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 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).
A Group 1 mattress overlay or mattress (E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0196,
E0197, E0198, E0199 and A4640) is covered if one of the following three criteria are met:
1. The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without
assistance, or
2. The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body
position significant enough to alleviate pressure and at least one of conditions A-D below, or
3. The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D
below.
Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition
sufficiently to demonstrate the medical necessity for a pressure reducing support surface):
A. Impaired nutritional status
B. Fecal or urinary incontinence
C. Altered sensory perception
D. Compromised circulatory status
When the coverage criteria for a Group 1 mattress overlay or mattress are not met, the claim will be denied as
not reasonable and necessary.
You can find this rule in Local Coverage Determination (LCD):Pressure Reducing Support Surfaces - Group 1
(L33830).
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 codes used for Medicare billing purposes have what is called a status code indicator. Codes
with a status code indicator of "S" are not valid for Medicare billing purposes. You can find this in the
Medicare Claims Processing Manual, Chapter 23 - Fee Schedule Administration and Coding Requirements,
Section Name. 30.2.2 (MPFSDB Status Indicators).
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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR 422.111(a) and (b).
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR 422.2.
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment. You can find
this rule at 42 CFR 424.5.
The rules say 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. You can see this in the Medicare
Program Integrity Manual Chapter 3  3.3.2.1.
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 50% coinsurance for outpatient therapy with an out of network provider.
You can find this information on page 66 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 plans must make reasonable and diligent efforts to gather and forward information
to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances,
Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1.
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 Medicare Part B generally does not pay for drugs that are usually self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are: 1. blood-clotting factors; 2. drugs used in immunosuppressive therapy; 3. erythropoietin for dialysis patients; 4. osteoporosis drugs for certain homebound patients; 5. certain oral cancer drugs; 6. oral anti-emetics used in certain situations; 7. drugs treated as supplies during an outpatient hospital procedure; and 8. drugs required for the effective use of durable medical equipment. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.
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 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.
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 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).
The rules say that the reasonable useful lifetime (RUL) of durable medical equipment is determined through
program instructions. In the absence of program instructions, carriers may determine the reasonable useful
lifetime of equipment, but in no case can it be less than 5 years. Computation of the useful lifetime is based on
when the equipment is delivered to the beneficiary, not the age of the equipment. Replacement due to wear is
not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime,
Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary
equipment owned by the beneficiary. Cases suggesting malicious damage, culpable neglect, or wrongful
disposition of equipment should be investigated and denied where the DME MACs determines that it is
unreasonable to make program payment under the circumstances. The rules can be found in the Medicare
Benefit Policy Manual Chapter 15 under Covered Medical and Other Services Section 110.2. for Repairs,
Maintenance, Replacement, and Delivery.
The rules state that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power
standing feature, it will be denied as non-covered.
You can find this rule in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).
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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment. You can find this rule at 42 CFR 410.21(b).  The rules say subluxation may be shown by x-ray or physical exam. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 240.1.2.
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).
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).
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.
Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise
reasonable and necessary for the patient. FDA approved drugs used for indications other than what is indicated
on the official label may be covered if the use is determined to be medically accepted, taking into consideration
the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. You
can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50.4.1 and 50.4.2.
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 for therapeutic continuous glucose monitors (CGMs) when they are medically reasonable and necessary. Therapeutic CGMs are defined in CMS Ruling 1682R. You can find these rules in Local Coverage Article A52464, effective on and after January 12, 2017.CGMs consist of three components: a glucose sensor, a transmitter, and a receiver. CGMs are considered therapeutic CGMs if they are:-approved by the FDA for use in place of a blood glucose monitor for making diabetes treatment decisions (for example, changes in diet and insulin dosage);-generally not useful to the individual in the absence of an illness or injury;-appropriate for use in the home; and-those which include a durable component that can withstand repeated use, are expected to last at least three years, and are capable of displaying the trending of the continuous glucose measurements.The rules also say that a CGM which does not replace a blood glucose monitor for making diabetes treatment decisions is not covered. You can find these rules in CMS Ruling 1682R.The rules say continuous glucose monitoring (CGM) devices covered by Medicare under the DME benefit are defined in CMS Ruling 1682R as therapeutic CGMs. Refer to the Non-Medical Necessity Coverage and Payment Rules in the LCD-related Policy Article for additional information. Therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria (1-6) are met:1.   The beneficiary has diabetes mellitus (Refer to the "ICD-10 Codes that are Covered" section of the LCD-related Policy Article, A52464, for applicable diagnoses); and,2.   The beneficiary has been using a blood glucose monitor (BGM) and performing frequent (four or more times a day) testing; and,3.   The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and,4.   The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,5.   Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and,6.   Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.When a therapeutic CGM (code K0554) is covered, the related supply allowance (code K0553) is also covered. If any of coverage criteria (1-6) are not met, the CGM and related supply allowance will be denied as not reasonable and necessary. You can find this information in Local Coverage Determination, Glucose Monitors, L33822.
