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 CFR 422.101.
The rules say that Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare policies. You can find this in the Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, Section 3.3.2.4 entitled Signature Requirements.
The rules say that for definitive drug testing, limitations apply when denials are likely, whether based on medical necessity or other coverage reasons. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. For codes G0480, G0481, G0482, G0483, G0659, 80305, 80306, and 80307, diagnosis codes must be coded to the highest level of specificity. You can find this in the Local Coverage Article: Billing and Coding: Drug Testing (A56915).
The rules say that definitive drug testing is not reasonable and necessary when presumptive testing is performed at point of care because the clinician may have enough information to manage the patient. If the clinician is not satisfied, he/she must determine the clinical appropriateness of and order specific subsequent definitive testing (e.g., the patient admits to using a particular drug, or the IA cut-off is set at such a point that is sufficiently low that the physician is satisfied with the presumptive test result). Routine standing orders for all patients in a physician's practice are not reasonable and necessary. Medicare will only pay for one presumptive test result per patient per date of service regardless of the number of billing providers submitted. You can find this in the Local Coverage Determination (LCD): Controlled Substance Monitoring and Drugs of Abuse Testing (L36707).
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 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this web site 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 9 and 10 of the 2019 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 CFR 422.101.
The rules say that Medicare Advantage Plans may not make payment directly or indirectly for Medicare
covered services furnished to a Medicare beneficiary by a physician or practitioner who has opted out of
Medicare except in cases involving emergency or urgent care services furnished to a beneficiary who has not
previously entered into a private contract with the physician or practitioner. You can find this rule at 42 CFR
422.220 and in the Medicare Benefit Policy Manual, Chapter 15, Section 40.37.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
Contract also says that while you can get your care from an out-of-network provider, the provider must be
eligible to participate in Medicare. Except for emergency care, the Plan cannot pay a provider who is not
eligible to participate in Medicare. If you go to a provider who is not eligible to participate in Medicare, you
will be responsible for the full cost of the services you receive. You can find this information on page 3-3 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 CFR 422.101.
The rules state that program reimbursement for HBO therapy is limited to the following conditions: Acute carbon monoxide intoxication, Decompression illness, Gas embolism, Gas gangrene, Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened. Progressive necrotizing infections (necrotizing fasciitis), Acute peripheral arterial insufficiency, Preparation and preservation of compromised skin grafts (not for primary management of wounds), Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, Osteoradionecrosis as an adjunct to conventional treatment, Soft tissue radionecrosis as an adjunct to conventional treatment, Cyanide poisoning, Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment, Diabetic wounds of the lower extremities. HBO's use in the treatment of Osteoradionecrosis and Soft Tissue Radiation Injury (Radionecrosis) is one part of an overall plan of care that also includes debridement or resection of nonviable tissue in conjunction with antibiotic therapy. A consistent cause and effect of radiation injury is vascular obliteration and stromal fibrosis or scarring; subsequently, the known impact of hyperbaric oxygen therapy, stimulation of angiogenesis, is an important mechanism of recovery. A reduction in fibrosis of soft tissue as well as mobilization and increase of stem cells within radiated tissue has been documented predominantly in animal studies; however, the impact of HBOT is likely to involve all these mechanisms. HBO treatment can be indicated in the preoperative and postoperative management of existing osteoradionecrosis or soft tissue radionecrosis, but must be utilized as an adjunct to conventional therapy. Beneficiaries suffering from soft tissue damage or bone necrosis present with disabling, progressive, painful tissue breakdown, bleeding, bladder dysfunction, wound dehiscence, infection, tissue loss and graft or flap loss. You can find these rules in Local Coverage Determination (LCD): Hyperbaric Oxygen (HBO) Therapy (L36504).
If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.
The rules say that Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for a person who meets the following criteria: 1. The person must have a personal mobility deficit; 2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, grooming and bathing in customary locations within the home; 3. The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 4. The person must be capable of safely operating the PMD. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.3(B). POWER OPERATED VEHICLES (K0800-K0808, K0812):
A POV is covered if all of the basic coverage criteria (A-C) have been met and if criteria D-I are also met. D. The beneficiary is able to: -Safely transfer to and from a POV, and -Operate the tiller steering system, and -Maintain postural stability and position while operating the POV in the home. E. The beneficiary's mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home. F. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided. G. The beneficiary's weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV - i.e., a Heavy Duty POV is covered for a beneficiary weighing 285 - 450 pounds; a Very Heavy Duty POV is covered for a beneficiary weighing 428 - 600 pounds. H. Use of a POV will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it in the home. I. The beneficiary has not expressed an unwillingness to use a POV in the home. If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable and necessary. You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices (L33789).
Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site evaluation of the beneficiary's home to verify that the beneficiary can adequately maneuver the device that is provided considering physical layout, doorway width, doorway thresholds, and surfaces. There must be a written report of this evaluation available on request. You can find this rule in Local Coverage Determination (LCD):Power Mobility Devices (L33789).
