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 state that an air-fluidized bed is covered only if all of the following criteria are met: 
 
    The beneficiary has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure ulcer 
(Refer to the ICD-10 codes in the LCD-related Policy Article for applicable diagnoses). 
 
    The beneficiary is bedridden or chair bound as a result of severely limited mobility. 
 
    In the absence of an air-fluidized bed, the beneficiary would require institutionalization. 
 
    The air-fluidized bed is ordered in writing by the beneficiarys treating practitioner based upon a 
comprehensive assessment and evaluation of the beneficiary after completion of a course of conservative 
treatment designed to optimize conditions that promote wound healing. The evaluation generally must be 
performed within one month prior to initiation of therapy with the air-fluidized bed. 
 
    The course of conservative treatment must have been at least one month in duration without progression 
toward wound healing. This month of prerequisite conservative treatment may include some period in an 
institution as long as there is documentation available to verify that the necessary conservative treatment was 
rendered. Conservative treatment must include: 
 
        Frequent repositioning of the beneficiary with particular attention to relief of pressure over bony 
prominences (usually every 2 hours); and 
 
        Use of a Group 2 support surface to reduce pressure and shear forces on healing ulcers and to prevent new 
ulcer formation; and 
 
        Necessary treatment to resolve any wound infection; and 
 
        Optimization of nutrition status to promote wound healing; and 
 
        Debridement by any means, including wet-to-dry gauze dressings, to remove devitalized tissue from the 
wound bed; and 
         Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings protected by an 
occlusive covering, while the wound heals. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD) Pressure Reducing Support Surfaces- Group 3 L33692. 
 
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 only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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. The health 
Plan contract says covered chiropractic services include manual manipulation of the spine to correct 
subluxation. Excluded from Medicare coverage is any service other than manual manipulation for the treatment 
of subluxation. You can find this information on page 4-12 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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 100 one-way trips each year. Each one-way trip must not exceed 50 miles of driving distance. You 
can find this information on page 4-54 of the Plans 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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 3-3 to 3-4 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 CONTINUED COVERAGE: 
 
    For wounds and ulcers described under A or B above, once placed on a NPWT pump and supplies, in order 
for coverage to continue, a licensed medical professional 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 ulcers dimensions and characteristics. 
If criteria C-1 and C-2 are not fulfilled, continued coverage of the NPWT pump and supplies will be denied as 
not reasonable and necessary. 
 
WHEN COVERAGE ENDS: 
 
    For wounds and ulcers described under A or B above, a NPWT pump and supplies will be denied as not 
reasonable and necessary with any of the following, whichever occurs earliest: 
 
            1. Criteria C1-C2 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 practitioners order 
 
 You can find this information in Medicare's Local Coverage Determination (LCD): Negative Pressure Wound 
Therapy Pumps (L33821). 
 
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 payment for inpatient psychiatric hospital services is to be made only for active treatment. 
For services to be designated as active treatment they must: 
 
1. be provided under an individualized treatment or diagnostic plan; 
 
2. reasonably be expected to improve the patients condition, or for the purpose of diagnosis; and 
 
3. be supervised and evaluated by a physician.   
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 2, Sections 30.2.2 and 30.2.2.1. 
 
The rules say that Medicare will not pay any expenses for items or services which are not medically necessary 
and reasonable for the diagnosis or treatment of illness or injury. This exclusion extends to claims for services 
which are provided in inappropriate settings. You can find this rule in the Social Security Act, Section 
1862(a)(1). 
 
The rules say that payment may not be made for more than a total of 190 days of inpatient psychiatric hospital 
services during the patient's lifetime. The limitation applies only to services furnished in a psychiatric hospital. 
You can find this information in the Medicare Benefit Policy Manual Chapter 4 - Inpatient Psychiatric Benefit 
Days Reduction and Lifetime Limitation 50 - Inpatient Psychiatric Hospital Services - Lifetime Limitation( 
Rev. 1, 10-01-03. 
 
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 the PACE benefit package must include the following:  
(a) All Medicare-covered services;  
(b) All Medicaid-covered services, as specified in the State's approved Medicaid plan; and  
(c) Other services determined necessary by the interdisciplinary team to improve and maintain the enrollee's 
overall health status.  
You can find this rule at 42 Code of Federal Regulations (CFR) Section 460.92. 
 
The rules say that Medicare will pay for an inpatient rehabilitation facility (IRF) admission when the services 
are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary 
approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one 
therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must 
need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. 
This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at 
least five days per week. The patient does not need to be expected to achieve complete independence in self-
care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a 
rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 
412.622. 
 
