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 state that a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). Refer to the diagnoses listed in the Groups 2 or 4 ICD-10 Codes in the LCD-related Policy Article.

Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the Group 4 ICD-10 Codes in the LCD-related Policy Article. 

For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test).

Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented. 

You can find more information at Local Coverage Determination (LCD): Knee Orthoses (L33318).

The rules also state that L coded additions to AFOs and KAFOs (L2180, L2182, L2184, L2186, L2188, L2190, L2192, L2200, L2210, L2220, L2230, L2232, L2240, L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335, L2340, L2350, L2360, L2370, L2375, L2380, L2385, L2387, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2500, L2510, L2520, L2525, L2526, L2530, L2540, L2550, L2750, L2755, L2760, L2768, L2780, L2785, L2795, L2800, L2810, L2820, L2830) will be denied as not reasonable and necessary if either the base orthosis is not reasonable and necessary or the specific addition is not reasonable and necessary.

You can find this rule at Local Coverage Determination (LCD): Ankle-Foot/Knee-Ankle-Foot Orthosis (L33686).

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 Medicare pays for medically necessary ambulance transport services. Medicare makes
separate payment for paramedic intercept services only when they are furnished:

1. in a rural area,
2. by a provider that is under a contract with 1 or more volunteer ambulance services. You can find this rule at
42 CFR Section 410.40(d).

The rules say that for the purposes of Paramedic Intercept coverage, an area is a rural area if:
- It is designated as a rural area by any law or regulation of a State;
- It is located outside of a Metropolitan Statistical Area (MSA) or New England County Metropolitan
Area (NECMA); or
- It is located in a rural census tract of an MSA as determined under the most recent Goldsmith
modification.

Presently, only the State of New York meets these requirements. You can find this information in the Centers
for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 15,
Section 20.1.4(a)(5).

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 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 Plan contract says that enrollees must pay a $30 copayment for Outpatient rehabilitation services. You can find this information on pages 83-84 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 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 or allowed practitioner'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 or allowed practitioner must document that there was 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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 pages 42-46 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 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, 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. The Plan says that you may see any licensed dental provider who accepts Medicare patients in the U.S. and has not opted out of Original Medicare. You can find this information on page 62 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.

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 Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 290(3). 

The rules state that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. You can find this rule in the Center for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 

The rules also state that modifiers are used to identify therapy services whether or not financial limitations are in effect. When limitations are in effect, the CWF tracks the financial limitation based on the presence of therapy modifiers. Providers/suppliers must continue to report one of these modifiers for any therapy code on the list of applicable therapy codes except as noted in 20 of this chapter. Consult 20 for the list of codes to which modifiers must be applied. These modifiers do not allow a provider to deliver services that they are not qualified and recognized by Medicare to perform. 

The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered: 

- GN Services delivered under an outpatient speech-language pathology plan of care; 
- GO Services delivered under an outpatient occupational therapy plan of care; or, 
- GP Services delivered under an outpatient physical therapy plan of care. 

You can find this rule in the Center for Medicare and Medicaid Services, Internet Only Manual, Claims Processing Manual, Chapter 5, Section 20.1.

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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable
and necessary when:

1. The services are specific and effective treatment for the patient's condition,

2. The services require the skills or direct supervision of a therapist,

3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and

4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver,
or carry out a maintenance program.

Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for
skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only
Manual, Medicare Benefit Policy Manual, Chapter 15, Section 220.2.

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.
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 Code of Federal Regulations (CFR) Section 409.42.

The rules say that eligibility for the home health benefit will be determined based on the certifying physician or allowed practitioner'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 or allowed practitioner must document that there was 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 Centers for Medicare and Medicaid Services, Internet Only Manual, 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.

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 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 Plan contract says that enrollees must pay a $10 copayment for diagnostic procedures and tests. You can find this information in Chapter 4 on pages 85 - 86 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 PCDs coded as E0650, E0651, E0652 are used only in the treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers. Reimbursement for these items is based upon the criteria in the following sections. PCD coded as E0675 is used in the treatment of peripheral arterial disease. A PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when all of the following three requirements are met:

1. The beneficiary has a diagnosis of lymphedema as defined above, and 
2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence of at least one of the following clinical findings:

-Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
-Papillomatosis cutis lymphostatica, 
-Deformity of elephantiasis, 
-Skin breakdown with persisting lymphorrhea, 
-Detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a likely etiology, and

3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other clinical treatment over the course of a required four-week trial.

You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) - Effective January 1, 2020.

The rules say that a four-week trial of conservative therapy demonstrating failed response to treatment is required. The four-week trial of conservative therapy must include all of the following:

1. Regular and compliant use of an appropriate compression bandage system or compression garment to provide adequate graduated compression.

-Adequate compression is defined as (1) sufficient pressure at the lowest pressure point to cause fluid movement, and (2) sufficient pressure across the gradient (from highest to lowest pressure point) to move fluid from distal to proximal. The compression used must not create a tourniquet effect at any point.
-The garment may be prefabricated or custom-fabricated but must provide adequate graduated compression starting with a minimum of 30 mmHg distally.

2. Regular exercise 
3. Elevation of the limb

You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) - Effective January 1, 2020.

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 Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for a person who meets the following criteria: 

1. The person must have a personal mobility deficit; 
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, grooming and bathing in customary locations within the home; 
3. The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Section 280.3(B).

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 417.414.

The rules say that Medicare does not pay for nutritional supplements. You can find this rule in the Centers for
Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determination Manual,
Chapter 1, Section 180.2.

The rules state that enteral nutrition is the provision of nutritional requirements through a tube into the stomach
or small intestine. Enteral nutrition is covered for a beneficiary who has (a) permanent non-function or disease
of the structures that normally permit food to reach the small bowel or (b) disease of the small bowel which
impairs digestion and absorption of an oral diet, either of which requires tube feedings to provide sufficient
nutrients to maintain weight and strength commensurate with the beneficiary's overall health status. Enteral
nutrition products that are administered orally and related supplies are non-covered, no benefit. Enteral
nutrition is non-covered for beneficiaries with a functioning gastrointestinal tract whose need for enteral
nutrition is due to reasons such as anorexia or nausea associated with mood disorder, end-stage disease, etc.
You can find this rule in Local Coverage Article: Enteral Nutrition-Policy Article, A52493.

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 neurogenic disorders can be distinguishable from myopathic disorders by a carefully
performed electromyograph (EMG). For example, both polymyositis and amyotrophic lateral sclerosis (ALS)
produce manifest weakness. The former carries a very different prognosis and treatment than the latter. An
EMG is valuable in making this distinction. Similarly, classification of nerve trauma into axonal vs.
demyelinating categories, with corresponding differences in prognoses, are possible with EMG. Below is a list
of common disorders where an EMG, in tandem with properly conducted nerve conduction study, will be
helpful in diagnosis:

1. Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions.
2. Radiculopathy - cervical, lumbosacral
3. Mono/polyneuropathy - metabolic, degenerative, hereditary
4. Myopathy - including poly-and dermatomyositis, myotonic and congenital myopathies
5. Plexopathy - idiopathic, trauma, infiltration
6. Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG is of special value here
7. At times, immediately prior to botulinum toxin injection, for localization
8. At times, immediately prior to injection of phenol or other substances for nerve blocking or
chemodenervation

There may be other instances not detailed here, where EMG may be of use. You can find this rule in Local
Coverage Determination (LCD): Nerve Conduction Studies and Electromyography (L36526) - Effective
December 1, 2019.

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.