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 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 as grab bars. You
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1.
The rules say reimbursement may be made for the rental or purchase of a medically necessary seat lift when
prescribed by a physician for a patient with severe arthritis of the hip or knee and patients with muscular
dystrophy or other neuromuscular diseases when it has been determined the patient can benefit therapeutically
from use of the device. In establishing medical necessity for the seat lift, the evidence must show that the item
is included in the physician's course of treatment, that it is likely to effect improvement, or arrest or retard
deterioration in the patient's condition, and that the severity of the condition is such that the alternative would
be chair or bed confinement.
Coverage of seat lifts is limited to those types which operate smoothly, can be controlled by the patient, and
effectively assist a patient in standing up and sitting down without other assistance. Excluded from coverage is
the type of lift which operates by a spring release mechanism with a sudden, catapult-like motion and jolts the
patient from a seated to a standing position. Limit the payment for units which incorporate a recliner feature
along with the seat lift to the amount payable for a seat lift without this feature. You can find this information
in Medicare's National Coverage Determination (NCD): Seat Lift (280.4.).
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 if medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan to determine the initial 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, National Coverage Determinations Manual, Section 220.6.17.  The rules say Indications and Limitations of Coverage     a. CMS continues to nationally cover FDG PET imaging for the initial anti-tumor treatment strategy for male and female breast cancer only when used in staging distant metastasis.     b. CMS continues to nationally cover FDG PET to determine initial anti-tumor treatment strategy for melanoma other than for the evaluation of regional lymph nodes.     c. CMS continues to nationally cover FDG PET imaging for the detection of pre-treatment metastasis (i.e., staging) in newly diagnosed cervical cancers following conventional imaging.  You can find this information in Medicare's National Coverage Determination (NCD): Positron Emission Tomography (FDG) for Oncologic Conditions (220.6.17).  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 while thinning the blood with anticoagulant medications has been proven to prevent strokes, percutaneous left atrial appendage closure (LAAC) has been studied as a non-pharmacologic alternative for patients with atrial fibrillation (AF). This procedure is considered medically reasonable and necessary for patients with: - A CHADS2 score greater than or equal to 2 (Congestive heart failure, Hypertension, Age over 75, Diabetes, Stroke/transient ischemia attack/thromboembolism) or CHA2DS2-VASc score at least 3 (Congestive heart failure, Hypertension, Age at least 65, Diabetes, Stroke/transient ischemia attack/thromboembolism, Vascular disease, Sex category) - A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following the conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral anticoagulants. You can find this information in the National Coverage Determination (NCD): Percutaneous Left Atrial Appendage Closure (LAAC) (20.34).
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 pay for an inpatient rehabilitation facility (IRF) admission when the services
are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary
approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one
therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must
need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program.
This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at
least five days per week. The patient does not need to be expected to achieve complete independence in selfcare nor be expected to return to his or her prior level of functioning. The patient must need supervision by a
rehabilitation physician. The physician must see the patient at least three days per week throughout the stay.
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication
100-02, Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section
412.622.
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 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).
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 the plan will arrange to pay for appropriate lodging and transportation costs for you and
a companion for transplant services. You can find this information on page 4-22 of the 2021 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 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, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). The rules say that all of the following basic criteria (A-C) must be met for a power mobility device (K0842) or a push-rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are listed below. A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that: Prevents the beneficiary from accomplishing an MRADL entirely, or Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or Prevents the beneficiary from completing an MRADL within a reasonable time frame. B. The beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. C. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories. You can find this information in Medicare's Local Coverage Determination (LCD): Power Mobility Devices (L33789).
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 general anesthesia is considered not medically reasonable and necessary for facet joint interventions. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely considered medically reasonable and necessary. Individual consideration may be given on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. Frequent reporting of these services together may trigger focused medical review. You can find this rule at First Coast Service Options, Inc. Local Coverage Determination L33930 entitled Facet Joint Interventions for Pain Management, effective date April 25, 2021.
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 providers/suppliers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).
The rules say that once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses have a direct relationship to the residents current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. You can find this rule in the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual.
