Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare 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.
The rules say that alginate or other fiber gelling dressing covers are covered for moderately to highly exudative
full thickness wounds (e.g., stage 3 or 4 ulcers); and alginate or other fiber gelling dressing fillers for
moderately to highly exudative full thickness wound cavities (e.g., stage 3 or 4 ulcers). They are not reasonable
and necessary on dry wounds or wounds covered with eschar. Dressing change is up to once per day. One
wound cover sheet of the approximate size of the wound or up to 2 units of wound filler (1 unit = 6 inches of
alginate or other fiber gelling dressing rope) is used at each dressing change. You can find this rule in the Local
Coverage Determination for Surgical Dressings, L33831 (eff. 05/01/21).
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 the deep brain stimulation (DBS) is not reasonable and necessary and is not covered for ET or PD
patients with any of the following:
Cognitive impairment, dementia, or depression, which would be worsened by or would interfere with the
patient's ability to benefit from DBS. You can find this information in Medicare's National Coverage
Determination (NCD): Deep Brain Stimulation for Essential Tremor and Parkinson's Disease (160.24).
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 MRIs are covered when medically necessary and reasonable for the diagnosis or treatment of
the specific patient involved. You can find this rule in the Centers for Medicare and Medicaid Services, Internet
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 220.2(B).
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 tests evaluated through the application process and/or technical assessment will be reviewed to answer the following questions: 1. Is the test performed in the absence of clinical signs and symptoms of disease? 2. Will the test results provide the clinician with information that will improve patient outcomes and/or change physician care and treatment of the patient? 3. Will the test results confirm a diagnosis or known information? 4. Is the test performed to determine risk for developing a disease or condition? 5. Will risk assessment change management of the patient? 6. Is there a diagnosis specific indication to perform the test? 7. Is the test performed to measure the quality of a process or for Quality Control/Quality Assurance (QC/QA), i.e., a test to ensure a tissue specimen matches the patient? You can find this rule in the Local Coverage Determination (LCD) - MolDX: Molecular Diagnostic Tests (MDT) (L36256) - Effective November 1, 2019.
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 pay for durable medical equipment that is needed for use in the home. 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(D).  The rules say that Medicare considers equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment already available to an enrollee. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(C).  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 417.414.  The rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 10.1.2.  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 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 codes billed that have a status indicator of "I" are not valid for Medicare purposes. Medicare 
uses another code for reporting of and payment for these services. You can find this rule at Centers for 
Medicare and Medicaid Services, Internet-only Manual, Publication 100-04, Medicare Claims Processing 
Manual Chapter 23, Section 30.2.2.
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 say that the treatment lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH) will
be considered reasonable and necessary when performed ONCE in patients with the following:
1. Indications including ALL of the following:
a. Age under 80
b. Prostate volume of 30-150 cc by transrectal ultrasound (TRUS)
c. Persistent moderate to severe symptoms despite maximal medical management including ALL of the
following
i. International Prostate Symptom Score (IPSS) 12 or more
ii. Maximum urinary flow rate (Qmax) of =15 mL/s4 (voided volume greater than 125 cc)
iii. Failure, contraindication, or intolerance to at least 3 months of conventional medical therapy for
LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride)
2. Only treatment using a Food and Drug Administration (FDA) approved/cleared device will be considered
reasonable and necessary.
You can find this rule in the Local Coverage Determination (LCD) - Transurethral Waterjet Ablation of the
Prostate (L38549) - Effective December 27, 2020.
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 in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection. You can find this rule at Wisconsin Physician Service Insurance Corporation Local Coverage Article A58777 entitled Billing and Coding: Epidural Steroid Injections for Pain Management. The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You can find this in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.3.2.1.
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.
Oncotype DX Breast was developed for patients with the following findings:
- estrogen-receptor positive, node-negative carcinoma of the breast
- estrogen-receptor positive micrometastases of carcinoma of the breast, and
- estrogen-receptor positive breast carcinoma with 1-3 positive nodes.
You can find this rule in the Centers for Medicare and Medicaid Services, Local Coverage Article: Billing and Coding: MolDX: Oncotype DX Breast Cancer Assay (A54480).
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 claims for services furnished on or after January 1, 2010, must be filed no later than the close 
of the period ending 1 calendar year after the date of service. You can find this rule at 42 CFR Section 
424.44(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.
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion 
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the 
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. 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 290(3).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that when durable medical equipment (DME) is furnished for use in a skilled nursing facility 
during a covered Part A stay, no separate payment is made for the DME, since the DME is already included in 
the payment that the nursing facility receives for the covered stay itself. You can find this rule at Centers for 
Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 20, Section 211.1.
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 magnetic resonance imaging scans (MRIs) are covered when medically necessary and 
reasonable for the diagnosis or treatment of the specific patient involved. You can find this rule in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determinations Manual, Section 220.2(B).
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 transforaminal ESIs (TFESIs) involving a maximum of two (2) levels in one spinal region 
are considered medically reasonable and necessary. It is not considered medically reasonable and necessary to 
perform TFESIs at more than two (2) nerve root levels during the same session. No more than 2 TFESIs should 
be performed at a single setting (e.g., single level bilaterally or two levels. You can find this information in the 
Local Coverage Determination (LCD): Epidural Steroid Injections for Pain Management (L33906).
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 page 43 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 Medicare will not pay self-help devices. 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.
The rules say that oximeters are not covered because they are precautionary monitoring devices that provide
information to physicians to assist in managing the patient's treatment. You can find this rule in the Medicare
Local Coverage Article: Oxygen and Oxygen Equipment - Policy Article - Effective October 2015 (A52514).
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 Plan
contract also says that covered, non-routine dental care is limited to surgery of the jaw or related structures,
setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of
neoplastic cancer disease, or services that would be covered when provided by a physician. You can find this
information on page 4-45 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 state that pneumatic compression devices coded as E0675 are only covered for the treatment of peripheral artery disease. Use of this device for any other condition will be denied as not reasonable and necessary. Accessories coded with E0673 is only covered when the compression device itself is covered. You can find this rule at CGS Administrators, LLC, Local Coverage Determination L33829 entitled Pneumatic Compression Devices, effective January 1, 2020.
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 pays for care in a skilled nursing facility (SNF) when all of the following four 
factors are met:
1. The patient requires skilled nursing or skilled rehabilitation services;
2. The patient requires these services on a daily basis;
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and
4. The services are reasonable and necessary for the treatment of the patient's illness or injury or the services 
must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from 
getting worse. 
You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30. 
The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need 
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of 
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, 
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also 
custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110.
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.