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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty)
procedures will be considered medically reasonable and necessary for the following indications:

1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have
not responded to non-surgical medical management (e.g., narcotic and/or non- narcotic medication,
physical therapy modalities) with and without methods of immobility (e.g., rest, bracing).
- Both PVP and PVA will be considered reasonable and necessary when ALL of the following
criteria are met:
o Acute (less than 6 wks.) or subacute (6-12 wks.)18,28,42 osteoporotic VCF (T1- L5), based
on symptom onset, and documented by advanced imaging demonstrating bone marrow
edema on MRI or bone-scan/SPECT/CT uptake 1-3,8,26,43 and
o The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating
Scale [NRS] or Visual Analog Scale [VAS] pain score greater than or equal to 8)4-7 or is
non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5)
despite optimal non-surgical management (NSM)8 with one of the following:
&#9642; Worsening Pain or
&#9642; Stable to improved pain (but NRS or VAS greater than or equal to 5) when 2 or
more of the following are present:
o Progression of vertebral body height loss
o Greater than 25% vertebral body height reduction
o Kyphotic deformity
o Severe impact of VCF on daily functioning (Roland Morris Disability
Questionnaire [RDQ] greater than 17)

You can find this rule in the Centers for Medicare and Medicaid Services, Local Coverage Determination
(LCD): Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L35130).

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 Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL the following criteria: 

1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale
 2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity.

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 general anesthesia is considered not reasonable and necessary for facet joint interventions.
Neither conscious sedation nor monitored anesthesia care (MAC) is routinely necessary for intraarticular facet
joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be
given on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of
sedation is unequivocal and clearly documented in the medical record. Frequent reporting of these services
together may trigger focused medical review.

You can find these rules in the Local Coverage Determination (LCD) for Facet Joint Interventions for Pain
Management, L38803.

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 does not cover chiropractic maintenance care. When further clinical improvement cannot be reasonably expected from ongoing care, the care is considered maintenance. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3.

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. The Plan contract says that manual manipulation (adjustment) of the spine to treat subluxation of the spine is covered up to 24 visits per calendar year. Visits exceeding 24 per calendar year or six per month may require a service authorization.You can find this information on page 55 of the plan's 2021 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 state that therapeutic continuous glucose monitors (CGMs) and related supplies are covered by
Medicare when all of the following coverage criteria are met:

1. The beneficiary has diabetes mellitus,
2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a
Medicare-covered continuous subcutaneous insulin infusion (CSII) pump,
3. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of
BGM or CGM testing results,
4. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the
beneficiary to evaluate their diabetes control and determined that criteria (1-3) above are met; and,
5. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an inperson
visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.

You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822).

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 you should receive your care from a network provider (for more information about this, see Section 2 in this chapter). Our plan does offer a Point of Service (POS) option for certain services. Most services obtained from out-of-network providers require prior authorization and are subject to a $500 deductible and fifty percent (50%) coinsurance. The maximum plan benefit for out-of-network covered services is $5,000. Once the plan has paid $5,000 for benefits, you will pay 100% of all out-of-network services for the rest of the calendar year. If you receive care from an out-of-network provider (a provider who is not part of our plan's network), such services will not be covered unless you obtain a prior authorization. Here are two exceptions: The plan covers emergency care or urgently needed services that you get from an out-of-network provider. The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan's service area. You can find this information in Chapter 3, on page 0 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 power operated vehicles are only covered when the enrollee does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform one or more mobility-related activities of daily living (MRADLs) in the home. The rules also require the enrollee to be able to safely use the power operated vehicle. You can find this information in the Local Coverage Determination (LCD): Power Mobility Devices (L33789). 

The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly used for medical purposes. Medicare will not pay for: 

1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 

The rules say that raised toilet seats are not covered because they are considered hygienic equipment that is not primarily medical in nature. The rules say that shower and bath chairs are not covered because they are considered hygienic equipment that is not primarily medical in nature. The rules say that elevators (such as stair lifts) are not covered because they are considered convenience items that are not primarily medical in nature. 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 280.1. 

The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your home may be a dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, an institution may not be considered your home if it is an acute hospital or a skilled nursing facility (SNF). You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(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.
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). 

