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 Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. The rules say that effective December 1, 2000, Medicare covers sodium ferric gluconate complex in sucrose injection as a first line treatment of iron deficiency anemia when furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplemental erythropoeitin therapy. Effective October 1, 2001, Medicare also covers iron sucrose injection as a first line treatment of iron deficiency anemia when furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplemental erythropoeitin therapy. You can find this rule in National Coverage Determination (NCD) for Intravenous Iron Therapy (110.10) - Effective October 1, 2001.
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 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 non-covered 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.
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 rules say that procedure code 82306 - Vitamin D; 25 hydroxy, includes fraction(s), if performed - is only covered by Medicare for certain, specific diagnosis codes. If a covered diagnosis code is not billed on the claim, the service will be automatically denied as not medically necessary. Diagnosis codes M06.9, M05.9, E10.29, R80.9, E03.9, and E78.5 are not among those diagnosis codes for which procedure code 82306 is covered. You can find this rule in Local Coverage Article (LCA) Billing and Coding: Assays for Vitamins and Metabolic Function (A56485).
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 routine vision care benefit includes one routine eye exam per calendar year. The vision benefit is limited to one pair of glasses or contact lenses per calendar year. Frames and standard lenses or standard contact lenses are provided at no cost per calendar year when purchased from a Collection. Additionally, there is a $200 allowance towards non vendor frames or non vendor contact lenses. You are responsible for all costs above the $200 maximum plan coverage benefit. You can find this information on page 87 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 the service of a physical therapist, speech-language pathologist, or occupational therapist is a
skilled therapy service if the inherent complexity of the service is such that it can be performed safely and/or
effectively only by or under the general supervision of a skilled therapist. To ensure therapy services are
effective, at defined points during a course of treatment, for each therapy discipline for which services are
provided, a qualified therapist (instead of an assistant) must perform the ordered therapy service. You can find
this rule in the Medicare Benefit Policy Manual Chapter 7, Section 40.2.1.
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 ifregular 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 Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1.Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Section 423.578(b)(5)(ii).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the 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 in the plan's Pharmacy Coverage policy for Viscosupplements.
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 if medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG)
Positron Emission Tomography (PET) scan to determine the initial level of cancer treatment needed for an
enrollee. After the completion of the initial anti-cancer therapy, additional FDG PET scans may be covered at
the discretion of Medicare. You can find this rule in the National Coverage Determinations Manual, Section
220.6.17.
The rules say that with the exception of suspected prostate cancer, Medicare covers one Fluorodeoxyglucose
(FDG) Positron Emission Tomography (PET) scan when medically necessary and reasonable to help determine
the initial treatment strategy for enrollees suspected of having cancer. Medicare may also cover up to three
FDG PET scans when used to guide subsequent management of cancer treatment after completion of initial
anti-cancer therapy. The local Medicare Administrative Contractor may determine if more than three scans are
coverable. Some limitations apply when FDG PET scan is used for initial diagnosis or staging of melanoma or
of cancers of the cervix or breast. You can find this rule in the National Coverage Determinations Manual,
Section 220.6.17.
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 may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Section 423.578(b)(5)(ii).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the 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. The health plan contract says that Granix is subject to step therapy. Step therapy encourages you to try the preferred drug(s), which is/are just as effective: Neupogen (filgrastim) and Nivestym (filgrastim-aafi). If the prescriber uses one of the preferred drugs, it will be covered. Exceptions are made when the prescriber says: why you can't take the preferred drugs (such as previous treatment, contraindication, or intolerance); OR that you are already using the requested drugs. You can find this rule in the plan's Pharmacy Coverage - Granix (tbo-filgrastim).
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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that enrollees must pay a $25 copayment for Medicare covered speech therapy services. You can
find this information on page 67 of the Plan's 2019 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 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).
The rules say subluxation may be shown by x-ray or physical exam. You can find this rule in the Medicare
Benefit Policy Manual, Chapter 15, Section 240.1.2.
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 contact covers manual manipulation of the spine to correct a subluxation. Other chiropractic services
provided are not covered. You can find this information on pages 49 and 78 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.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 says that we cover one pair of eyeglasses or contact lenses after each cataract surgery. Corrective lenses/frames (and replacements) needed after a cataract removal without a lens implant are not covered. Tinting, scratch protection, or other enhancements to the eyewear are also not covered. You can find this information on page 98 of the 2019 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.
Local Coverage Determination (LCD): Transcutaneous Electrical Nerve Stimulators (TENS) (L33802) TENS therapy for CLBP is only covered when all of the following criteria are met: The beneficiary has one of the diagnosis codes listed. (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses.) The beneficiary is enrolled in an approved clinical study that meets all of the requirements set out in NCD 160.27 (CMS Internet Only Manual 100-03, Chapter 1). Refer to the APPENDICES section for additional information about approved clinical studies. TENS therapy for CLBP that does not meet these criteria will be denied as not reasonable and necessary. 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): headache visceral abdominal pain pelvic pain 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.
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 Centers for Medicare & Medicaid Services (CMS) covers PERCUTANEOUS LAAC for
non-valvular atrial fibrillation (NVAF) through Coverage with Evidence Development (CED) with the
following conditions:
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.
You can find this rule in the National Coverage Determination Manual Chapter 1, Section 20.34.
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 GIP panels utilizing NAATs are medically reasonable and necessary for the evaluation of
Medicare beneficiaries with the following:
- Acute or persistent diarrhea of at least 7 days duration; or
- Acute or persistent diarrhea with signs or risk factors for severe disease (fever, bloody diarrhea, dysentery,
dehydration, severe abdominal pain, hospitalization or immunocompromised state); or
- Paralytic ileus with either persistent abdominal pain with fever or nausea and vomiting lasting 24 hours or
less.
You can find this rule in the Local Coverage Determination (LCD) for Gastrointestinal Pathogen (GIP) Panels
Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) (L38229).
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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that enrollees must pay a $40 copayment for lab services at an outpatient hospital setting. You can
find this information on page 84 of the Plan's 2019 and 2020 Evidence of Coverage (EOC).