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 a Medicare plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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, 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 53 of the 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 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 defined as:
- 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.
You can find these rules in Local Coverage Determination (LCD) Hyaluronan Acid Therapies for Osteoarthritis of the Knees (L35427).
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, 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. The health plan contract says that major services such as oral surgery are not covered by the dental plan. You can find this information on page 74 of the 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 say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41(a). The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 4, Section 30.3.
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 contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers 35 round trips each year to health-related, plan-approved locations. You can find this information on page 7 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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. The rules also state that treatment with erythropoiesis stimulating agents (ESAs) for the anemia secondary to myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, lymphoma, and lymphocytic leukemia is only reasonable and necessary under certain conditions. ESA treatment is not reasonable and necessary for the anemia of cancer not related to cancer treatment or anemia associated only with radiotherapy. You can find these rules and full criteria for coverage in the National Coverage Determination (NCD) for Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions (110.21).

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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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) Section 422.101.

The rules say that there is insufficient evidence in the published peer-reviewed scientific literature to support coverage for genetic testing for inherited thrombophilias outside the pregnant women as described above. Genetic testing for FVL and F2 G20210A is considered investigational for all other indications. However, Medicare may consider coverage for FVL and/or F2 genetic testing in unusual circumstances where testing will change clinical management of the patient. Denied claims can be appealed with supporting evidence of specific medical necessity. Only providers with evidence of formal training with board eligibility or certification in hematology/oncology, hematopathology or coagulation disorders at an accredited program satisfy reasonable and necessary criteria for these tests. There is broad consensus in the medical literature that MTHFR genotyping has no clinical utility in any clinical scenario. This testing is considered investigational and is NOT a Medicare benefit. You can find this information in Medicare's Local Coverage Determination (LCD): MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) (L36400).

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 state that program payment may be made for diagnosis and treatment of sexual impotence. Since causes and, therefore, appropriate treatments vary, if abuse is suspected it may be necessary to request documentation of appropriateness in individual cases. If treatment is furnished to patients (other than hospital inpatients) in connection with a mental condition, psychiatric service limitations apply. You can find these rules in National Coverage Determination (NCD) for Diagnosis and Treatment of Impotence (230.4).

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 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, Medicare Benefit Policy Manual, Chapter 15, Section 110.1.

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 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 only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41(a). The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 4, Section 30.3.
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 contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers 20 one-way transportation trips per calendar year. You can find this information on page 93 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 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, 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 benefit. This includes coverage for fixed bridgework. A pontic (bridge) of porcelain fused to high metal coded as D6240 is covered with a $425 copayment. Likewise, bridge retainer crowns of porcelain fused to high metal (D6750) are covered with a $425 copayment. Core buildups coded D2950 is covered with a $50 copayment. It is also noted that For molars, a covered crown or unit of a fixed partial denture (bridge) is metallic without porcelain or other tooth-colored material. If you elect to have porcelain, porcelain-fused-to-metal, resin or resin-with-metal used instead, the maximum additional cost for this tooth-colored material upgrade is $150.00 per molar. You can find this information in Schedules A and B of the Description of Benefits and Copayments for your dental plan.
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 may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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 Sections 422.2 and 422.136.
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 pages 79-80 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 say that a Medicare plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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, 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 8 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 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, 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 in most cases, care you receive from an out of network provider will not be covered. You can find this information on page 42 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 state that invasive procedures for the treatment of varicose veins are considered medically reasonable and necessary when ALL of the following criteria have been met: 

1. An evaluation of the patient has been performed including a history and physical examination, the CEAP clinical classification and the revised Venous Clinical Severity Score (VCSS), AND 

2. A duplex scan of the deep and superficial venous systems supports the examination findings, AND 

3. A duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers in the saphenous, or perforator veins is 500 milliseconds or greater3 and absence of deep venous obstruction, AND 

4. The documentation supports signs and/or symptoms that interfere with activities of daily living and/or quality of life, AND 

5. The CEAP clinical classification is C1 to C6 with the following criteria: 

a. Treatment of C1 disease (telangiectasia and their feeding reticular veins) is considered medically reasonable and necessary for patients with spontaneous and/or traumatic venous hemorrhage. 

b. For patients with C2 or C3 disease and VCSS <6, the plan of care shall include documentation of a period of conservative therapy (2 to 4 weeks) including graduated compression 20-30 mmHg or greater, ambulation, elevation, and avoiding prolonged sitting and standing. 

c. For patients who meet any one of the following criteria, the mandatory conservative therapy prior to the invasive procedure may be waived. 
i. VCSS =6 
ii. C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, and active venous leg ulceration) iii. Hemorrhage 
iv. Recurrent superficial thrombophlebitis 

You can find this rule in Local Coverage Determination (LCD): Treatment of Chronic Venous Insufficiency of the Lower Extremities (L34924).

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.