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 the criteria for BRCA testing is: -Individual with breast, ovarian1, pancreatic, or prostate cancer from a family with a known deleterious BRCA1 or BRCA2 gene mutation. -Individual with a personal history of ovarian1 cancer -Individual with a breast cancer diagnosis meeting any of the following criteria: 1. Diagnosed 45 years old or younger 2. Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR) negative, and human epidermal growth factor receptor 2 (HER2) negative) breast cancer diagnosed 60 years or younger 3. Diagnosed at 50 years or younger with: A. An additional breast cancer primary B. 1 or more first, second, or third degree relative5 with breast cancer at any age, or C. 1 or more first, second, or third degree relative5 with prostate cancer (Gleason score of 7 or more), or D. An unknown or limited family history 4. Breast cancer diagnosed at any age, and A. 1 first, second, or third degree relative diagnosed with breast cancer 50 years old or younger, or B. 1 or more first, second, or third degree relative5 with ovarian cancer at any age, or C. 1 or more first, second, or third degree relative5 with metastatic prostate cancer or pancreatic cancer at any age D. 2 or more additional diagnoses of breast cancer at any age in patient and/or in close blood relative,or E. A first, second, or third degree male relative with breast cancer F. For an individual of ethnicity associated with higher mutation frequency (e.g. Ashkenazi Jewish) no additional family history may be required. 5. Male breast cancer -Personalhistory of prostate cancer (Gleason score 7 or more) at any age with: 1. 1 or more first, second, or third degree relative with ovarian cancer at any age, or 2. 1 or more first, second, or third degree relative with breast cancer 50 years or younger, or 3. 1 or more first, second, or third degree relative5 with pancreatic cancer at any age, or 4. 1 or more first, second, or third degree relative5 with metastatic prostate cancer at any age, or 5. 2 or more first, second, or third degree relatives5 with breast cancer and/or pancreatic cancer and/or prostate cancer (Gleason score &#8805;7 or metastatic) at any age, or 6. Ashkenazi Jewish ancestry -Personal history of pancreatic cancer at any age -Personal history of metastatic prostate cancer (radiographic evidence of or biopsy-proven disease) -BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of germline mutation analysis You can find this rule in Local Coverage Determination (LCD): MolDX: BRCA1 and BRCA2 Genetic Testing (L36161) -Effective January 1, 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 Plancovers 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 claims for services furnished on or after January 1, 2010 must be filed no later than the close of the period ending 1 calendar year after the date of service. You can find this rule at 42 CFR 424.44(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 Plancovers 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 the treatments to eliminate the saphenous vein reflux will be considered medically necessary if the patient remains symptomatic after a six-week trial of conservative therapy and has reflux in a saphenous
vein.
The treatments for symptomatic varicose tributaries are either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative therapy. The following interventional treatments are not considered medically reasonable or necessary and are denied as such: - Surgery, endovenous ablation, or sclerotherapy are typically not performed for varicose veins that develop or worsen during pregnancy because most will spontaneously resolve or improve after delivery. - Reinjection following recanalization or failure of vein closure without recurrent signs or symptoms. - Sclerotherapy of the saphenous vein at its junction with the deep system. - Non-compressive sclerotherapy. - Compressive sclerotherapy for large, extensive or truncal varicosities. - Sclerotherapy, ligation and/or stripping of varicose veins, or endovenous ablation therapy are generally not covered for patients with severe distal arterial occlusive disease; obliteration of deep venous system; an allergy to the sclerosant; or a hypercoaguable state. - Any interventional treatment that uses equipment or sclerosants not approved for such purposes by the FDA. You can find this rule in the Local Coverage Determination for Varicose Veins of the Lower Extremity, Treatment of, L33575 (eff 11/21/19).
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 itin this case. You can find this rule at 42 CFR 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).
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 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 web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract lists the specific dental services that are covered by the Plan. Root canals are not listed and therefore are not a covered service. Crowns are not listed and therefore are not a covered service. Core build up is not listed and therefore is not a covered service either. The Plan contract also says that any services not listed are not covered. You can find this information on pages 4-54 to 4-58 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 ifregular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that for patients with severe and unambiguous obstructive sleep apnea, the initiation of treatment with nasal CPAP may be incorporated into the diagnostic study night. A "split-night" study (initial diagnostic polysomnogram confirming the diagnosis of obstructive sleep apnea followed by CPAP titration during polysomnography on the same night) may be an alternative to one full night of diagnostic polysomnography followed by a second night of titration as long as:-CPAP titration is carried out for more than 3 hours; and-Polysomnography or home sleep study (HST) documents that CPAP eliminates or nearly eliminates the respiratory events during REM and NREM sleep.Repeat polysomnography or HST for diagnosing sleep apnea requires documentation justifying the medical necessity for the repeated test. Repeat polysomnography may be indicated:-if the first study is technically inadequate due to equipment failure;-if the subject could not sleep or slept for an insufficient amount of time to allow a clinical diagnosis;-if the results were inconclusive or ambiguous; or-if initiation of therapy or confirmation of the efficacy of prescribed therapy is needed. You can find this rule in the Local Coverage Determination for Polysomnography, L36593 (eff 10/24/19).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plancovers 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 a long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).  The rules say that services in anLTACH must be medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need medical care. You can find this rule in the Medicare Program Integrity Manual, Chapter 6, Section 6.5.2.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.
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, Chapter4, 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 health plan contract says routine transportation is covered for up to 36 one-way trips per calendar year. Each one-way trip must not exceed 50 miles. A trip is considered one way, a round trip is considered two trips. You can find this information on page 4-67 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 CFR 422.101.The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your home may be a dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, an institution may not be considered your home if it is an acute hospital or a skilled nursing facility (SNF). You can findthese rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D).The rules say that Medicare will pay for durable medical equipment (DME) that is reasonable and necessary for treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment already available to an enrollee. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1(C).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 ifregular Medicare would pay for it in this case. You can find this rule at 42 CFR 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 replacementof 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 web site www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules. The Plan contract provides a list of covered services when rendered by a participating provider. The contract also says that the services must be performed by a participating general dentist. You can find this information on pages 64 and 65 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 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 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 includes a list of covered supplemental dental benefits. The periodontal maintenance is not on this list and is not a covered supplemental benefit. You can find this information on page 61 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.Therules 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).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 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 page 61 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 CFR 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 web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract lists the specific dental services that are covered by the Plan. You can find this information on pages 63 and 64 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 CFR 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 web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract includes a list of covered supplemental dental services. The contract specifically says that any procedure not listed is not covered. Core buildup, including any pins when required (D2950), pontic (D6240), and retainer crown (D6750) are not included on this list and are not covered supplemental benefits. You can find this information on pages 21 to 29 of the Plan's 2020 Preventive & Comprehensive Dental Coverage Customer Handbook.
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 drugshave 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).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 withMedicare 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 CFR 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 replacementof 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 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 if there is a pre-existing prosthesis, it must be at least 5 years old and unserviceable to qualify for replacement. The Plan contract also says that replacement of lost or broken dentures less than 5 years of age is not a covered benefit. 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 CFR 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).The rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Physicians must report services correctly. There are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. You can find this information in the Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1.