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 the evidence does not support the use of the GeneSight test. It has been postulated based on an observational study utilizing the GeneSight that there may be little gained from the proprietary algorithms in these tests above single and multi-gene panels. You can find this rule in the Local Coverage Determination (LCD) - MolDX: Pharmacogenomics Testing (L38394) - Effective August 3, 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 payment for inpatient hospital services in made of the basis of a DRG (diagnosis related group).
Hospitals must provide proper information about the patient (i.e., age, sex, discharge status, principal and
secondary diagnoses, and procedures) in order for the correct DRG to be assigned. You can find this rule in the
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims
Processing Manual, Chapter 3, Section 20.2.1.
The rule say that the circumstances of inpatient admission always govern the selection of principal diagnosis.
The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition
established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for
care." For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that
affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures;
or extended length of hospital stay; or increased nursing care and/or monitoring. The UHDDS item #11-b
defines Other Diagnoses as "all conditions that coexist at the time of admission, that develop subsequently, or
that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which
have no bearing on the current hospital stay are to be excluded." You can find this information in the
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines
for Coding and Reporting, Sections II and III.
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 does not pay for hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d).  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health Plan contract says hearing services includes selected hearing aids purchased through select participating audiology providers covered under one of three benefit tier. The price of the hearing aids includes the following: pre-fitting hearing aid evaluation appointment, cost of the hearing aid, fitting of the hearing aid device (including programming, verification measures), up to two follow-up visits in the first 12 months after purchase. You can find this information on page 88-89 of the Plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).  The rules say that 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).  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health plan contract says if you've had Part B for longer than 12 months, you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. This is covered once every 12 months. You can find this information in Chapter 4 on page 66 of the plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  The rules state that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT code accurately describes the procedure performed, the laboratory may report CPT code 81479 (Unlisted molecular pathology procedure) with one unit of service or may report multiple individual CPT codes describing the component test results when medically reasonable and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 10 (F8).  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 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).  A manual wheelchair for use inside the home (E1037, E1038, E1039, E1161, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009) is covered if:      Criteria A, B, C, D, and E are met; and     Criterion F or G is met.  A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.  B. The beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.  C. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.  D. Use of a manual wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home.  E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.  F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.  G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.  You can find this information in the Local Coverage Determination L33788: Manual Wheelchair Bases  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 page 28 of the Plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).  The rules say that 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).  The rules say that a microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. You can find this information in the Local Coverage Determination L33787: Lower Limb Prostheses.  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 Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) require a written
order/prescription from the treating practitioner. If the information in the medical record does not adequately
support the medical necessity for the item, the supplier is liable for the dollar amount involved unless a
properly executed Advance Beneficiary Notice (ABN) of possible denial has been obtained. You can find this
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare
Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10.
The rules say that a manual wheelchair for use inside the home is covered if the beneficiary has a mobility
limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of
daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in
the home. A mobility limitation is one that: 1. Prevents the beneficiary from accomplishing an MRADL
entirely, or 2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality
secondary to the attempts to perform an MRADL; or 3. Prevents the beneficiary from completing an MRADL
within a reasonable time frame. The beneficiary's mobility limitation cannot be sufficiently resolved by the use
of an appropriately fitted cane or walker. The beneficiary's home provides adequate access between rooms,
maneuvering space, and surfaces for use of the manual wheelchair that is provided. You can find this in the
Local Coverage Determination (LCD) for Manual Wheelchair Bases (L33788).
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, Publication 100-16, 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 46 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  The rules say coverage of Neuromuscular Electrical Stimulaton (NMES) to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. Some examples would be casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins).   The rules also say that coverage for the use of NMES/functional electrical stimulation (FES) is limited to spinal cord injury patients for walking.  You can find this in the National Coverage Determination (NCD) for NEUROMUSCULAR ELECTRICAL Stimulaton (NMES) (160.12).  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 diagnostic procedures should be performed with the intent that if successful, a radiofrequency ablation (RFA) procedure would be considered the primary treatment goal at the diagnosed level(s). 1. An initial diagnostic facet joint procedure will be considered medically reasonable and necessary when the patient meets the criteria outlined under the indications for facet joint interventions. 2. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in patients who meet BOTH of the following criteria: - The patient meets the criteria for the first diagnostic procedure; AND - After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used).  Therapeutic intraarticular facet injections are not considered medically reasonable and necessary unless there is documentation explaining why RFA cannot be performed. You can find this rule in the Local Coverage Determination for Facet Joint Interventions for Pain Management, L33930 (eff 04/25/21).  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 coverage of nutritional therapy as a Part B benefit is provided under the prosthetic device benefit
provision which requires that the patient must have a permanently inoperative internal body organ or function
thereof. Therefore, enteral and parenteral nutritional therapy are normally not covered under Part B in
situations involving temporary impairments. You can find this information in Medicare's National Coverage
Determination (NCD): Enteral and Parenteral Nutritional Therapy (180.2).
The rules say when nutritional support other than the oral route is necessary, enteral nutrition (EN) is usually
initially preferable to parenteral nutrition for the following reasons: (1) In a fluid restricted beneficiary, EN
permits delivery of all necessary nutrients in a more concentrated volume than parenteral nutrition; (2) EN
allows for safer home delivery of nutrients; and (3) EN lowers the risk of Central Line-Associated Bloodstream
Infections (CLABSI).
For parenteral nutrition to be considered reasonable and necessary, the treating practitioner must document that
enteral nutrition has been considered and ruled out, tried and been found ineffective, or that EN exacerbates
gastrointestinal tract dysfunction. The beneficiary must have (a) a condition involving the small intestine and/or
its exocrine glands which significantly impairs the absorption of nutrients or (b) disease of the stomach and/or
intestine which is a motility disorder and impairs the ability of nutrients to be transported through and absorbed
by the gastrointestinal (GI) system. The beneficiary must have a permanent impairment. Please refer to the
LCD-related Policy Article for further guidance regarding the test of permanence.
The treating practitioner is required to evaluate the beneficiary within 30 days prior to initiation of parenteral
nutrition. If the treating practitioner does not see the beneficiary within this timeframe, they must document the
reason why and describe what other monitoring methods were used to evaluate the beneficiary's parenteral
nutrition needs. There must be documentation in the medical record supporting the clinical diagnosis.
You can find this information in Medicare's Local Coverage Determination (LCD): Parenteral Nutrition
(L38953).
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 for services performed on or after January 21, 2020, Medicare will now provide limited coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may be provided by a physician in accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 30.3.3.  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 also says that you may not get more than 20 acupuncture treatments for chronic low back pain each year. You can find this information on page 67 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 say that definitive urine drug testing (UDT) is reasonable and necessary for the following circumstances:  1. Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT; 2. Definitively identify specific drugs in a large family of drugs; 3. Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, meperidine, synthetic cannabinoids and other synthetic/analog drugs; 4. Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., discontinuation of THC use according to a treatment plan); 5. Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patient's self-report, presentation, medical history, or current prescribed pain medication plan; 6. Rule out an error as the cause of a presumptive UDT result; 7. Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 8. Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions.  You can find this rule in the Local Coverage Determination (LCD) - Lab: Controlled Substance Monitoring and Drugs of Abuse Testing (L36707) - Effective April 8, 2021.  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.