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 t his case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will pay for an IRF admission when the services are reasonable and medically 
necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing 
rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of 
the therapies must be physical therapy or occupational therapy. The patient must need and be expected to 
actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive 
rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per 
week. The patient does not need to be expected to achieve complete independence in self-care nor be expected 
to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation 
physician. The physician must see the patient at least three days per week throughout the stay. You can find 
these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy 
Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622. 
 
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 $240 copayment for ambulance services. You can find this information 
on page 61 of the Plan's 2021 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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with
BOTH the following: 1. Inclusion criteria (ALL are required): a. Acute (less than 6 weeks) or subacute (6-12
weeks) osteoporotic VCF (T1 - L5), based on symptom onset, and documented by advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake); b. Symptomatic (ONE): i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score equals 8) (4-7); ii. Non-hospitalized with moderate to severe pain (NRS or VAS equals 5) despite optimal non-surgical management (NSM) (10) (ONE): 1. Worsening pain; 2. Stable to improved pain (but NRS or VAS still equals 5) (with equals 2 of the following): A. Progression of vertebral body height loss; B. Greater than 25% vertebral body height reduction; C. Kyphotic deformity; D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) greater than 17; c. Continuum of care (10) (Both) ; i. All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis education for subsequent treatment as indicated; ii. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program.; 2. Exclusion criteria (Can have NONE of the following): a. Absolute contraindication; i. Current back pain is not primarily due to the identified acute or subacute VCF(s).; ii. Osteomyelitis, discitis, active systemic or surgical site infection; iii. Pregnancy; b. Relative contraindication; I. Greater than three vertebral fractures per procedure; II. Allergy to bone cement or opacification agents; III. Uncorrected coagulopathy; IV. Spinal instability; V. Myelopathy from the fracture; VI. Neurologic deficit; VII. Neural impingement; VIII. Fracture retropulsion/canal compromise. You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L33569).
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 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 patient has impairment of visual function due to cataract(s) and the following criteria are met and clearly documented: a. Decreased ability to carry out activities of daily living including (but not limited to): reading, watching television, driving, or meeting occupational or vocational expectations; and b. The patient has a best corrected visual acuity of 20/50 or worse at distant or near; or additional testing shows one of the following: 1. Consensual light testing decreases visual acuity by two lines, or 2. Glare testing decreases visual acuity by two lines c. The patient has determined that he/she is no longer able to function adequately with the current visual function; and d. Other eye disease(s) including, but not limited to macular degeneration or diabetic retinopathy, have been ruled out as the primary cause of decreased visual function; and e. Significant improvement in visual function can be expected as a result of cataract extraction; and f. The patient has been educated about the risks and benefits of cataract surgery and the alternative(s) to surgery (e.g., avoidance of glare, optimal eyeglass prescription, etc.); and g. The patient has undergone an appropriate preoperative ophthalmologic For patients with a best corrected visual acuity of 20/40 or better, cataract extraction will be considered if all other criteria have been met and there is substantial documentation of the medical necessity of the procedure for that patient. You can find this information in Local Coverage Determination (LCD): Cataract Extraction (L33954).
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 facet joint interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL of the following criteria: 1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale, and 2. Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive conservative care management (as tolerated), and 3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst) 4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity. You can find this rule in Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892) - Effective April 25, 2021. The rules say that second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in patients who meet BOTH of the following criteria: 1. The patient meets the criteria for the first diagnostic procedure; AND 2. 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) You can find this rule in Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892) - Effective April 25, 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.
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 Advantage (MA) plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only those preferred brands and manufacturers, as long as the following conditions are met (42 CFR 422.100(l)): 1. The MA plan provides all categories of DME covered under original Medicare Part B; 2. The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME products or brands; 3. The MA plan's contracted suppliers provide access to all preferred DME brands; 4. During an enrollee's first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and repairs, as applicable) non-preferred DME brands furnished in the previous year; 5. Although the MA plan may add brands to its preferred formulary during the year, it may not remove any brands mid-year; 6. The MA plan treats denials of non-preferred DME products or brands as organization determinations; 7. The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred DME product or brand with the Evidence of Coverage (EOC) and Annual Notice of Changes (ANOC) and on its website; and 8. The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or subcategories annually determined by Medicare to require full coverage. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 4, Section 10.12.2.
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.
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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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 Sections 422.2 and 422.136.
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 pages 68-69 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 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 Medicare-covered diagnostic procedures and tests rendered by an in-network provider. You can find this information on page 86 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 minimally-invasive surgical (MIS) fusion of the sacroiliac (SI) joint is considered medically 
necessary when all of the following criteria are met: 
- Have moderate to severe pain with functional impairment and pain persists despite a minimum six 
months of intensive nonoperative treatment that must include medication optimization, activity 
modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip 
including a home exercise program 
- Patient's report of typically unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized 
over the posterior SIJ, and consistent with SIJ pain 
- A thorough physical examination demonstrating localized tenderness with palpation over the sacral 
sulcus (Fortin's point, i.e. at the insertion of the long dorsal ligament inferior to the posterior superior 
iliac spine or PSIS) in the absence of tenderness of similar severity elsewhere (e.g. greater trochanter, 
lumbar spine, coccyx) and that other obvious sources for their pain do not exist 
- Positive response to a cluster of 3 provocative tests (e.g. thigh thrust test, compression test, 
Gaenslen's test, distraction test, Patrick's sign, posterior provocation test). 
- Absence of generalized pain behavior (e.g. somatoform disorder) or generalized pain disorders (e.g. 
fibromyalgia) 
- Diagnostic imaging studies that include ALL of the following: 
~ Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of 
destructive lesions (e.g. tumor, infection), fracture, traumatic SIJ instability, or inflammatory 
arthropathy that would not be properly addressed by percutaneous SIJ fusion 
~ Imaging of the pelvis (AP plain radiograph) to rule out concomitant hip pathology 
~ Imaging of the lumbar spine (CT or MRI) to rule out neural compression or other 
degenerative condition that can be causing low back or buttock pain 
- At least 75 percent reduction of pain for the expected duration of two anesthetics (on separate visits 
each with a different duration of action), and the ability to perform previously painful maneuvers, 
following an image-guided, contrast-enhanced intra-articular SIJ injection. 
- A trial of at least one therapeutic intra-articular SIJ injection (i.e. corticosteroid injection) 
 
You can find these rules in Local Coverage Determination (LCD) Minimally-invasive Surgical (MIS) Fusion 
of the Sacroiliac (SI) Joint (L36406). 
 
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 one to two levels, either unilateral or bilateral, are allowed per session per spine region. You 
can find this rule at Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management 
(L38841) (eff. 4/25/21). 
 
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 that providers must report services correctly. Procedures should be reported with the Current 
Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the 
Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
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).
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.
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 45-55 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 ambulance services are only covered when the patient's clinical condition is such that other methods of transport are contraindicated. You can find this rule at 42 CFR Section 410.40(e).
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 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 50-60 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 that general anesthesia is considered not medically reasonable and necessary for facet joint interventions. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely considered medically reasonable and necessary. Individual consideration may be given on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892).
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