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.
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 an inpatient admission is generally appropriate when the admitting physician expects the
patient to need hospital care that crosses at least two midnights. The expectation should be based on such
complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and
medical risk. The factors must be documented in the medical record.
If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be
considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as
"inpatient only" is generally appropriate, regardless of the length of stay. An inpatient admission may be
appropriate if the admitting physician expects a patient to require hospital care for only a limited period of
time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be
supported by the medical record. You can find this rule at 42 CFR 412.3.
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.
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 for definitive drug testing, limitations apply when denials are likely, whether based on
medical necessity or other coverage reasons. The limitation of liability and refund requirements do not apply
when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for
screening purposes. For codes 80307, diagnosis codes and specific physician documentation must be coded to
the highest level of specificity. You can find this in the Local Coverage Article: Billing and Coding: Drug
Testing (A56645).
The rules say that Medicare requires that services provided/ordered/certified be authenticated by the persons
responsible for the care of the beneficiary in accordance with Medicare policies. You can find this in the
Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking Corrective Actions,
Section 3.3.2.4 entitled Signature Requirements.
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 at42 CFR 422.101. The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual, Section 50.12.1.
Appeal type: unknown
Decision: unknown

The rules say that Medicare pays for care in a skilled nursing facility (SNF) when all of the following four
factors are met:
1. The patient requires skilled nursing or skilled rehabilitation services;
2. The patient requires these services on a daily basis;
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and
4. The services are reasonable and necessary for the treatment of the patient's illness or injury or the services
must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from
getting worse.
You can find these rules at 42 CFR 409.31 and in the Medicare Benefit Policy Manual, Chapter 8, Section 30.
The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding,
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also
custodial care services. You can find this rule in the Medicare Benefit Policy Manual, Chapter 16, Section 110.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 CFR 422.101.
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees
to obtain authorization before receiving services. You can find this rule at 42 CFR 422.112(a) and in the
Medicare Managed Care Manual, Chapter 1, Section 20.2.
The rules say that Medicare requires that services provided/ordered/certified be authenticated by the persons
responsible for the care of the beneficiary in accordance with Medicare policies. You can find this in the
Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking Corrective Actions,
Section 3.3.2.4 entitled Signature Requirements.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that It is important to know which providers are part of our network because, with limited
exceptions, while you are a member of our plan you must use network providers to get your medical care and
services. The only exceptions are emergencies, urgently needed services when the network is not available
(generally, when you are out of the area), out-of-area dialysis services, and cases in which our plan authorizes
use of out-of-network providers. You can see this on page 9 of the 2019 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that Medicare pays for therapeutic continuous glucose monitors (CGMs) when they are medically reasonable and necessary. Therapeutic CGMs are defined in CMS Ruling 1682R. You can find these rules in Local Coverage Article A52464, effective on and after January 12, 2017. CGMs consist of three components: a glucose sensor, a transmitter, and a receiver. CGMs are considered therapeutic CGMs if they are: - approved by the FDA for use in place of a blood glucose monitor for making diabetes treatment decisions (for example, changes in diet and insulin dosage); - generally not useful to the individual in the absence of an illness or injury; - appropriate for use in the home; and - those which include a durable component that can withstand repeated use, are expected to last at least three years, and are capable of displaying the trending of the continuous glucose measurements. The rules also say that a CGM which does not replace a blood glucose monitor for making diabetes treatment decisions is not covered. You can find these rules in CMS Ruling 1682R.