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 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, Publication 100-02, 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 Evidence of Coverage
(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 4-66 to 4-79 of the plan's 2022 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 removal or revision of a breast implant whether placed for reconstructive or cosmetic reasons, is considered medically necessary when it is removed for one of the following reasons: a. Mechanical complication of breast prosthesis; including rupture or failed implant, and/or implant extrusion. b. Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or rejection of breast implants. c. Other complication of internal breast implant; including siliconoma, granuloma, interference with diagnosis of breast cancer, and/or painful capsular contracture with disfigurement You can find this information in Medicare's Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L39051).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

It appears BiPAP with AVAPS has not been tried. Medicare does not cover a home ventilator when used as BiPAP. If the enrollee is benefiting from BiPAP, there is no reason to use a ventilator in addition. The denial is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the out-of-network twelve (12) month rental of non-invasive home ventilator (CPT code E0466RR), the purchase of a heated humidifier (CPT code E0562NU), water chamber for humidifier (CPT code A7046NU x 1), full face mask (A7030NU x1), nasal interface used with PAP device (CPT code A7034NU x 1)], tubing (CPT code A7037NU x 1), no disposable filter (CPT code A7039NU X 12), oxygen tubing (CPT code A4616 x 1), and disposable filter (CPT code A7038NU X 12) to be provided from dates of service January 27, 2022, through January 26, 2023.
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 for episodes beginning on or after July 1, 2013, HHAs must report where home health
services were provided. The location where services were provided must always be reported along with the first
visit reported on the claim. In addition to reporting a visit line using G codes, HHAs must report an additional
line item with the same revenue code and date of service, reporting one of the three Q codes (Q5001, Q5002,
and Q5009), one unit and a nominal covered charge (e.g., a penny). Q5001 should be reported for Hospice or
home health care provided in patient's home/residence. Q5002 is for Hospice or home health care provided in
assisted living facility. Q5009 is for Hospice or home health care provided in place not otherwise specified.
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual,
Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 40.2.
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 minimally-invasive surgical (MIS) fusion of the sacroiliac (SI) joint is considered medically necessary when ALL of the following criteria are met: Have moderate to severe pain with functional impairment and pain persists despite a minimum six months of intensive nonoperative treatment that must include medication optimization, activity modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip including a home exercise program Patient's report of typically unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized over the posterior SIJ, and consistent with SIJ pain A thorough physical examination demonstrating localized tenderness with palpation over the sacral sulcus (Fortin's point, i.e. at the insertion of the long dorsal ligament inferior to the posterior superior iliac spine or PSIS) in the absence of tenderness of similar severity elsewhere (e.g. greater trochanter, lumbar spine, coccyx) and that other obvious sources for their pain do not exist Positive response to a cluster of 3 provocative tests (e.g. thigh thrust test, compression test, Gaenslen's test, distraction test, Patrick's sign, posterior provocation test). Absence of generalized pain behavior (e.g. somatoform disorder) or generalized pain disorders (e.g. fibromyalgia) Diagnostic imaging studies that include ALL of the following: Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of destructive lesions (e.g. tumor, infection), fracture, traumatic SIJ instability, or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion Imaging of the pelvis (AP plain radiograph) to rule out concomitant hip pathology Imaging of the lumbar spine (CT or MRI) to rule out neural compression or other degenerative condition that can be causing low back or buttock pain At least 75 percent reduction of pain for the expected duration of two anesthetics (on separate visits each with a different duration of action), and the ability to perform previously painful maneuvers, following an image-guided, contrast-enhanced intra-articular SIJ injection. A trial of at least one therapeutic intra-articular SIJ injection (i.e. corticosteroid injection)
You can find this information in Medicare's Local Coverage Determination (LCD): Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint (L36406).
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 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 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 in Chapter 3 of the Plan's 2022 
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 Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, 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 a prefabricated oral appliance (E0485) will be denied as not reasonable and necessary. There
is insufficient evidence to show that these items are effective. You can find this in the Medicare Local
Coverage Determination (LCD) Oral Appliances for Obstructive Sleep Apnea (L33611).
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.