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 Part B generally does not pay for drugs that are usually self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are:  1. blood-clotting factors;  2. drugs used in immunosuppressive therapy; 3. erythropoietin for dialysis patients;  4. osteoporosis drugs for certain homebound patients; 5. certain oral cancer drugs;  6. oral anti-emetics used in certain situations;  7. drugs treated as supplies during an outpatient hospital procedure; and  8. drugs required for the effective use of durable medical equipment. 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, Sections 50, 50.2, 50.5, and 110.3.  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.
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 contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes one comprehensive exam every three plan years. You can find this information on pages 4-56 to 4-57 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  The rules say that the provider must notify the enrollee in writing before a Medicare plan ends coverage of skilled nursing facility services. A Notice of Medicare Non-Coverage (NOMNC) must be issued no later than two days before the last covered day. The notice must state:     1. The date that coverage of services ends, 2. The date that the enrollee must begin to pay for the services, and 3. A description of the enrollee's right to a fast-track appeal and other appeal procedures. The Medicare plan must continue to cover services until two days after valid notice is delivered. You can find this rule at 42 CFR Section 422.624.  The rules say that notification of changes for an enrollee who is incapable of receiving or incompetent to receive the notice must be made to a representative of the enrollee. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 260.3.8.  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 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; and  3. be supervised and evaluated by a physician.   You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 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 ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive pulmonary disease (COPD). You can find this rule in the Centers for Medicare and Medicaid Services, Internet     Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.1.  The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device is made based upon the specifics of each person's medical condition. There must be enough detailed information in the medical record to justify the treatment selected. You can find this rule in the Local Coverage Determination (LCD): Respiratory Assist Devices (L33800).  The rules say that Medicare will pay for durable medical equipment (DME) that is reasonable and necessary for treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment already available to an enrollee. 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(C).  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 contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 20% coinsurance for restorative services, endodontics, periodontics, and extractions. You can find this information on pages 67-68 of the Plan's 2021 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 an epidural steroid injection (ESI) will be considered medically reasonable and necessary when there is a history, physical examination, and concordant radiological image-based diagnostic testing supporting lumbar, cervical or thoracic radiculopathy; radicular pain or neurogenic claudication due to central disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis; post-laminectomy syndrome; or acute herpes zoster associated pain. The radiculopathy, radicular pain, or neurogenic claudication must be severe enough to greatly impact quality of life or function. There also must be a pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes zoster refractory to conservative management where a four (4) week wait is not required. You can find these rules in Local Coverage Determination:  Epidural Steroid Injections for Pain Management (L38994).  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 Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL of the following criteria: 1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale11; AND* 2. Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive conservative care management (as tolerated)4,12; AND 3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)4,7; AND 4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity.11 *Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for functional assessment (if patient qualifies for treatment). You can find this rule in the Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892).  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 plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and     Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Grievance Manual, Section 50.12.1.  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 therapeutic continuous glucose monitors (CGMs) and related supplies are covered by Medicare when all of the following coverage criteria are met:   1. The beneficiary has diabetes mellitus,   2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump,   3. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results,   4. 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 (1-3) above are met; and,   5. 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.  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.  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 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.   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 Sections 422.2 and 422.136.  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You can find this information on pages 98-99 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 Standing Tables: Deny - convenience item; not primarily medical in nature (Section 1861(n) of
the Act). You can find this information in Medicare's National Coverage Determination (NCD): Durable
Medical Equipment Reference List (280.1).
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 coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee. This information must be retained in the treating practitioner's or prosthetist's files. This rule can be found in Local Coverage Determination LCD Lower Limb Prostheses L33787.  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 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.
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 Sections 422.2 and 422.136.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals.
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You
can find this information in Chapter 4 on page 70 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 list the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes that support medical necessity and provide limited coverage for Current Procedural Terminology (CPT) codes 93880 and 93882. It is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. You can find this information in the Local Coverage Article: Billing and Coding: Non-invasive Extracranial Arterial Studies (A57670).  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 each endovenous ablation approach has advantages and disadvantages; which one is best depends on the unique clinical/anatomical scenario. While saphenous vein ligation and stripping remains an important option in selected cases, it has been largely supplanted by endovenous ablation therapy as primary treatment of saphenous (axial/truncal) vein incompetence. The treatments to eliminate the saphenous vein reflux will be considered medically necessary if the patient remains symptomatic after a six-week trial of conservative therapy and has reflux in a saphenous vein.
The treatments for symptomatic varicose tributaries are either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater than than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative therapy. The components of the conservative therapy include, but are not limited to:
- weight reduction,
- a daily exercise plan,
- periodic leg elevation, and
- the use of graduated compression stockings.
The conservative therapy must be documented in the medical record. Inability to tolerate compressive bandages or stockings and the reason for such intolerance must be documented in the medical record. The patient is considered symptomatic if any of the following signs and symptoms of significantly diseased vessels of the lower extremities are documented in the medical record:
- stasis ulcer of the lower leg,
- significant pain and significant edema that interferes with activities of daily living,
- bleeding associated with the diseased vessels of the lower extremities,
- recurrent episodes of superficial phlebitis,
- stasis dermatitis, or
- refractory dependent edema.
Coverage of endovenous ablation therapy is limited to patients with:
- a maximum vein diameter of 12 mm for CAE, PEM and MOCA; and
- absence of thrombosis or vein tortuosity, which would impair catheter advancement (except for PEM).
You can find this rule in the Centers for Medicare and Medicaid Services, Local Coverage Determination
(LCD): Treatment of Varicose Veins of the Lower Extremity (L33575).
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