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 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.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.ThePlan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules saythat 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 Medicare plan may restrict members to a network 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 422.112(a)(3).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contractsays 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 pages 62 and 63 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 pay for durable medical equipment that is mainly used to serve amedical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly used for medical purposes. Medicare will not pay for:1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners;2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1.Equipment which is primarily and customarily used for a nonmedical purpose may not be considered medical equipment for which payment can be made under the medical insurance program. This is true even though the item has some remote medically related use.B. Maintenance The rules state that routine periodic servicing, such as testing, cleaning, regulating, and checking of the beneficiary's equipment, is not covered. The owner is expected to perform such routine maintenance rather than a retailer or some other person who charges the beneficiary. Normally, purchasers of durable medical equipment (DME) are given operating manuals which describe the type of servicing an owner may perform to properly maintain the equipment. It is reasonable to expect that beneficiaries will perform this maintenance. Thus, hiring a third party to do such work is for the convenience of the beneficiary and is not covered. However, more extensive maintenance which, based on the manufacturers' recommendations, is to be performed by authorized technicians, is covered as repairs for medically necessary equipment which a beneficiary owns. This might include, for example, breaking down sealed components and performing tests which require specialized testing equipment not available to the beneficiary. Medicare Benefit Policy Manual Chapter 15 -Covered Medical and Other Health Services under Section 110: Definition of Durable Medical Equipment 110.1 and Durable Medical Equipment -110.2.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 ?417.414.The rules say that a seat lift mechanism is covered if all of the following are met:1. The enrollee must have severe arthritis of the hip or knee or have a severe neuromuscular disease. 2. The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to improve, or stop deterioration of, the enrollee's condition.3. The enrollee must be completely unable to stand up from a regular armchair or any chair in the home. 4. Once standing, the enrollee must have the ability to walk.You can find this rule in the Medicare Local Coverage Determination (LCD) L33801, Seat Lift Mechanisms. This LCD is effective for services provided on or after July 1, 2016.If you want to read theseMedicare 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 use of ERG for either glaucoma diagnosis or management is considered investigational. You can find this rule at Local Coverage Determination (LCD): Electroretinography (ERG) (L37371) (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 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.The rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A).If you want to read these Medicare rules, you can go to this 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 says that porcelain/stainless steel crowns are covered once per tooth every 60 months. You can find this information on page63 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 pay for durable medical equipment that is mainly used to serve a medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly used for medical purposes. Medicare will not pay for:1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners;2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1. The rules also state that an expandable controller is capable of accommodating one or more of the following additional functions:-Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.)-Non-proportional input devices (e.g., sip and puff, head array, etc.)-Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)An expandable controller may also be able to operate one or more of the following:-A separate display (i.e., for alternate control devices)-Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control)-An attendant control For power wheelchairs which are capable of being upgraded to an expandable controller (K0835 -K0891), E2377 is used if an expandable controller is provided at the time of initial issue. Code E2376 is used with complete replacement of an expandable controller.A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and with complete replacement of the expandable controller. 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 these rules 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 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 find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D).A custom fabricated seat cushion (E2609) is covered if criteria (1) and (3) are met. A custom fabricated back cushion (E2617) is covered if criteria (2) and (3) are met:1. Beneficiary meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion;2. Beneficiary meets all of the criteria for a prefabricated positioning back cushion;3. There is a comprehensive written evaluation by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated seating system is not sufficient to meet the beneficiary's seating and positioning needs. The PT or OT may have no financial relationship with the supplier.If a custom fabricated cushion is provided for a beneficiary who does not meet the stated coverage criteria, it will be denied as not reasonable and necessary.A positioning seat cushion (E2605, E2606), positioning back cushion (E2613-E2616, E2620, E2621), and positioning accessory (E0953, E0955-E0957, E0960) are covered for a beneficiary who meets both of the following criteria:1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and2. The beneficiary has any significant postural asymmetries that are due to one of the following(a or b):a. A diagnosis code listed in Group 2 of the "ICD-10 Codes that are Covered" section in the LCD-related Policy Article; orb. A diagnosis code listed in Group 3 of the "ICD-10 Codes that are Covered" section in the LCD-related Policy Article.You can find this information in Local Coverage Determination (LCD): Wheelchair Seating (L33312).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item ifregular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that if medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan to determine theinitial level of cancer treatment needed for an enrollee. After the completion of the initial anti-cancer therapy, additional FDG PET scans may be covered at the discretion of Medicare. You can find this rule in the National Coverage Determinations Manual, Section 220.6.17.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.Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 290(3). Therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if all of the following criteria are met:1. The beneficiary has diabetes mellitus; and 2. The certifying physician has documented in the beneficiary's medical record one or more of the following conditions: a. Previous amputation of the other foot, or part of either foot, or b. History of previous foot ulceration of either foot, or c. History of pre-ulcerative calluses of either foot, or d. Peripheral neuropathy with evidence of callus formation of either foot, ore. Foot deformity of either foot, or f. Poor circulation in either foot; You can find this information at Local Coverage Article:Therapeutic Shoes for Persons with Diabetes -Policy Article (A52501). 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 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 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 state that continued coverage of a PAP device (E0470 or E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy. For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is demonstrated by: 1.Face-to-face clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive sleep apnea are improved; and, 2.Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner.Adherence to therapy is defined as use of PAP =4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as not reasonable and necessary.You can find this in the Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718). 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 transport only by ambulance. 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(a) and (b).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 at42 CFR422.101.Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise reasonableand 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 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 immunizations are not covered unless they are directly related to the treatment of an injury or direct exposure to a disease or condition. In the absence of injury or directexposure, vaccination or inoculation is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule. You can find this rule at 42 CFR 411.15(e).If you want to read these Medicare rules, you can go to thisweb 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 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 111 in the Plan's 2019 EOC.