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.
Medicare guidance says, "For any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient's diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. If an item requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patient's record. However, neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient's medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable)". Also, "Before submitting a claim to the DME MAC the supplier must have on file a dispensing order, the detailed written order, the CMN (if applicable), the DIF (if applicable), information from the treating physician concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain DME MAC policies. The supplier should also obtain as much documentation from the patient's medical record as they determine they need to assure themselves that coverage criteria for an item have been met. If the information in the patient's medical record does not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed ABN of possible denial has been obtained." You can find this guidance in the Medicare Program Integrity Manual, Chapter 5 - Items and Services Having Special DME Review Considerations, Section 5.7 - Documentation in the Patient's Medical Record and Section 5.8 - Supplier Documentation.
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 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 health
plan contract says that enrollees must pay 30% coinsurance per day per admission for out-of-network SNF
care. You can find this information in Chapter 4 on page 85 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 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 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 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 74-75 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 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 51 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 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 health plan contract says that enrollees must pay 20% coinsurance for Medicare-covered DME and related supplies. You can find this information in Chapter 4 on page 4-16 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 Code of Federal Regulations (CFR) Section 422.101.
The rules say that effective September 1, 1992, all laboratory testing sites (except as provided in 42CFR
493.3(b)) must have either a CLIA certificate of waiver, certificate for provider-performed microscopy
procedures, certificate of registration, certificate of compliance, or certificate of accreditation to legally perform
clinical laboratory testing on specimens from individuals in the United States. The Food and Drug
Administration approves CLIA waived tests on a flow basis. The CMS identifies CLIA waived tests by
providing an updated list of waived tests to the A/B MACs (A) and (B) on a quarterly basis via a Recurring
Update Notification. To be recognized as a waived test, some CLIA waived tests have unique HCPCS
procedure codes and some must have a QW modifier included with the HCPCS code. You can find this in the
Medicare Claims Processing Manual, Chapter 16 - Laboratory Services, Section 70.8.
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 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 health plan contract says that enrollees must pay a $285 copayment per day for days 1-7 for inpatient hospital care. You can find this information in Chapter 4 on page 72 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 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 Plan
covers certain dental services as a supplemental (extra) benefit. The contract says that crowns are listed as
covered benefits when medically reasonable and necessary. The contract says that some dental services require
prior authorization to be covered. Other dental services may be subject to limitations You can find this
information on page 52 of the Plan's 2020 Evidence of Coverage (EOC).
The contract also says that permanent anterior teeth must have pathologic destruction to the tooth by caries or
trauma, and must involve four or more surfaces and at least 50% of the incisal edge. Criteria for crowns will be
met only for permanent teeth needing multi-surface restorations where other restorative materials have a poor
prognosis. You can find this information on page 39 of the Plan's supplemental dental coverage 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 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 only certain codes/services are covered under the Plan. The EOC lists specific services
which are a covered benefit and any service not listed in this section is not a covered benefit. You can find this
information in Chapter 4 on pages 60-61 and 92-95 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 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 43 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 dorsal column stimulators may be covered as therapies for the relief of chronic intractable
pain under the following circumstances:
1. To treat chronic pain caused by lumbosacral arachnoiditis that has not responded to medical management
including physical therapy. (Presence of arachnoiditis is usually documented by presence of high levels of
proteins in the Cerebrospinal Fluid [CSF] and/or by myelography or Magnetic Resonance Imaging [MRI]).
2. To treat intractable pain caused by nerve root injuries, post-surgical or post-traumatic including that of postlaminectomy
syndrome (failed back syndrome).
3. To treat intractable pain caused by complex regional pain syndrome I & II.
4. To treat intractable pain caused by phantom limb syndrome that has not responded to medical management.
5. To treat intractable pain caused by end-stage peripheral vascular disease, when the patient cannot undergo
revascularization or when revascularization has failed to relieve painful symptoms and the pain has not
responded to medical management.
6. To treat intractable pain caused by post-herpetic neuralgia.
7. To treat intractable pain caused by plexopathy.
8. To treat intractable pain caused by intercostal neuralgia that did not respond to medical management and
nerve blocks.
9. To treat intractable pain caused by cauda equina injury.
10. To treat intractable pain caused by incomplete spinal cord injury.
You can find this rule in Local Coverage Determination (LCD): Spinal Cord Stimulation (Dorsal Column
Stimulation) (L35450) - Effective September 26, 2019.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare does not pay for gym benefits. Gym benefits include exercise classes, such as Tai
Chi, yoga, and dance classes. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section
30.3.
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 contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes oral exam, routine cleanings, and x-rays. You can find this information on page 72 of the Plan's 2020 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 a group 2 support surface is covered if the beneficiary meets at least one of the following three Criteria (1, 2 or 3): 1. The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses) which have failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program including each of the following: a. Use of an appropriate group1 support surface, and b. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and c. Appropriate turning and positioning, and d. Appropriate wound care, and e. Appropriate management of moisture/incontinence, and f. Nutritional assessment and intervention consistent with the overall plan of care 2. The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses), 3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses), and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days If the beneficiary is on a group 2 surface, there should be a care plan established by the treating practitioner or home care nurse which includes the above elements. The support surface provided for the beneficiary should be one in which the beneficiary does not "bottom out" (see Appendices section). When a group 2 surface is covered following a myocutaneous flap or skin graft, coverage generally is limited to 60 days from the date of surgery. When the stated coverage criteria for a group 2 mattress or bed are not met, a claim will be denied as not reasonable and necessary. A support surface which does not meet the characteristics specified in the Coding Guidelines section of the Pressure Reducing Support Surfaces - Group 2 Policy Article will be denied as not reasonable and necessary. (See Policy Article sections concerning billing of E1399.) Continued use of a group 2 support surface is covered until the ulcer is healed, or if healing does not continue, there is documentation in the medical record to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the use of the group 2 support surface is reasonable and necessary for wound management. You can find this information in Medicare's Local Coverage Determination (LCD): Pressure Reducing Support Surfaces - Group 2 (L33642).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that the supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) must have an order from the treating physician before giving any DMEPOS item to an enrollee. The supplier must keep the order and proof of delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. You can find this rule in the Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1 and 5.8. The rules say that section 1833(e) grants Medicare contractors the authority to request any information necessary to determine the amounts due. This includes proof of delivery in order to verify that the beneficiary received the DMEPOS item and thus to determine the amounts due to the provider. You can find this rule in the Medicare Program Integrity Manual, Chapter 4, 4.26.
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.