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 one of a specific list of diagnosis codes must be billed with procedure code 87507. You can find this rule at Local Coverage Article: Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs) (A56593) (eff. 10/31/19).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 CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, 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 CFR 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 411.15 and 411.15(o). The rules state that contract suppliers are not required to furnish a specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical outcome. A physician or treating practitioner (that is a physician assistant, clinical nurse specialist, or nurse practitioner) may prescribe, in writing, a particular brand of a competitively bid item or mode of delivery for an item if he or she determines that the particular brand or mode of delivery is necessary to avoid an adverse medical outcome for the beneficiary. The physician or treating practitioner must document in the beneficiary's medical record the reason why the specific brand or mode of delivery is necessary to avoid an adverse medical outcome. You can find this information in Medicare Manual Chapter 36 of the Claims Processing Manual Section 30.4. The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that the only covered brands of blood glucose monitors and test strips are Accu-Chek or Trividia. If you are new to the Plan and are using a brand not on the preferred brand list, you may contact them within the first 90 days of enrollment to request a temporary supply of the alternate non-preferred brand. You can find this information on page 66 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 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 SSA, Section 1862(a)(12) and 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 health plan contract says that the plan doesn't cover most dental care, dental procedures, or supplies, like cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices. You have coverage for certain dental services that you get when you're in a hospital. You also have coverage for services required for the initial treatment of an injury to the jaws, sound natural teeth, mouth or face. The injury must have occurred after the effective date of your coverage with your retirement system. Services must be performed by a physician or dentist. The health plan does not cover injuries resulting from biting or chewing, or preventive or maintenance services. You can find this information in Chapter 4 on page 54 of the plan's 2019 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

he rules say that plans must pay fora 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 presumptive UDT testing is limited due to:-Primarily screens for drug classes rather than specific drugs, and therefore, the practitioner may not be able to determine if a different drug within the same class is causing the positive result-Produces erroneous results due to cross-reactivity with other compounds or does not detect all drugs within a drug class-Given that not all prescription medications or synthetic/analog drugs are detectable and/or have assays available, it is unclear as to whether other drugs are present when some tests are reported as positive;-Cut-off may be too high to detect presence of a drugThe rules state that definitive UDT is reasonable and necessary for the following circumstances:-Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT;-Definitively identify specific drugs in a large family of drugs;-Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, meperidine, synthetic cannabinoids and other synthetic/analog drugs;-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);-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;-Rule out an error as the cause of a presumptive UDT result;-Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and-Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions.You can find these rules in the Local Coverage Determination (LCD) for Lab: Controlled Substance Monitoring and Drugsof Abuse Testing (L35724. This LCD is effective for services provided on or after December 27, 2018 and before August 28, 2019.The rules state that:-To receive reimbursement for controlled substance and drugs of abuse testing, the service reported on the claim MUST match the service ordered by the physician.-Incidental findings not ordered by the physician are not a covered service and will be denied.-A maximum of one presumptive urine drug test may be submitted and paid per patient DOS.-A maximum of one definitive urine drug test may be submitted and paid per patient DOSYou can find these rules in the Local Coverage Article for Controlled Substance Monitoring and Drugs of Abuse Coding and Billing Guidelines, A54799. This Local Coverage Article is effective for services provided on or after April 5,2018 and before August 28, 2019.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 ifregular 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 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 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 CFR ?422.101. The rules say that reduction mammaplasty is considered medically necessary:

1. When the patient has significant symptoms that have interfered with normal daily activities, despite conservative management, for at least 6 months, including at least one of the following criteria:
 History of back and/or shoulder pain which adversely affects activities of daily living (ADLs) unrelieved by, e.g.:
 conservative analgesia (e.g., such as NSAID, compresses, massage, etc.)
