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 payment for inpatient psychiatric hospital services is to be made only for active treatment. For services to be designated as active treatment they must:1. be provided under an individualized treatment or diagnostic plan;2. reasonably be expected to improve the patient's condition, or for the purpose of diagnosis; and3. besupervised and evaluated by a physician.  You can find these rules in the Medicare Benefit Policy Manual, Chapter 2, Sections 30.2.2 and 30.2.2.1.The rules say that Medicare will not pay any expenses for items or services which are not medically necessary and reasonable for the diagnosis or treatment of illness or injury. This exclusion extends to claims for services which are provided in inappropriate settings. You can find this rule in the Social Security Act, Section 1862(a)(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 Code of Federal Regulations (CFR) Section 422.101.The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).Local Coverage Determination (LCD):Pain Management (L33622) -If previous diagnostic or therapeutic SI injections of an anesthetic and/or steroid to block the joint for immediate, and potentially long lasting, pain relief have not effectively relieved the pain, further injections would not be considered medically necessary. Radio frequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed radio frequency.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that a Medicare plan may restrict members to anetwork of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3).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 1-8 of the 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 state that carriers generally distinguish between an "interpretation and report" of an x-ray or an EKG procedure and a "review" of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service. This is because the review is already included in the emergency department evaluation and management (E/M) payment. You can find this informationin the Medicare Claims Processing Manual, Chapter 13, 100.1.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 Code of Federal Regulations (CFR) Section 422.101.The rules state that effective for items and services furnished on or after July 9, 2007, Medicare covers the routine costs of qualifying clinical trials, as such costs are defined below, as well as reasonable and necessary items and services used to diagnose and treat complications arising from participation in all clinical trials. All other Medicare rules apply.Routine costs of a clinical trial include all items and services that are otherwise generally available to Medicare beneficiaries (i.e., there exists a benefit category, it is not statutorily excluded, and there is not a national non-coverage decision) that are provided in either the experimental or the control arms of a clinical trial except:&#61623;The investigational item or service, itself unless otherwise covered outside of the clinical trial;&#61623;Items and services provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient (e.g., monthly CT scans for a condition usually requiring only a single scan); and&#61623;Items and services customarily provided by the research sponsors free-of-charge for any enrollee in the trial.Routine costs in clinical trials include:&#61623;Items or services that are typically provided absent a clinical trial (e.g., conventional care);&#61623;Items or services required solely for the provision of the investigational item or service (e.g., administration of a noncovered chemotherapeutic agent), the clinically appropriate monitoring of the effects of the item or service, or the prevention of complications; and&#61623;Items or services needed for reasonable and necessary care arising from the provision of an investigational item or service in particular, for the diagnosis or treatment of complications.You can find these rules in the Medicare National Coverage Determination (NCD) for Routine Costs in Clinical Trials, Section 310.1.
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 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.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 treatment for Symptomatic Chronic Venous Insufficiency or Varicose Veins (VV), in the absence of bleeding, phlebitis or skin necrosis, may be covered as medically necessary with:1. A documented 3-month trial of conservative therapy including graduated compression stockings with a minimum of (12-18 mmHg), weight reduction to BMI less than 35, therapeutic leg elevation, and an exercise program of calf muscle pumping activity with compression of the involved veins, which results in limited alteration/improvement of symptoms or findings without satisfactory endpoint, and2. Duplex venous studies of the involved lower extremity(s), mapping size and course of the greater and lesser saphenous vein and prominent tributaries and demonstrating the: -Presence and Patency of the Deep Venous System.-Absence of Deep Venous Thrombosis, and-Documented Incompetence (reflux greater than 500msec) of the Valves of the Saphenous, Perforator or Deep venous systems consistent with the patient's symptoms and findings.You can find this rule in the Local Coverage Determination for Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities, L34924 (eff 11/14/19).
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 422.101The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the 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 Code of Federal Regulations (CFR) Section 422.101.The rules say that payment for inpatient psychiatric hospital services is to be made only for active treatment. For services to be designated as active treatment they must:1. be provided under an individualized treatment or diagnostic plan;2. reasonably be expected to improve the patient's condition, or for thepurpose of diagnosis; and3. be supervised and evaluated by a physician.  You can find these rules in the Medicare Benefit Policy Manual, Chapter 2, Sections 30.2.2 and 30.2.2.1.The rules say that Medicare will not pay any expenses for items or services which are not medically necessary and reasonable for the diagnosis or treatment of illness or injury. This exclusion extends to claims for services which are provided in inappropriate settings. You can find this rule in the Social Security Act, Section 1862(a)(1).If you want to read these Medicare rules, you can go to this website 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 Code of Federal Regulations (CFR) Section 422.101.
The rules state that whole gland HIFU is considered medically necessary as a local treatment for recurrent PCa following radiation therapy (RT) when ALL of the following criteria are met (1,2): Biochemical recurrence (BCR) according to the Phoenix definition (PSA nadir + 2 ng/mL) Positive post-RT transrectal ultrasound guided (TRUS) biopsy Candidate for local curative therapy as evidenced by favorable clinical and pathologic factors (BOTH of the following) Original (pre-RT)- clinical stage T1-T2, NX or N0 Current (ALL are required) PSA < 10 ng/mL absence of distant metastases per National Comprehensive Cancer Network (NCCN) imaging guidelines no lymph node involvement interval to biochemical failure > 18 months International Society of Urological Pathology (ISUP) grade < 4 local recurrence amenable to entire destruction Multi-disciplinary consensus (surgeon, oncologist, radiologist) Hi comorbidity (i.e., not a candidate for radical prostatectomy (RP). You can find these rules and further information in Local Coverage Determination (LCD): Salvage High-intensity Focused Ultrasound (HIFU) Treatment in Prostate Cancer (PCa) (L38262).
