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 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 in Chapter 4 of the Plan's 2023 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 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 36 of the Plan's 2023 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 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.
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 determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary's potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to:
  1. The beneficiary's past history (including prior prosthetic use if applicable); and 
  2. The beneficiary's current condition including the status of the residual limb and the nature of other medical problems; and 
  3. The beneficiary's desire to ambulate.

Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels:

Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.

The records must document the beneficiary's current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications. You can find this rule at Local Coverage Determination (LCD) L33787: Lower Limb Prostheses (eff. 1/1/20).

The rules say that a protective outer surface covering systems (L5962, L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are used by a beneficiary who has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707. They are not for cosmetic or convenience reasons, or for everyday usage in a typical environment. Protective outer surface coverings are different from the covering that is already reimbursed as part of L5704, L5705, L5706, and L5707.

Codes L5968, L5982, L5984, L5985, L5986 and L5988 describe separate products which provide either a single motion or a combination of motions generally attributed to functional movement of the lower limb during ambulation. The use of these codes can be used to fully describe additional features or functions not found in the prosthetic foot system (L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979 L5980, L5981 and L5987). You can find these rules at Local Coverage Article (LCA) A52496: Lower Limb Prostheses (eff. 8/1/20).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that a determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary's potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to:
  1. The beneficiary's past history (including prior prosthetic use if applicable); and 
  2. The beneficiary's current condition including the status of the residual limb and the nature of other medical problems; and 
  3. The beneficiary's desire to ambulate.

Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels:

Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.

The records must document the beneficiary's current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications. You can find this rule at Local Coverage Determination (LCD) L33787: Lower Limb Prostheses (eff. 1/1/20).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that 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.
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 effective for claims with dates of service July 1, 2007 and after, the non-Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. This integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital claims, through a single integrated OCE eliminating the need to update two separate OCE software packages on a quarterly basis. The integrated OCE does not change the current logic that is applied to outpatient bill types that already pass through the OPPS OCE software. It merely expands the software usage to include non-OPPS hospitals. This new software product will be referred to as the Integrated OCE (I/OCE).
You can find this rule in the Medicare Claims Processing Manual, Chapter 4, Section 40.1.

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 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).

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).

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 30-day period of care is the unit of payment for the home health prospective 
payment system (HH PPS). The period of care payment is specific to one individual homebound 
beneficiary. It pays all Medicare covered home care that is reasonable and necessary for the 
patient's care, including routine and nonroutine supplies used by that beneficiary during the 
period of care. It is the only Medicare form of payment for such services. Home health agencies 
(HHAs) shall no longer submit Requests for Anticipated Payment (RAPS -Type of Bill 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).

For all beneficiaries receiving HH services in 2021 whose services will continue in 2022, the HHA 
shall submit an NOA with a one-time, artificial 'admission' date corresponding to the "From" date 
of the first period of continuing care in 2022. Only one NOA is required for any series of HH 
periods of care beginning with admission to home care and ending with discharge. After a discharge 
has been reported to Medicare, a new NOA is required before the HHA submits any additional claims.

You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.1.4 and 
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 that for all beneficiaries receiving home health services in 2021 whose services will continue in 2022, the home health agency (HHA) shall submit a Notice of Admission (NOA) with a one-time, artificial 'admission' date corresponding to the "From" date of the first period of continuing care in 2022. For example, if a period of care begins in 2021 and ends on January 10, 2022, the HHA submits an NOA with an admission date of January 11, 2022, and then submits a claim when the 30-day period of care is over. The HHA should submit the January 11, 2022, admission date on all subsequent claims until the beneficiary is discharged and another NOA is required. This is to ensure the claim is matched to the correct NOA and the correct receipt date is used for payment. You can find this information 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 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. 
 
The rules say that Prolia is allowed under the following circumstances: 
 
1. criteria for the diagnosis of osteoporosis is met, and 
2. there is a history of treatment as related to progression of disease and ongoing risk factors, and 
3. The patient meets the definition of osteoporosis with high risk for fracture, or 
4. The patient has failed or is intolerant of other available osteoporotic therapy 
 
You can find this rule in the Local Coverage Determination (LCD) - Bisphosphonates (Intravenous [IV]) and 
Monoclonal Antibodies in the Treatment of Osteoporosis and Their Other Indications (L33270). 
 
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 $125 copayment for Medicare-covered radiological 
diagnostic services, not including X-rays, performed in a physician's office or at a free-standing 
facility under the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. You can find this information on page 4-34 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 state that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive 
control system, it will be denied as non-covered. (See the related LCD for situations in which it is provided in 
place of a beneficiary-operated system.) 
 
An attendant control is one which allows a caregiver to drive the wheelchair instead of the beneficiary. The 
attendant control is usually mounted on one of the rear canes of the wheelchair. This code is limited to 
proportional control devices, usually a joystick. Code E2331 is used when an attendant control is provided in 
addition to a beneficiary-operated drive control interface. 
 
You can find this information in the Local Coverage Article Wheelchair Options/Accessories - Policy Article 
A52504. 
 
Wheelchair seat and back cushion codes are all-inclusive. Use of HCPCS code K0108 or any other HCPCS 
code to separately bill for added components such as the foam blocks, gel packs, air cells, or equivalent 
material is incorrect coding. 
 
You can find this information in the Local Coverage Article Wheelchair Seating - Policy Article A52505. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.