, effective for services performed on or after July
24, 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.
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device.
This rule does not apply to:
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after
each cataract surgery with insertion of an IOL; and
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with
an IOL.
You can find this rule at 42 CFR Section 411.15(b).
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact
lenses for refractive error only. Medicare does not pay for procedures performed during any eye exam to
determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection
with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR Section
411.15(c).
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 covered routine vision services include routine eye exams, frames, and lenses. You can find
this information on pages 87-88 of the Plan's 2021 Evidence of Coverage.