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 contract suppliers are not required to furnish a specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical outcome. A physician or treating practitioner (that is a physician assistant, clinical nurse specialist, or nurse practitioner) may prescribe, in writing, a particular brand of a competitively bid item or mode of delivery for an item if he or she determines that the particular brand or mode of delivery is necessary to avoid an adverse medical outcome for the beneficiary. The physician or treating practitioner must document in the beneficiary's medical record the reason why the specific brand or mode of delivery is necessary to avoid an adverse medical outcome. This documentation should include the following:

1. The product's brand name or mode of delivery
2. The features that this product or mode of delivery has versus other brand name products or modes 
of delivery; and
3. An explanation of how these features are necessary to avoid an adverse medical outcome.

You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 36, Section 30.4.

The rules say that if a physician or treating practitioner prescribes a particular brand or mode of delivery to avoid an adverse medical outcome, the contract supplier must either:

1. Furnish the particular brand or mode of delivery as prescribed by the physician or treating practitioner;
2. Consult with the physician or treating practitioner to find another appropriate brand of item or 
mode of delivery for the beneficiary and obtain a revised written prescription from the physician or 
treating practitioner; or
3. Assist the beneficiary in locating a contract supplier that can furnish the particular brand of 
item or mode of delivery prescribed by the physician or treating practitioner.

You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 36, Section 30.4.

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 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.
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 37-42 of the Plan's 2023 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 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.
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.

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 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 evaluation and management services on the day before major surgery (90-day postoperative period) or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery and, therefore, may be billed and paid separately. In addition to the CPT evaluation and management code, modifier "-57" (decision for surgery) is used to identify a visit which results in the initial decision to perform surgery.

If evaluation and management services occur on the day of surgery, the physician bills using modifier "-57," not "-25." The "-57" modifier is not used with minor surgeries because the global period for minor surgeries (10-day postoperative period) does not include the day prior to the surgery. Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.

You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, 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 state that the use of hyperbaric oxygen (HBO) therapy is covered as adjunctive therapy only after 
there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and 
must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds 
includes assessment of a patients vascular status and correction of any vascular problems in the affected limb 
if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to 
remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist 
dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present. 
Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 
consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. 
Continued treatment with HBO therapy is not covered if measurable signs of healing have not been 
demonstrated within any 30-day period of treatment. You can find this information in National Coverage 
Determination (NCD): Hyperbaric Oxygen Therapy (20.29). 
 
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 one treatment for lower urinary tract symptoms attributable to benign prostatic hyperplasia 
(LUTS/BPH) treatment is covered once in patients with both the following:  
1. Indications including all of the following: 
a. Age 50 
b. Symptomatic despite maximal medical management including all of the following: 
i. International Prostate Symptom Score (IPSS) 13 
ii. Maximum urinary flow rate (Qmax) of 15 mL/s (voided volume greater than 125 cc) 
iii. Failure, contraindication or intolerance to at least three months of conventional medical 
therapy for BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
c. Prostate volume of 30-80 cc, 
d. Poor candidate for other surgical interventions for BPH due to underlying disease (e.g., cardiac 
disease, pulmonary disease, etc.), or at high risk of bleeding 
2. No contraindications including all of the following: 
a. Known or suspected prostate cancer (based on NCCN Prostate Cancer Early Detection 
guidelines) or a prostate specific antigen (PSA) >10 ng/mL 
b. Active urinary tract infection 
c. History of bacterial prostatitis in the past three months 
d. Prior prostate surgery 
e. Neurogenic bladder 
f. Active urethral stricture (i.e., the source of the current LUTS) 
You can find this information in Local Coverage Determination (LCD): Water Vapor Thermal Therapy for 
LUTS/BPH (L37808). 
 
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 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). 
 
Therapeutic embolization is covered when done for hemorrhage, and for other conditions amenable to 
treatment by the procedure, when reasonable and necessary for the individual patient. Renal embolization for 
the treatment of renal adenocarcinoma continues to be covered, effective December 15, 1978, as one type of 
therapeutic embolization, to: 
 
    Reduce tumor vascularity preoperatively; 
    Reduce tumor bulk in inoperable cases; or 
    Palliate specific symptoms. 
 
You can find this information in the National Coverage Determination (NCD) Therapeutic Embolization 20.28. 
 
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 repeat epidural steroid injection (ESI) when the first injection directly and significantly 
provided improvement of the condition being treated may be considered medically reasonable and necessary 
when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement 
in function measured from baseline using SAME scale for at least three months. You can find this information 
in the Local Coverage Determination (LCD) for Epidural Steroid Injections for Pain Management (L33906). 
 
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 Medicare payment may be made for the replacement of prosthetic devices, which are 
artificial limbs, or for the replacement of any part of such devices, without regard to continuous use or useful 
lifetime restrictions if a treating practitioner determines that the replacement device, or replacement part of 
such a device, is necessary. 
 
Claims involving the replacement of a prosthesis or major component (foot, ankle, knee, socket etc.) must be 
supported by a new treating practitioner's order and documentation supporting the reason for the replacement. 
The reason for replacement must be documented by the treating practitioner, either on the order or in the 
medical record, and must fall under one of the following: 
 
    A change in the physiological condition of the patient resulting in the need for a replacement. Examples 
include but are not limited to, changes in beneficiary weight, changes in the residual limb, beneficiary 
functional need changes; or, 
    An irreparable change in the condition of the device, or in a part of the device resulting in the need for a 
replacement; or, 
    The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be 
more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced. 
 
The prosthetist must retain documentation of the prosthesis or prosthetic component replaced, the reason for 
replacement, and a description of the labor involved irrespective of the time since the prosthesis was provided 
to the beneficiary. This information must be available upon request. It is recognized that there are situations 
where the reason for replacement includes but is not limited to changes in the residual limb; functional need 
changes; or irreparable damage or wear/tear due to excessive beneficiary weight or prosthetic demands of very 
active amputees. 
 
You can find this information in the Local Coverage Article Standard Documentation Requirements for All 
Claims Submitted to DME MACs A55426. 
 
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 products reviewed by the Pricing, Data Analysis and Coding (PDAC) which do not meet the 
Durable Medical Equipment (DME) benefit category requirements must be coded as A9276, A9277, A9278, or 
A9279 and will be denied as non-covered (no Medicare Benefit). You can find this rule in the Local Coverage 
Article (LCA) for Glucose Monitor - Policy Article (A52464). 
 
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). 
 
The rules say that benefits are not available for endoluminal treatment for Gastroesophageal Reflux Disease 
(GERD) using the Stretta procedure, the Bard EndoCinchTM Suturing System, PlicatorTM, Enteryx or 
similar treatments as these procedures are not considered reasonable and necessary for the diagnosis or 
treatment of an injury or disease. Coverage is not available for LINX Reflux Management System, which is 
not a true endoluminal treatment but is also not considered reasonable and necessary for the diagnosis or 
treatment of an injury or disease. Currently, these procedures other than TIF are considered non-covered due to 
the fact that current peer-reviewed literature does not support the long-term efficacy and long-term safety of the 
services. Claims will be denied as "not proven effective." Current Procedural Terminology (CPT) 43257 - 
esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower 
esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease, is considered not 
medically necessary. You can find this rule in the Local Coverage Determination and Article for Select 
Minimally Invasive GERD procedures, L35080 and A56863. 
 
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 page 60 of the Plan's 2023 Evidence of Coverage.