 supportive measures (e.g., such as garments, back brace, etc.),
 physical therapy
 correction of obesity
 History of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity, e.g.:
 Signs and symptoms of ulnar paresthesias
 Cervicalgia
 Torticollis
 Acquired kyphosis
Signs and symptoms of:
 intertrigonous maceration or infection of the inframammary skin (e.g., hyperpigmentation, bleeding, chronic moisture, and evidence of skin breakdown), refractory to dermatologic measures, or
 shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by appropriate supporting garment
AND
Considerable attention has been given to the amount of breast tissue removed in differentiating between cosmetic and medically necessary reduction mammoplasty. To be considered a non-cosmetic procedure it is expected that at least a minimal amount of breast tissue will be removed. Yet, arbitrary minimum weight breast tissue removed criteria do not consistently reflect the consequences of mammary hypertrophy in individuals with a unique body habitus. There are wide variations in the range of height, weight, and associated breast size that cause symptoms. The amount of tissue that must be removed in order to relieve symptoms will vary and depend upon these variations. You can find this rule at Local Coverage Determination (LCD): Reduction Mammaplasty (L35001) (eff. 11/7/19).
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 Code of Federal Regulations (CFR) Section 422.101.The rules say that payment under the fee schedule for ambulance services covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport; and does not include a separate payment for items and services furnished under the ambulance benefit. Payment for items and services is included in the fee schedule payment. Such items and services include but are not limited to oxygen, drugs, extra attendants, and EKG testing but only when such items and services are both medically necessary and covered by Medicare under the ambulance benefit. You can find this in the Medicare Claim Processing Manual, Chapter 15, Section 20.1.1.
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 may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Section 423.578(b)(5)(ii). 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. The health plan contract says that Entyvio is subject to step therapy. The member must meet the following criteria: has had prior, therapy, contraindication, or intolerance with Remicade OR Inflectra; AND Stelara (step therapy requirement). You can find this rule in the the Plan's Pharmacy and Therapeutics Entyvio Coverage Policy.
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 MA plans may specify brands and manufacturers as preferred and charge lower cost -sharing
for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the
following conditions are met (42 CFR 422.100(l)):
- The MA plan provides all categories of DME covered under original Medicare Part B;
- The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME
products or brands;
- The MA plan's contracted suppliers provide access to all preferred DME brands;
- 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;
- Although the MA plan may add brands to its preferred formulary during the year, it may not remove any
brands mid-year;
- The MA plan treats denials of non-preferred DME products or brands as organization determinations;
- 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 EOC and ANOC and on its website; and
- The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or
subcategories annually determined by CMS to require full coverage.
You can find this information at Medicare Managed Care Manual Chapter 4 - Benefits and Beneficiary
Protections 10.12.2- Specifying Brands or Manufacturers of DME.
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 states that the only covered brands of blood glucose monitors and test strips are ACCU-CHEK
manufactured by Roche, or Trividia products sometimes packaged under your pharmacy's name. The Plan
covers any blood glucose monitors and test strips specified within the preferred brand list above. In general,
alternate non-preferred brand products are not covered unless your doctor provides adequate information that
the use of an alternate brand is medically necessary in your specific situation. If you are new to the Plan and
are using a brand of blood glucose monitor and test strips that are not on the preferred brand list, you may
contact us within the first 90 days of enrollment into the plan to request a temporary supply of the alternate
non-preferred brand. During this time, you should talk with your doctor to decide whether any of the preferred
product brands listed above are medically appropriate for you. Non-preferred brand products will not be
covered following the initial 90 days of coverage without an approved prior authorization for a coverage
exception. You can find this information on page 63 of the Plan's 2020 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. The rules say 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 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 55 in 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 say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR 410.41. The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 30.3.
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 states that it covers routine transportation for up to 36 one-way transportation trips per calendar year. Each one-way trip must not exceed 50 miles. You can find this information on page 4-65 of the Plan's 2020 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The contractor shall verify that the face-to-face encounter documentation includes information supporting that the beneficiary was evaluated or treated for a condition that supports the DME item(s) ordered. If this information is not included, the contractor shall deny the claim. If the physician completed the written order before the face-to-face encounter, the contractor shall deny the claim. You can find these rules in the Medicare Program Integrity Manual, Chapter 5 - Items and Services Having Special DME Review Considerations Section 5.2.5.1 - Face-to-Face Encounter
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 $40 copayment for each Medicare-covered podiatry visit. You can find this information on page 71 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 at42 Code of Federal Regulations (CFR) Section 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 thisrule in the Medicare National Coverage Determinations Manual, Section 220.1(A).