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 psychiatry and psychology services have an individualized treatment plan. The treatment 
plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the 
diagnoses and anticipated goals. Services must be for the purpose of diagnostic study or reasonably be expected 
to improve the patients condition. The treatment must, at a minimum, be designed to reduce or control the 
patient's psychiatric symptoms so as to prevent relapse or hospitalization, and improve or maintain the patient's 
level of functioning. You can find this information in the Local Coverage Determination (LCD) for Psychiatry 
and Psychology Services (L33632). 
 
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 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 $275 copayment for surgery or other services provided to you at an 
outpatient hospital. You can find this information on pages 4-50 to 4-55 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. 
 
The rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the 
following conditions are met (42 CFR 422.100(l)): 
 
The MA plan provides all categories of DME covered under original Medicare Part B; 
The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
The MA plans contracted suppliers provide access to all preferred DME brands; 
During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 90-
day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year; 
Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the EOC and ANOC and on its website; and 
The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by CMS to require full coverage. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-16, Medicare Managed Care Manual, Chapter 4, 10.12.2. 
 
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 glucose monitors and blood glucose test strips is limited to the OneTouch products manufactured 
by LifeScan, Inc. Please note, there is no preferred brand for lancets or glucose control solutions. Covered 
therapeutic Continuous Glucose Monitors (CGMs) include Dexcom and FreeStyle Libre products. You can 
find this information in Chapter 4 on page 73 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 cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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 the Schnur sliding scale is an evaluation method for physicians to use on individuals 
considering breast reduction surgery. If the individual's body surface area and weight of breast tissue removed 
fall above the 22nd percentile, then the surgery is considered medically reasonable and necessary with the 
appropriate criteria. The scale abbreviated below allows a rough estimate of the minimal amount of soft tissue 
to be removed to justify surgery to alleviate symptoms based on body surface area; breast tissue may be 
removed from the other breast in order to achieve symmetry. You can find this rule in Local Coverage 
Determination (LCD) Cosmetic and Reconstructive Surgery L35090. 
 
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 molecular diagnostic tests used to assist in risk stratification of melanoma patients are covered 
when ALL of the following are true: 
 
    The patient has a personal history of melanoma AND: 
        Either: 
            Has Stage T1b and above OR 
            Has T1a with documented concern about adequacy of microstaging 
        Is undergoing workup or being evaluated for treatment, AND 
        Does not have metastatic disease AND 
        Presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, histological, or other 
information is >5% AND 
        Has a disease stage, grade, and Breslow thickness (or other qualifying conditions) within the intended use 
of the test 
    The TEST has demonstrated, as part of a Technical Assessment: 
        Clinical validity of analytes tested in predicting metastatic disease (or the absence of metastatic disease) in 
peer-reviewed scientific literature 
        Utility beyond clinical, histological, and radiographical factors in the ability to accurately stratify patients 
into risk groups to manage patient care, such by precluding unnecessary sentinel lymph node biopsies 
        Appropriate analytical validity 
        Performance characteristics equivalent or superior to other covered, similar tests. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): MolDX: Melanoma Risk 
Stratification Molecular Testing (L37748). 
 
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 on pages 45-46 of the Plan's 2022 
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 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 multiple medical visits on the same day in the same revenue center may be submitted on 
separate claims. Hospitals should report condition code G0 on the second claim. Appropriate reporting of 
Condition Code G0 allows for accurate payment under OPPS in this situation. The OCE contains an edit that 
will reject multiple medical visits on the same day with the same revenue code without the presence of 
Condition Code G0. You can find this information in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, 180.4. 
 
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 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 on pages 11 and 47 of the Plan's 
2022 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 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 Plan 
contract says that they have a link that will take you to a list of Part B Drugs that may be subject to Step 
Therapy. You can find this information in Chapter 4 on page 104 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 for parenteral nutrition to be considered reasonable and necessary, the treating practitioner 
must document that ENTERAL nutrition has been considered and ruled out, tried and been found ineffective, 
or that EN exacerbates gastrointestinal tract dysfunction. The beneficiary must have (a) a condition involving 
the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients or (b) 
disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to be 
transported through and absorbed by the gastrointestinal (GI) system. The beneficiary must have a permanent 
impairment. The treating practitioner is required to evaluate the beneficiary within 30 days prior to initiation of 
parenteral nutrition. If the treating practitioner does not see the beneficiary within this timeframe, they must 
document the reason why and describe what other monitoring methods were used to evaluate the beneficiary's 
parenteral nutrition needs. There must be documentation in the medical record supporting the clinical 
diagnosis. You can find this rule in the Local Coverage Determination (LCD) Parenteral Nutrition L38953. 
 
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 20% coinsurance for covered items and related supplies. You can find 
this information in Chapter 4 on page 80 of the Plan's 2022 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 Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 hearing aids purchased outside of the Plan network are not covered. You can find this 
information on page 4-24 of the Plan's 2022 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 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 Guidance Manual, Section 50.12.1. 
 
The rules say that for periods beginning on or after January 1, 2021 through December 31, 2021, all home 
health agencies (HHAs) must submit a request for anticipated payment within 5 calendar days after the start of 
care date for initial 30-day periods and within 5 calendar days after the from date for each subsequent 30-day 
period of care, which is set at 0 percent at the beginning of every 30-day period. HHAs receive a single 
payment for a 30-day period of care after the final claim is submitted. You can find this rule at 42 CFR Section 
484.205.  
 
The rules say that HHAs shall no longer submit Requests for Anticipated Payment (RAPS -TOB 0322) for any 
HH period of care with a From date on or after January 1, 2022. Instead, for each admission to home health, the 
HHA notifies Medicare systems via submission of a Notice of Admission (NOA). You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 10, Section 10.1.10.3. 
 
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 an ultrasonic osteogenesis stimulator (E0760) is covered only if all of the following criteria are 
met: 
 
        Nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to starting 
treatment with the osteogenesis stimulator, separated by a minimum of 90 days. Each radiograph set must 
include multiple views of the fracture site accompanied by a written interpretation by a treating practitioner 
stating that there has been no clinically significant evidence of fracture healing between the two sets of 
radiographs; and 
        The fracture is not of the skull or vertebrae; and 
        The fracture is not tumor related. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Osteogenesis Stimulators 
(L33796). 
 
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, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
The rules say a brace includes rigid and semi-rigid devices which are used for the purpose of supporting a weak 
or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. Elastic 
stockings, garter belts, and similar devices do not come within the scope of the definition of a brace. You can 
find this rule in Medicare Benefits Policy Manual Chapter 15 Section 130 - Leg, Arm, Back, and Neck Braces, 
Trusses, and Artificial Legs, Arms, and Eyes. 
 
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 page 44 of the Plan's 2022 
Evidence of Coverage.