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 28 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 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 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 health plan contract says that only certain codes/services are covered under the Plan. The EOC lists specific services which are a covered benefit and any service not listed in this section is not a covered benefit. You can find this information in Chapter 4 on page 62 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 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 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 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. However, gradient compression stockings described by codes A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, A6541, A6544, and A6549 are noncovered because they do not meet the statutory definition of a dressing. You can find these rules in the Local Coverage Determination (LCD): Surgical Dressings L33831 and Local Coverage Article: Surgical Dressings-Policy Article A54563.
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.
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find
this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 290(3).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) 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 Plan contract says that the only covered chiropractic service is manual manipulation of the spine to correct a subluxation. You can find this information on page 9 of the Plan's 2019 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 only the physician admitting the patient to outpatient observation care may bill the observation CPT procedure codes. This includes the admission (99218 - 99220), subsequent observation (99224 - 99226), and discharge from observation (99217). Anyone else seeing the patient while in observation care would bill using appropriate outpatient service codes. You can find this information in the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.8.
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 will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that specifically listed dental services are covered by the plan. Crown (D2750) is listed as a covered benefit when medically reasonable and necessary. You can find this information on pages 90 and 104 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.
Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise reasonable and necessary for the patient. FDA approved drugs used for indications other than what is indicated
on the official label may be covered if the use is determined to be medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50.4.1 and 50.4.2.
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 LAAC devices are covered when the device has received Food and Drug Administration
(FDA) Premarket Approval (PMA) for that device's FDA-approved indication and meet all of the conditions
specified below:
The patient must have:
- A CHADS2 score greater than or equal to 2 (Congestive heart failure, Hypertension, Age > 75, Diabetes,
Stroke/transient ischemia attack/thromboembolism) or CHA2DS2-VASc score greater than or equal to 3
(Congestive heart failure, Hypertension, Age greater than or equal to 65, Diabetes, Stroke/transient ischemia
attack/thromboembolism, Vascular disease, Sex category)
- A formal shared decision making interaction with an independent non-interventional physician using an
evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. Additionally, the
shared decision making interaction must be documented in the medical record.
- A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following the
conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral anticoagulants.
The patient (preoperatively and postoperatively) is under the care of a cohesive, multidisciplinary team (MDT)
of medical professionals. The procedure must be furnished in a hospital with an established structural heart
disease (SHD) and/or electrophysiology (EP) program.
The procedure must be performed by an interventional cardiologist(s), electrophysiologist(s), or cardiovascular
surgeon (s) that meet the following criteria:
- Has received training prescribed by the manufacturer on the safe and effective use of the device prior to
performing LAAC; and,
- Has performed greater than or equal to 25 interventional cardiac procedures that involve transeptal puncture
through an intact septum; and,
- Continues to perform greater than or equal to 25 interventional cardiac procedures that involve transeptal
puncture through an intact septum, of which at least 12 are LAAC, over a 2-year period.
The patient is enrolled in, and the multidisciplinary team and hospital must participate in, a prospective,
national, audited registry that: 1) consecutively enrolls LAAC patients, and, 2) tracks the following annual
outcomes for each patient for a period of at least 4 years from the time of the LAAC:
- Operator-specific complications
- Device-specific complications including device thrombosis
- Stroke, adjudicated, by type
- Transient Ischemic Attack (TIA)
- Systemic embolism
- Death
- Major bleeding, by site and severity
LAAC is non-covered for the treatment of NVAF when not furnished under CED according to the above-noted
criteria. You can find this rule in the Medicare National Coverage for Percutaneous LEFT ATRIAL
APPENDAGE CLOSURE (LAAC), 20.34.
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 Medicare Managed Care Manual, Chapter 1, Section 20.2. Medicare does not pay for acupuncture as an anesthetic, as an analgesic, or for other therapeutic purposes. You can find this rule in the Medicare National Coverage Determinations Manual, Chapter 1, Sections 30.3, 30.3.1, and 30.3.2. The rules say that for services performed on or after January 21, 2020, Medicare will now provide limited coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may be provided by a physician in accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Medicare National Coverage Determinations Manual, Section 30.3.3. 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 page 36 of the plan's 2019 Evidence of Coverage and in Chapter 3 on page 36 of the plan's 2020 Evidence of Coverage.The health plan contract says covered for ten (10) visits per calendar year. In-network acupuncture: you pay 50% coinsurance per visit. Out-of-network acupuncture is not covered. You can find this information in Chapter 4 on page 48 of the plan's 2019 Evidence of Coverage and in Chapter 4 on page 48 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 an initial thermal RFA of the facet joint nerves is considered reasonable and necessary only after the patient has had at least two (2) medically reasonable and necessary diagnostic medial branch blocks (MBBs), with each one providing a minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) or at least 50% improvement in the ability to perform previously painful movements and ADLs OR, after the patient has had at least one (1) medically reasonable and necessary therapeutic injection that provided at least 50% pain relief for at least three (3) months. You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892).
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 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 44 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 find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. The rules say that under the home health prospective payment system, before January 1, 2020, a case-mix adjusted payment for a 60-day episode is made using one of 153 HHRGs. After January 1, 2020, under the Patient-Driven Payment Model, a case-mix adjusted payment for a 30-day period of care is made using one of 432 HHRGs. On Medicare claims, these HHRGs are represented as Health Insurance Prospective Payment System (HIPPS) codes. You can find this rule in the Medicare Claims Processing Manual, Chapter 10, Section 10.1.8. 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 a Medicare plan may not pay for services given by a physician or other practitioner who has
opted out of Medicare. This rule does not apply to emergency or urgently needed services. This rule applies to
all other services, as well as to supplemental benefits. A Medicare plan must pay for emergency or urgently
needed services given by a physician or practitioner who has not signed a private contract with the enrollee.
You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the Medicare Managed Care Manual,
Chapter 6, Section 60.2.
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 health
plan contract says that you can get your care from an out-of-network provider; however, in most cases that
provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who
is not eligible to participate in Medicare. If you receive care from a provider who is not eligible to participate in
Medicare, you will be responsible for the full cost of the services you receive. Check with your provider before
receiving services to confirm that they are eligible to participate in Medicare. You can find this information in
Chapter 4 on pages 44-45 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 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 a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and necessary. You can find this rule in the Local Coverage Determination for Cold Therapy, L33735 (eff 01/01/20).
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 Code of Federal Regulations (CFR) Section 422.101.
The rules state that for the purposes of Medicare coverage of lung cancer screening with low-dose computed tomography (LDCT), beneficiaries must meet all of the following eligibility criteria:
- Age 55 to 77 years;
- Asymptomatic (no signs or symptoms of lung cancer);
- Tobacco smoking history of at least 30 pack-years (1 pack-year being smoking 1 pack (20 cigarettes) per day for 1 year);
- Current smoker or one who has quit smoking within the last 15 years; and
- Receive a written order for lung cancer screening with LDCT. Written orders for lung cancer LDCT screening must be appropriately documented in the beneficiary's medical records, and must contain the following information:
o Beneficiary date of birth;
o Actual pack-year smoking history (number);
o Current smoking status, and for former smokers, the number of years since quitting smoking;
o Statement that the beneficiary is asymptomatic; and
o National Provider Identifier (NPI) of the ordering practitioner
You can find these rules in National Coverage Determination (NCD) for Lung Cancer Screening with Low-Dose Computed Tomography (LDCT) (210.14).
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). 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 pages 1-6 to 1-7 of the Plan's 2020 EOC.