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 when billing multiple units of a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code, providers must enter the actual number of units provided on the claim form. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.4. 

 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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with
BOTH the following:

1. Inclusion criteria (ALL are required):

a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1 - L5) by recent (within 30 days)
advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake)
b. Symptomatic (ONE):
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain
score  8)
ii. Non-hospitalized with moderate to severe pain (NRS or VAS 5) despite optimal non-surgical
management (NSM)* (ONE):

1. Worsening pain

2. Stable to improved pain (but NRS or VAS still 5) (with  2 of the following):

A. Progression of vertebral body height loss
B. > 25% vertebral body height reduction
C. Kyphotic deformity
D. Severe impact of VCF on daily functioning (Roland Morris Disability
Questionnaire (RDQ) >17)
* consider including pedicle periosteal infiltration

c. Continuum of care (BOTH):

1.
i. All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis
education for subsequent treatment as indicated.
ii. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment
program.

2. Exclusion criteria (Can have NONE of the following):

a. Absolute contraindication

1.
i. Current back pain is not primarily due to the identified acute or subacute VCF(s)
ii. Osteomyelitis, discitis or active systemic or surgical site infection
iii. Pregnancy

b. Relative contraindication

1.
i. Allergy to bone cement or opacification agents
ii. Uncorrected coagulopathy
iii. Spinal instability
iv. Myelopathy from the fracture
v. Neurologic deficit
vi. Neural impingement
vii. Fracture retropulsion/canal compromise
viii. Greater than three vertebral fractures

You can find this in the Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation (PVA)
for Osteoporotic Vertebral Compression Fracture (VCF) (L38737).

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 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 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. The health plan contract says that Entyvio is subject to step therapy. The member must meet the following criteria: has tried or cannot use Stelara (step therapy requirement). You can find this rule in the plan's step therapy policy.
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 self-care 
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.

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 group 2 support surface is covered if the beneficiary meets at least one of the following
three criteria (1, 2, or 3):
1. The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis which have failed to
improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment
program including each of the following:
a. Use of an appropriate group 1 support surface
b. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and
c. Appropriate turning and positioning, and
d. Appropriate wound care
e. Appropriate management of moisture/incontinence, and
f. Nutritional assessment and intervention consistent with the overall plan of care
2. The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis
3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the
past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses),
and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing
facility within the past 30 days
You can find this rule in Local Coverage Determination (LCD): Pressure Reducing Support Surfaces - Group 2
(L33642) - Effective January 1, 2020.
Medicare rules state that a total electric hospital bed is not covered. The height adjustment feature is a
convenience feature. You can find this rule in the DME MAC Local Coverage Determination L33820, Hospital
Beds and Accessories (effective October 1, 2015).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that an expandable controller is capable of accommodating one or more of the following additional functions: a. Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) b. Non-proportional input devices (e.g., sip and puff, head array, etc.) c. 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: d. A separate display (i.e., for alternate control devices) e. Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control) f. An attendant control You can find this rule in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that genomic derived tests that assess risk in localized prostate cancer are considered reasonable and necessary to help identify men with localized Prostate Cancer and a life expectancy of at least 10 years who are good candidates for active surveillance according to the most recent National Comprehensive Cancer Network (NCCN) guidelines. Testing is covered for men with prostate cancer:
- With localized or biochemically recurrent adenocarcinoma of the prostate (i.e., no clinical evidence of metastasis) who have a life expectancy of greater than or equal to 10 years if they are a candidate for and are considering (or being considered for) at least 1 of the following:
~ Conservative management and yet would be eligible for definitive therapy (radical prostatectomy (RP), radiation or brachytherapy), or;
~ Radiation therapy and yet would be eligible for the addition of a brachytherapy boost, or;
~ Radiation therapy and yet would be eligible for the addition of short-term androgen deprivation therapy (ADT), or;
~ Radiation therapy with short-term ADT yet would be eligible for the use of long term ADT, or;
~ Radiation with standard aADT yet would be eligible for systemic therapy intensification using next generation androgen signaling inhibitors or chemotherapy, or;
~ Observation post-prostatectomy yet would be eligible for the addition of post-operative adjuvant radiotherapy, or;
~ Salvage radiotherapy post-prostatectomy yet would be eligible for the addition of ADT.
- The following criteria must also be met for coverage:
~ The assay is performed on formalin-fixed paraffin embedded (FFPE) prostate biopsy tissue with at least 0.5 mm of linear tumor diameter or FFPE tissue from a prostate resection specimen, and;
~ Result will be used to determine treatment according to established practice guidelines, and;
~ Patient has not received pelvic radiation or ADT prior to the biopsy or prostate resection specimen, and;
~ Patient is monitored for disease progression according to established standards of care.
Other genomic tests that demonstrate an equivalent analytical validity and clinical validity will be considered reasonable and necessary for the same indications. Analytical and clinical validity will be assessed as part of a thorough and comprehensive technical assessment (TA) by the MolDX program and will similarly attain coverage for indications that are supported by the evidence and intended use within the scope of this policy. You can find these rules in Local Coverage Determination (LCD) MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (L38433).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that 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:

- Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale; and
- Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive conservative care management (as tolerated); and
- Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst); and
- 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.

Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who meet all of the following criteria:

- The patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with each one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used); and
- Subsequent therapeutic facet joint procedures at the same anatomic site result in at least consistent 50% pain relief for at least three (3) months from the prior therapeutic procedure or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale; and
- Documentation of why the patient is not a candidate for radiofrequency ablation (such as established spinal pseudarthrosis, implanted electrical device) is in the medical record.

You can find these rules in 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 a Group 3 PWC with no power options (K0848, K0849, K0850, K0851, K0852, K0853,
K0854, K0855) is covered if:
A. All of the coverage criteria (a)-(e) for a PWC are met; and
B. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital
skeletal deformity; and
C. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical
professional, such as a PT or OT, or practitioner who has specific training and experience in
rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and
its special features (see Documentation Requirements section). The PT, OT, or practitioner may have no
financial relationship with the supplier; and
D. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology
Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the
wheelchair selection for the beneficiary.
If a Group 3 PWC is provided and if criteria (IV)(A) - (IV)(D) are not met, it will be denied as not reasonable
and necessary.
A Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with Multiple Power
Options (K0861, K0862, K0863, K0864) is covered if:
A. The Group 3 criteria IV(A) and IV(B) are met; and
B. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A]
and III[B]) (respectively) are met.
If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or (V)(B)
is not met, it will be denied as not reasonable and necessary. You can find this rule at Local Coverage
Determination (LCD) L33789: Power Mobility Devices (eff. 1/1/20).
The rules say that 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 this rule in the Local Coverage Article:
Wheelchair Options/Accessories - Policy Article (A52504) (eff. 1/1/20).
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 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 does not include 
implants. You can find this information on page 101 of the Plan's 2022 Evidence of Coverage (EOC).