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 state that for a beneficiary who is currently being treated with insulin injections, more than 300 test strips and more than 300 lancets every 3 months are covered if criteria (a) - (c) below are met. a. Basic coverage criteria (1)-(2) listed above for all home glucose monitors and related accessories and supplies are met; and, b. Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, the treating practitioner has had an in-person visit with the beneficiary to evaluate their diabetes control and their need for the specific quantity of supplies that exceeds the usual utilization amounts described above; and, c. Every six (6) months, for continued dispensing of quantities of testing supplies that exceed the usual utilization amounts, the treating practitioner must verify adherence to the high utilization testing regimen. If neither basic coverage criterion (1) or (2) is met, all testing supplies will be denied as not reasonable and necessary. If quantities of test strips or lancets that exceed the utilization guidelines are provided and criteria (a) - (c) are not met, the amount in excess will be denied as not reasonable and necessary. You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822).
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 state that an "order" is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed. You can find this information in the Medicare Benefit Policy Manual, Chapter 15, Section 80.6
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 laboratory services furnished by an independent laboratory are covered under SMI if the laboratory is an approved Independent Clinical Laboratory. However, as is the case of all diagnostic services, in order to be covered these services must be related to a patient's illness or injury(or symptom or complaint) and ordered by a physician. You can find this rule in the Medicare Claims Processing Manual, Chapter 16, Section 10.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that total hip replacement surgery will be considered medically necessary when one or more of the following criteria are met:
 Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; or
 Avascular necrosis (osteonecrosis of femoral head); or
 Fracture of the femoral neck; or
 Acetabular fracture; or
 Non-union or failure of previous hip fracture surgery; or
 Mal-union of acetabular or proximal femur fracture; or
 Advanced joint disease demonstrated by:
o Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance imaging (MRI) supported evidence; and
o Pain or functional disability from injury due to trauma or arthritis of the joint); and
o Unsuccessful history of appropriate conservative therapy
Total hip replacement will not be considered medically necessary when the following contraindications are present:
 Active infection of the hip or knee joint or active systemic bacteremia
 Active skin infection or open wound within the planned surgical site of the hip or knee
 Neuropathic arthritis
 Rapidly progressive neurological disease
You can find these rules in Local Coverage Determination (LCD) Major Joint Replacement (Hip and Knee) (L33618).
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 state that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary when ALL of the following conditions are met: 1. The patient is symptomatic. Such symptoms may include pain which interferes with the activities of daily living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness. 2. The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. 3. If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, laboratory and imaging studies (i.e., the pain and functional disability is not considered likely to be due to a diagnosis other than osteoarthritis of the knee). 4. The patient has failed at least three months of conservative therapy. Conservative therapy is defined as: -Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss, physical therapy if indicated); and -If not contraindicated, simple analgesics and (e.g., acetaminophen) or NSAIDS per hyaluronan product prescribing information. 5. The patient has failed to respond to aspiration of the knee when effusion is present and intra-articular corticosteroid injection therapy when inflammation is a significant component of the patient's symptoms and intra-articular corticosteroids are not contraindicated. You can find this information in the Local Coverage Determination (LCD): Hyaluronan Acid Therapies for Osteoarthritis of the Knee (L35427).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that a spinal orthosis (L0450 -L0651) is covered when it is ordered for one of the following indications:To reduce pain by restricting mobility of the trunk; or To facilitate healing following an injury to the spine or related soft tissues; orTo facilitate healing following a surgical procedure on the spine or related soft tissue; or To otherwise support weak spinal muscles and/or a deformed spine.If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary. You can find this rule at Local Coverage Determination (LCD): Spinal Orthoses: TLSO and LSO (L33790) (eff. 1/1/18)
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 medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o)
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 to qualify for home health services, the patient must be: 1. Confined to the home; 2. Under the care of a physician or allowed practitioner; 3. Receiving services under a plan of care established and reviewed by a physician; 4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) continuing occupational therapy. You can find this rule at 42 CFR Section 409.42. The rules say that eligibility for the home health benefit will be determined based on the certifying physician's records. If the enrollee was directly admitted to home health from an acute or post-acute care facility, the facility records may be used instead. The medical records for the enrollee must contain information that justifies the referral for home health services. The certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face encounter visit. You can find these rules in the Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1, 30.5.1.1, and 30.5.1.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that cryosurgery of the prostate gland, also known as cryosurgical ablation of the prostate (CSAP), destroys prostate tissue by applying extremely cold temperatures in order to reduce the size of the prostate gland. It is safe and effective, as well as medically necessary and appropriate, as primary treatment for patients with clinically localized prostate cancer, Stages T1-T3. Salvage Cryosurgery of Prostate After Radiation Failure. Salvage cryosurgery of the prostate for recurrent cancer is medically necessary and appropriate only for those patients with localized disease who: 1. Have failed a trial of radiation therapy as their primary treatment; and 2. Meet one of the following conditions: Stage T2B or below, Gleason score <9, PSA <8 ng/mL. Cryosurgery as salvage therapy is therefore not covered under Medicare after failure of other therapies as the primary treatment. Cryosurgery as salvage is only covered after the failure of a trial of radiation therapy, under the conditions noted above. You can find this rule in the Medicare National Coverage Determination for Cryosurgery of Prostate, 230.9.
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.