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 if the disease progressed while receiving another PD-1 directed agent (for example, pembrolizumab), the use of nivolumab is not considered reasonable/necessary. If the PD-1 directed agent was discontinued for reasons other than disease progression, then nivolumab may be used when an approved indication is met. You can find this rule at Local Coverage Article:Billing and Coding: Nivolumab (A54862) (eff. 5/1/20).
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 say that therapeutic continuous glucose monitors (CGMs) and related supplies are covered when all of the following coverage criteria (1-6) are met: 1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses); and, 2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and 3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and, 4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and, 5. 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 (1-4) above are met; and, 6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan You can find these rules in Local Coverage Determination (LCD) L33822, effective on and after January 1, 2020.
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 $30 copayment for urgently needed services at an out-of-network urgent care. You can find this information on page 92 of the Plan's 2020 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 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 $10 copayment for specialist visits. You can find this information in
Chapter 4 on page 81 of the Plan's 2020 Evidence of Coverage (EOC).
The Plan contract also says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs.
You can find this information in Chapter 4 on page 74 of the Plan's 2020 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 medically necessary services are those that are reasonable and necessary for the diagnosis or
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).
The rules say that services that are not medically necessary are not covered. The rules also say that
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and
411.15(o).
National Coverage Determination (NCD) for Electrical Nerve Stimulators (160.7) - No payment may be made
for the implantation of dorsal column or depth brain stimulators or services and supplies related to such
implantation, unless all of the conditions listed below have been met:
*The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic
intractable pain;
*With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for
the given patient;
*Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to
implantation. (Such screening must include psychological, as well as physical evaluation);
*All the facilities, equipment, and professional and support personnel required for the proper diagnosis,
treatment training, and follow up of the patient (including that required to satisfy item c) must be available; and
*Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation.
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 injection procedure of the SI joint will be considered medically reasonable and necessary
when it is used for imaging confirmation of intra-articular needle positioning for arthrography with or without
therapeutic injection. In addition, the injection procedure of the SI joint will be considered medically necessary
when an injection is given for therapeutic indications, such as injection of an anesthetic and/or steroid, to block
the joint for immediate and potentially lasting pain relief. When therapeutic injections of the SI joint are
performed, it would be expected that the record reflects noninvasive treatments (i.e., rest, physical therapy,
NSAID's, etc.) have failed. You can find this rule in the Local Coverage Determination for Sacroiliac Joint
Injection, L33957 (eff prior to 03/27/20).
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 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 in Chapter 3 on pages 28 to 30 of
the Plan's 2020 Member Handbook.
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 $675 copayment for Inpatient Care. You can find this information on pages 65 and 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 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). 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 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 on page 71 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 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 $50 copayment for specialist visits. You can find this information in Chapter 4 on page 80 of the Plan's 2020 Evidence of Coverage (EOC). The Plan contract also says that enrollees must pay a $35 copayment for laboratory services provided in an outpatient hospital facility. You can find this information in Chapter 4 on page 76 of the Plan's 2020 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 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 $200 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You can find this information in Chapter 4 on page 35 of the Plan's 2019 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that the PACE benefit package must include the following: (a) All Medicare-covered items and services; (b) All Medicaid-covered items and services, as specified in the State's approved Medicaid plan; and (c) Other services determined necessary by the interdisciplinary team to improve and maintain the enrollee's overall health status.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 460.92.
The rules say that PACE (Program of All-inclusive Care for the Elderly) benefits must include all services and items covered by Medicare and Medicaid. The benefits must also include all other services determined necessary by the interdisciplinary team (IDT) to improve and maintain the enrollee's overall health status. You can find this rule at 42 CFR Section 460.92. The rules also say that enrollees in a PACE program must have a written plan of care. This plan must meet their needs in all care settings 24 hours a day every day of the year. You can find this rule at 42 CFR Section 460.98.
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 PACE Enrollment Agreement describes all of the PACE services available and how to get services from the PACE organization. This Agreement also describes how to get emergency and urgently needed services out-of-network.
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 $225 copayment for each advanced imaging service. You can find this information in Chapter 4 on page 95 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 medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o). Local Coverage Determination (LCD): Wheelchair Seating (L33312) - A positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, E2616, E2620, E2621), and positioning accessory (E0953, E0955, E0956, E0957, E0960) are covered for a beneficiary who meets both of the following criteria: 1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and 2. The beneficiary has any significant postural asymmetries that are due to one of the following (a or b): a. A diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article; or b. A diagnosis code listed in Group 3 of the ICD-10 code list in the LCD-related Policy Article. 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 8 of the 2020 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 effective for claims with dates of service on and after March 3, 2009, the Centers for Medicare & Medicaid Services finds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary's treating physician to diagnose OSA, that the use of such sleep testing technologies demonstrates improved health outcomes in Medicare beneficiaries who have OSA and receive the appropriate treatment, and that these tests are thus reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act.

1. Type I PSG is covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if performed attended in a sleep lab facility.

2. Type II or Type III sleep testing devices are covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.

3. Type IV sleep testing devices measuring three or more channels, one of which is airflow, are covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.

4. Sleep testing devices measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone, are covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.

You can find this rule in National Coverage Determination (NCD) for Sleep Testing for Obstructive Sleep Apnea (OSA) (240.4.1) - Effective March 3, 2009.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.