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 plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 1, Section 20.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on pages 62-63 and 68 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 co-payments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).

The rules say that a co-payment 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 $105 co-payment for outpatient diagnostic tests/radiological diagnostic services. You can find this information on pages 4-28 to 4-31 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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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. A qualifying wound is either a wound caused or treated by surgery or a wound that must be debrided. A gradient compression stocking or wrap described by codes A6531, A6532, or A6545 is only covered when it is used in the treatment of an open venous stasis ulcer. Gradient compression stockings and wraps identified with codes A6531, A6532, and A6545 are not covered when they are used to treat the following conditions:
- Venous insufficiency without stasis ulcers; 
- Prevention of stasis ulcers; 
- Prevention of the reoccurrence of stasis ulcers that have healed; 
- Treatment of lymphedema in the absence of ulcers. 
You can find these rules in Local Coverage Determination (LCD): Surgical Dressings L33831 and Local Coverage Article: Surgical Dressings-Policy Article A54563, effective for services performed on or after July 24, 2017.

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 TAVR is covered for the treatment of symptomatic aortic valve stenosis when furnished according to a Food and Drug Administration (FDA)-approved indication and when all of the following conditions are met:

1. The procedure is furnished with a complete aortic valve and implantation system that has received FDA premarket approval (PMA) for that system's FDA approved indication.
2. The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care. The heart team includes the following:
a. Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis who have:
i. independently examined the patient face-to-face, evaluated the patient's suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy;
ii. documented and made available to the other heart team members the rationale for their clinical judgment.
b. Providers from other physician groups as well as advanced patient practitioners, nurses, research personnel and administrators.
3. The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-operative technical aspects of TAVR.
4. TAVR must be furnished in a hospital with the appropriate infrastructure that includes but is not limited to:
a. On-site heart valve surgery and interventional cardiology programs,
b. Post-procedure intensive care facility with personnel experienced in managing patients who have undergone open-heart valve procedures,
c. Appropriate volume requirements

You can find this rule in the National Coverage Determination Manual. Section 20.32.

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 to report a Comprehensive Genomic Profile, service providers should use Current Procedural Terminology (CPT) code 81479 (used for the entire bundled multi-test panel) at this time, not unbundled to separate codes. This rule can be found in Medicare Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Sequencing Testing in [Solid Tumor] Cancers (A55624).

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. This benefit includes specific preventative and comprehensive services that are listed by code in the contract. Services not listed are not covered. In addition, services performed by an out-of-network dentist will not be covered if your Plan does not have out-of-network coverage (such as an HMO (Health Maintenance Organization) Plan). You can find this information on pages 4-55 to 4-69 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.

This policy denies coverage for all CV risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. The policy indicates the medical indication(s) based on published scientific articles and consensus guidelines for individual lipid biomarkers that may be covered to characterize a given lipid abnormality or disease, to determine a treatment plan or to assist with intensification of therapy. Each individual lipid biomarkers must be specifically ordered and the reason for the test order documented in the patient's medical record. The policy denies coverage for all non-lipid biomarkers when used for CV risk assessment including but not limited to, biochemical, immunologic, and hematologic, and genetic biomarkers for CV risk assessment regardless of whether ordered in a panel or individually. You can find this information in Local Coverage Determination (LCD): MolDX: BIOMARKERS IN CARDIOVASCULAR RISK ASSESSMENT (L36129).

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 $20 copayment for each outpatient surgery at a specialist's office. You can find this information on page 98 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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Chapter 1, Section 270.5.

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 co-payments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).

The rules say that a co-payment 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 $160 co-payment for diagnostic radiology. You can find this information on page 4-31 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 physician/practitioner services/in-network/specialist. You can find this information on pages 4-47 to 4-52 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 state that Continued coverage of a PAP device (E0470 or E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy.

For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is demonstrated by:

1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive sleep apnea are improved; and, 
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. Adherence to therapy is defined as use of PAP =4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.

If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as not reasonable and necessary.

You can find this information in the Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718).

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 the PACE benefit package must include the following: 
(a) All Medicare-covered services; 
(b) All Medicaid-covered 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 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 that for an E0471 respiratory assist device to be covered, the treating practitioner must fully document in the beneficiary's medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, dyspnea, etc. A respiratory assist device (E0471) is covered for those beneficiaries with one of the following clinical disorders: restrictive thoracic disorders (i.e., neuromuscular diseases or severe thoracic cage abnormalities), severe chronic obstructive pulmonary disease (COPD), CSA or CompSA, or hypoventilation syndrome. You can find this rule in Local Coverage Determination (LCD): Respiratory Assist Devices (L33800) - Effective January 1, 2020. 

The rules say that beneficiaries covered for the first three months of an E0471 must be re-evaluated to establish the medical necessity of continued coverage by Medicare beyond the first three months. While the beneficiary may certainly need to be evaluated at earlier intervals after this therapy is initiated, the re-evaluation upon which Medicare will base a decision to continue coverage beyond this time must occur no sooner than 61 days after initiating therapy by the treating practitioner. Medicare will not continue coverage for the fourth and succeeding months of therapy until this re-evaluation has been completed. You can find this rule in Local Coverage Determination (LCD): Respiratory Assist Devices (L33800) - Effective January 1, 2020. 

The rules say that there must be documentation in the medical record about the progress of relevant symptoms and beneficiary usage of the device up to that time. Failure of the beneficiary to be consistently using the E0471 for an average of 4 hours per 24 hour period by the time of the re-evaluation (on or after 61 days after initiation of therapy) would represent non-compliant utilization for the intended purposes and expectations of benefit of this therapy. This would constitute reason for Medicare to deny continued coverage as not reasonable and necessary. You can find this rule in Local Coverage Determination (LCD): Respiratory Assist Devices (L33800) - Effective 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 power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. You can find this information in the Local Coverage Article 'Wheelchair Options/Accessories - Policy Article' (A52504). Per Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792)

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 1, Section 20.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 45 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 state that Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. This rule can be found in Medicare Local Coverage Determination: MolDX: Biomarkers in Cardiovascular Risk Assessment (L36523).

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.