If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.
The rules say that CT scans are covered if there is literature to support its use for the patient's condition and the
scan is reasonable and necessary for the patient. You can find this rule in the Medicare National Coverage
Determinations Manual, Section 220.1(A).

If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.
During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary. Cases suggesting malicious damage, culpable neglect, or wrongful disposition of equipment should be investigated and denied where the DME MACs determines that it is unreasonable to make program payment under the circumstances. The rules can be found in the Medicare Benefit Policy Manual Chapter 15 under Covered Medical and Other Services Section 110.2. for Repairs, Maintenance, Replacement, and Delivery.
If you want to read these Medicare rules, you can go to this web site 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 CFR 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 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this web site 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 48 of the Plan's 2019 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 CFR 422.101.The rules say that Medicare Advantage Plans may not make payment directly or indirectly for Medicare covered services furnished to a Medicare beneficiary by a physician or provider who has opted out of Medicare except in cases involving emergency or urgent care services furnished to a beneficiary who has not previously entered into a private contract with the physician or provider. You can find this rule at 42 CFR 422.220 and in theMedicare Benefit Policy Manual, Chapter 15, Section 40.37.
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 CFR 422.101.
The rules say that a pneumatic compression device that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a preventative service or function are excluded from coverage under the Medicare DME benefit. You can find this rule in the Local Coverage Article for Pneumatic Compression Devices, A52488 (eff 01/01/2017).
If you want to read these Medicare rules, you can go to this web site 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 CFR 422.101.
The rules say that an expandable controller is capable of accommodating one or more of the following
additional functions:
-Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin
control, head control, etc.)
-Non-proportional input devices (e.g., sip and puff, head array, etc.)
-Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)
You can find this rule in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504) -
Effective January 1, 2020.
The rules say that an expandable controller may also be able to operate one or more of the following:
-A separate display (i.e., for alternate control devices)
-Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive
control)
-An attendant control
You can find this rule in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504) -
Effective January 1, 2020.
If you want to read these Medicare rules, you can go to this web site 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 CFR 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 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 422.2.If you want to read these Medicare rules, you can go to this web site 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 $45 copayment per specialist visit. Covered services include consultation, diagnosis, and treatment by a specialist. You can find this information on pages 94 to 96 of the Plan's 2019 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 CFR 422.101.
The rules say that indications for Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy include: - Patient must have history of at least 3 months of moderate to severe pain with functional impairment and pain is inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical therapy (as tolerated). - Pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with radiculopathy or neurogenic claudication. - There is no non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor, infection, or significant deformity. - Clinical assessment implicates the facet joint as the putative source of pain. Diagnostic Facet Joint Injections - Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably high false positive rate of single MBB injections. o A second confirmatory MBB is allowed if documentation indicates the first MBB produced greater than or equal to 80% relief of primary (index) pain and duration of relief is consistent with the agent employed. - Intraarticular facet block will not be reimbursed as a diagnostic test unless medial branch blocks cannot be performed due to specific documented anatomic restrictions. Thermal Medial Branch Radiofrequency Neurotomy (includes RF and microwave technologies): - Only when dual MBBs provide greater than or equal to 80% relief of the primary or index pain and duration of relief is consistent with the agent employed may facet joint denervation with RF medial branch neurotomy be considered. You can find this rule in the Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L35936) effective December 5, 2019
If you want to read these Medicare rules, you can go to this web site 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 CFR 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 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 422.2.If you want to read these Medicare rules, you can go to this web site 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% coinsurance for Medicare-covered Part B drugs. You can find this information on page 51 of the Plan's 2019 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 CFR 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 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 422.2.
If you want to read these Medicare rules, you can go to this web site 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 $345 copayment outpatient surgical services provided in an outpatient hospital facility. You can find this information in Chapter 4 on pages 75 - 76 of the Plan's 2019 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 CFR 422.101. 
 
The rules say that the ambulatory blood pressure monitor (ABPM) is only covered for suspected white coat hypertension, and must be performed for at least 24 hours to meet coverage criteria. ABPM is not covered for any other uses." You can find this Medicare guidance in the Medicare National Coverage Determination (NCD) for Ambulatory Blood Pressure Monitoring (20.19).
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 CFR 422.101.
The rules say that a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints
(L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both mediallateral
and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury
to or a surgical procedure on the knee(s).
The rules also say that knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a
beneficiary who is ambulatory and has knee instability due to a condition specified in the ICD-10 Codes that
Support Medical Necessity Group 4 Codes section. Knee instability must be documented by examination of the
beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer
test). Claims will be denied as not reasonable and necessary when the beneficiary does not meet the above
criteria for coverage.
You can find this rule at Local Coverage Determination (LCD): Knee Orthoses (L33318).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.