TENS is covered for chronic, intractable pain other than chronic low back pain when all of the following criteria must be met: 

The presumed etiology of the pain must be a type that is accepted as responding to TENS therapy. Examples of conditions for which TENS therapy is not considered to be reasonable and necessary are (not all-inclusive): 
a. headache 
b. visceral abdominal pain 
c. pelvic pain 
d. temporomandibular joint (TMJ) pain 

The pain must have been present for at least three months. 

Other appropriate treatment modalities must have been tried and failed. 

TENS therapy for chronic pain that does not meet these criteria will be denied as not reasonable and necessary. 

You can find this information in Local Coverage Determination (LCD): Transcutaneous Electrical Nerve Stimulators (TENS) (L33802). 

1. The use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema. 
2. Specific indications for the use of vasopneumatic devices include: 
a. Reduction of edema after acute injury 
b. Lymphedema of an extremity 
c. Education and training on the use of vasopneumatic devices for home use

You can find this information in Local Coverage Determination (LCD) - Outpatient Occupational Therapy (L34427). 

The use of nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not considered medically reasonable and necessary. You can find this information in Local Coverage Determination (LCD) - Nerve Blocks for Peripheral Neuropathy (L35222).

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 ESRD facilities are responsible for supplies necessary for the effective performance of all modalities of home dialysis, for example, alcohol wipes, sterile drapes, gloves, telfa pads, bandages, etc. Necessary supplies could also include but are not limited to start-up durable supplies (whether or not they are part of a start-up kit) such as weight scales, sphygmomanometer, I.V. stand, and dialysate heaters; and consumable and disposable supplies such as dialysate, tubing, and gauze pads. Instruments and nonmedical supplies, such as scales, stopwatches, and blood pressure apparatus (this does not include automatic blood pressure monitoring devices such as those mentioned in Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 3), are included in the ESRD PPS, regardless of whether provided separately or as part of a start-up kit. You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual chapter 11, section 20.4.

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 only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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 health Plan contract says excluded from Medicare coverage is any service other than manual manipulation for the treatment of subluxation.
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, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by the Centers for Medicare and Medicaid Service. 

You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64.

The rules say that this policy denies coverage for all CV risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. The policy denies coverage for all non-lipid biomarkers when used for CV risk assessment including but not limited to, biochemical, immunologic, and hematologic, and genetic biomarkers for CV risk assessment regardless of whether ordered in a panel or individually. You can find this rule in the Local Coverage Determination for Molecular Diagnostics Service Program (MolDX): Biomarkers in Cardiovascular Risk Assessment, L36358 (eff 10/01/19).

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) 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 on page 44 of the Plan's 2021
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 pays for home health care services under a prospective payment system (HH PPS). Home health services under a plan of care are paid based on a 60-day episode of care. Payment for home health care episodes is usually made in two parts. To receive the first part of the HH PPS split payment, the home health agency must submit a Request for Anticipated Payment (RAP). Specific data elements are required to submit a RAP. The home health agency must enter the claim - Outcome and Assessment Information Set (OASIS) matching key output by the Grouper software. This is known as the Treatment Authorization Code. You can find this rule, a list of the data elements, and instructions for the Treatment Authorization Code in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 40.1.

The rules say that after a RAP has been paid and a 60-day episode has been completed or the enrollee has been discharged, the home health agency must submit a claim to receive the rest of payment due for the episode. You can find this rule and detailed instructions for the claim in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 40.2.

The rules say that since RAP payments are automatically recouped against other payments if the claim for a given episode does not follow the RAP in the later of: (1) 120 days from the start of the episode; or (2) 60 days from the payment date of the RAP. The RAP must be re-billed once payment has been recouped if the claim is to be billed.

The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid information for all of these elements may be returned as unprocessable. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 80.3.1.

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) 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 say that the applicable payments made under the prospective payment systems are payment in full for
all facility services, as defined in 42 CFR Section 409.10. CMS does not pay any provider or supplier other
than the facility for services furnished to a beneficiary. The facility must furnish all necessary covered services
to the beneficiary either directly or under arrangements (as defined in 42 CFR Section 409.3). You can find this
rule at 42 CFR Section 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.