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.  

A pneumatic compression device (PCD) coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when all of the following are met:  

1. The beneficiary has lymphedema of an extremity.  
2. The coverage criteria for an E0650 or E0651 PCD are met.  
3. The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial.  

A four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651 is required. The four-week trial of conservative therapy must include all of the following:  

- At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 PCD after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided 
- Compliant use of an appropriate compression bandage system or compression garment to provide adequate graduated compression 
- Regular exercise 
- Elevation where appropriate 
- Manual lymphatic drainage (where available) and self-manual lymphatic drainage (MLD) for at least 30 minutes per day 
- Evaluation of diet and implementation of any necessary change - Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.) 
- Correction (where possible) of anemia and/or hypoproteinemia  

You can find this information at Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).  

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 up to $750 every year for non-Medicare covered preventive dental services and non-Medicare covered comprehensive dental services combined. You are responsible for any amount above the dental coverage limit. You can find this information on page 67 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 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 $0 for days 1 to 20 of a benefit period, $178 per day for days 21 to 59 of a benefit period, and $0 for days 60 to 100 of a benefit period for Skilled Nursing Facility (SNF) care. You can find this information on pages 108 and 109 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.  Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. This rule does not apply to:   1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;   2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL; and   3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with an IOL.  You can find this rule at 42 CFR Section 411.15(b).   Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR Section 411.15(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. The Plan contract also says that vision services must be rendered with an in-network provider. You can find this information on page 112 of the Plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  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 also says that the benefit for an abdominal aortic aneurysm includes a one-time screening ultrasound for people at risk. The plan only covers this screening if you have certain risk factors and if you get a referral for it from your physician, physician assistant, nurse practitioner, or clinical nurse specialist. You can find this information on page 54 of the Plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  Medicare rules state that genes not identified as having actionable use are not considered reasonable and necessary. The algorithms employed in combinatorial testing are also not currently considered reasonable and necessary components of multi-gene testing. Pharmacogenomic testing is not covered when a treating clinician is not considering treatment with a medication that has an actionable drug-gene interaction, or when the use of a medication with a drug-gene interaction is not reasonable and necessary. In order for services to be covered, the patient's medical record must clearly reflect the following: - The patient has a diagnosis for which pharmacologic therapy is reasonable and necessary, and the drug or drugs that the clinician is considering using must be reasonable and necessary for the treatment of the patient's diagnosis. - The clinician has made an initial personalized decision for the patient based on the patient's diagnosis, the patient's other medical conditions, other medications the patient is taking, professional judgement, clinical science and basic science pertinent to the drug (e.g. mechanism of action, side effects), the patient's past medical history and when pertinent family history and the patient's preferences and values. - The provider performing the service must have a record of what drug(s) is/are being considered and for what indication(s) to ensure the test performed is reasonable and necessary.  You can find these rules in Local Coverage Determination (LCD) MolDX: Pharmacogenomics Testing (L38394).  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 $300 copayment for each of the first six days of an inpatient stay. There is a $0 copayment for additional days. You can find this information on pages 72-74 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 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 $250 copayment per inpatient hospital admission. Copayment applies on the date of hospital admission. You can find this information on page 74 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 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).  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.
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.  Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. This rule does not apply to:   1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;   2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL; and   3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with an IOL.  You can find this rule at 42 CFR Section 411.15(b).   Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR Section 411.15(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. The contract says that you have $150 vision allowance for routine contact lenses or eyewear every year. This benefit is administered on a rolling calendar year since your last date of service. You can find this information on page 107 of the Plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  The rules say that in order for coverage of negative pressure wound therapy (NPWT) to continue, a licensed medical practitioner must do the following:  1. On a regular basis:  a. Directly assess the wound(s) being treated with the NPWT pump, and b. Supervise or directly perform the NPWT dressing changes, and  2. On at least a monthly basis, document changes in the ulcer's dimensions and characteristics.  If these criteria are not fulfilled, continued coverage of the NPWT pump and supplies will be denied as not reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD) - Negative Pressure Wound Therapy Pumps (L33821) - Effective May 1, 2021.  The rules say that coverage for a negative pressure wound therapy will end, and be denied as not reasonable and necessary with any of the following, whichever occurs earliest:  1. The criteria above cease to occur 2. In the judgment of the treating practitioner, adequate wound healing has occurred to the degree that NPWT may be discontinued, 3. Any measurable degree of wound healing has failed to occur over the prior month. Wound healing is defined as improvement occurring in either surface area (length times width) or depth of the wound 4. 4 months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) have elapsed using a NPWT pump in the treatment of the most recent wound 5. Once equipment or supplies are no longer being used for the beneficiary, whether or not by the treating practitioner's order  You can find this rule in the Local Coverage Determination (LCD) - Negative Pressure Wound Therapy Pumps (L33821) - Effective May 1, 2021.  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  The rules say that 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. The contract lists the specific dental services that are covered. Caries risk assessment and documentation is not listed and therefore is not a covered service. The contract also says that you receive a comprehensive oral evaluation once every 6 months. The contract also says you receive a periodontal scaling and root planning, four or more teeth per quadrant once every 24 months, per arch. You can find this information on pages 87-89 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 Abdominal Lipectomy/Panniculectomy:        Panniculectomy will be considered medically necessary when the pannus or panniculus hangs below the level of the pubis, and the medical records document that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing that consistently recurs or remains refractory to appropriate medical therapy (e.g. topical antifungals, corticosteroids, antibiotics) over a period of 3 months.12         When surgery is performed to alleviate such complicating factors as inability to walk normally due to pannus size, chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, such surgery is considered reconstructive. Preoperative photographs may be required to support justification and should be supplied upon request.12         This procedure may also be medically necessary for the patient that has had a significant weight-loss following the treatment of morbid obesity, in addition to meeting the criteria noted above, there should be evidence that the individual has maintained a stable weight for at least 6 months. If the weight loss is the result of bariatric surgery, abdominoplasty/panniculectomy should not be performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the most recent 6 months and infection and inflammation has continued for the most recent 3 months.12  Limitations  Abdominal Lipectomy/Panniculectomy      Repairing abdominal wall laxity, or diastasis recti     Redundancies resulting from weight loss or weight loss surgery when that tissue is without evidence of chronic infection or inflammation that is refractory to conservative treatment as outlines in the indications listed above.     Solely to improve appearance     All other indications unless covered in the section above  Note: Abdominal Lipectomy/Panniculectomy is considered experimental and investigational for minimizing the risk of hernia formation or recurrence. There is no evidence that pannus contributes to hernia formation. The primary cause of hernia formation is an abdominal wall defect or weakness, not a pulling effect from a large or redundant pannus. You can find this information in Medicare's Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L39051).  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 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.  

Medicare rules state that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). For example, an independent laboratory taking a sample in its laboratory reports "81" as Place of Service. You can find this rule in Medicare Claims Processing Manual Chapter 26, Section 10.6.  

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.