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 BRCA1 and BRCA2 genetic testing is covered for: 
 Individual with breast, ovarian, pancreatic, or prostate cancer from a family with a known deleterious 
BRCA1 or BRCA2 gene mutation 
 Individual with a personal history of ovarian cancer 
 Individual with a breast cancer diagnosis meeting any of the following criteria:  
o Diagnosed at 45 years or older 
o Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR) 
negative, and human epidermal growth factor receptor 2 (HER2) negative) breast cancer 
diagnosed at 60 years or older 
o Diagnosed at 46-50 years old with:  
 An additional breast cancer primary 
 At least 1 first, second, or third degree relative with breast cancer at any age, or 
 At least 1 first, second, or third degree relative with prostate cancer (Gleason score of at 
least 7), or 
 An unknown or limited family history 
o Breast cancer diagnosed at any age, and  
 At least 1 first, second, or third degree relative with breast cancer 50 years old or 
younger, or 
 At least 1 first, second, or third degree relative with ovarian cancer at any age, or 
 At least 1 first, second, or third degree relative with metastatic prostate cancer or 
pancreatic cancer at any age, or 
 At least 2 additional diagnoses of breast cancer at any age in patient and/or in close 
blood relative, or 
 A first, second, or third degree male relative with breast cancer 
 For an individual of ethnicity associated with higher mutation frequency (e.g. Ashkenazi 
Jewish) no additional family history may be required. 
o Male breast cancer 
 Personal history of prostate cancer (Gleason score of at least 7) at any age with: 
o At least 1 first, second, or third degree relative with ovarian cancer at any age, or 
o At least 1 first, second, or third degree relative with breast cancer at 50 years or younger, or 
o At least 1 first, second, or third degree relative with pancreatic cancer at any age, or 
o At least 1 first, second, or third degree relative with metastatic prostate cancer at any age, or o At least 2 first, second, or third degree relatives with breast cancer and/or pancreatic cancer 
and/or prostate cancer (any grade) at any age, or 
o Ashkenazi Jewish ancestry 
 Personal history of pancreatic cancer at any age 
 Personal history of metastatic prostate cancer (radiographic evidence of or biopsy-proven disease) 
 BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of 
germline mutation analysis 
You can find this information in the Local Coverage Determination (LCD): MolDX: BRCA1 and BRCA2 
Genetic Testing (L36161). 
 
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). 
 
The rules say that Medicare pays for outpatient rehabilitation therapy services only when they are provided by 
those trained specifically in physical therapy, occupational therapy or speech-language pathology. This means 
that the services of massage therapists may not be billed as covered therapy services. 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 230.5. 
 
The rules say that Medicare plans may not offer a massage therapy benefit. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 4, 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. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 44 of the Plan's 2022 
Evidence of Coverage.
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 there is insufficient evidence in the published medical literature to determine the safety and 
efficacy of these emerging alternative modalities or approaches compared to thermal radiofrequency 
denervation for the treatment of spinal pain including pulsed radiofrequency, cryoablation, laser ablation, and 
chemical ablation. You can find this rule in Local Coverage Determination (LCD): Facet Joint Interventions for 
Pain Management (L35936). 
 
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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
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 280.3(B). 
 
The rules say that prior to or at the time of delivery of a power operated vehicle (POV) or power wheelchair 
(PWC), the supplier or practitioner must perform an on-site evaluation of the beneficiarys home to verify that 
the beneficiary can adequately maneuver the device that is provided considering physical layout, doorway 
width, doorway thresholds, and surfaces. There must be a written report of this evaluation available on request. 
You can find this information in the Local Coverage Determination (LCD) Power Mobility Devices (L33789). 
 
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 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.  
 
The rules say that Medicare recognizes these Part B providers as eligible to provide diagnostic and Behavioral 
Health Integration or Screening, Brief Intervention and Referral to Treatment services, as permitted under state 
law: 
 
Physicians (Medical Doctors [MDs] and Doctors of Osteopathy [DOs]), particularly Psychiatrists 
Clinical Psychologists (CPs) 
Clinical Social Workers (CSWs) 
Clinical Nurse Specialists (CNSs) 
Nurse Practitioners (NPs) 
Physician Assistants (PAs) 
Certified Nurse-Midwives (CNMs) 
Independently Practicing Psychologists (IPPs) 
 
You can find this information in the Medicare Learning Network: Medicare Mental Health 
 
The rules say that Mental Health Counselors frequently attempt to enroll in Medicare, but are not eligible to do 
so. If the contractor receives an enrollment application from a Mental Health Counselor, the contractor shall 
deny the application. You can find this information in the Centers for Medicare and Medicaid Services Internet 
Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 1, 10.2.8. 
 
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.