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 endoscopy procedures can only be allowed if abnormal signs or symptoms or known disease are present. Indications which support esophagogastroduodenoscopies (EGD[s]) for diagnostic purpose(s) are as follows: upper abdominal distress which persists despite an appropriate trial of therapy; upper abdominal distress associated with symptoms and/or signs suggesting serious organic disease (e.g., prolonged anorexia and weight loss); dysphagia or odynophagia; esophageal reflux symptoms which are persistent or recurrent despite appropriate therapy; persistent vomiting of unknown cause; other systemic diseases in which the presence of upper GI pathology might modify other planned management. Examples include patients with a history of GI bleeding who are scheduled for organ transplantation; long term anticoagulation; and chronic non-steroidal therapy for arthritis; X-ray findings of a suspected neoplastic lesion, for confirmation and specific histologic diagnosis; gastric or esophageal ulcer; or evidence of upper gastrointestinal tract stricture or obstruction. The presence of gastrointestinal bleeding: in most actively bleeding patients or those recently stopped; when surgical therapy is contemplated; when re-bleeding occurs after acute self-limited blood loss or after endoscopic therapy; when portal hypertension or aortoenteric fistula is suspected; or for presumed chronic blood loss and for iron deficiency anemia when colonoscopy is negative. When sampling of duodenal or jejunal tissue or fluid is indicated; to assess acute injury after caustic agent ingestion; or intraoperative EGD when necessary to clarify location or pathology of a lesion. You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD) L35350 Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic).

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.

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 the Plan will provide reimbursement up to $120 per calendar year for routine vision benefits. You can find this information on pages 100-101 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 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 claims or claim lines that have been determined to be an exact duplicate are rejected and do not have appeal rights. An exact duplicate for institutional claims is a claim or claim line that exactly matches another claim or claim line with respect to the following elements: - Medicare beneficiary identifier;  Type of Bill; - Provider Identification Number; - From Date of Service; - Through Date of Service; - Total Charges (on the line or on the bill); and - HCPCS, CPT-4, or Procedure Code modifiers.  You can find this information in the Medicare Claims Processing Manual Chapter 1 - General Billing Requirements: 120.2 - Exact Duplicates (Rev. 4201, Issued: 01-18-19, Effective: 02-19-19, Implementation: 02-19-19).  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 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 pages 91 and 127 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 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 erythropoiesis stimulating agents (ESAs) are covered for the following indications: 1. Treatment of significant anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy; 2. Treatment of anemia induced by AZT and/or other Nucleoside Reverse Transcriptase Inhibitors (NRTI) used in treatment of HIV/AIDS; 3. Treatment of selected patients with anemia related to myelodysplastic syndrome; 4. Perisurgical adjuvant therapy (epoetin alfa only); 5. Treatment of anemia of selected chronic diseases: rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel diseases, and hepatitis C undergoing treatment.  The ESA treatment is not reasonable and necessary for beneficiaries with certain clinical conditions, either because of a deleterious effect of the ESA on their underlying disease or because the underlying disease increases their risk of adverse effects related to ESA use. You can find this rule in the Local Coverage Determination for Erythropoiesis Stimulating Agents (ESA), L34356 (eff 03/04/21).  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 state that pegfilgrastim (including pegfilgrastim-jmdb, pegfilgrastim-cbqv, pegfilgrastim-bmez and pegfilgrastim-apgf) will be covered for Food and Drug Administration (FDA) approved label indications. The recommended dosage of pegfilgrastim is 6 mg administered once per chemotherapy cycle. The administration should not occur within 14 days before, and 24 hours after, administration of cytotoxic chemotherapy. The following off-label exception to this rule will be allowed as follows:
- If the patient is on a dose dense 14 day chemotherapy cycle, it would be acceptable to administer pegfilgrastim outside of the 14 day before and 24 hour after rule for chemotherapy. Pegfilgrastim would typically be administered on the second day of the 14-day dose dense chemotherapy cycle. An example of this would be a patient receiving dose dense cytoxan/adriamycin and taxol for breast cancer. The chemotherapy drug record/orders should indicate that the patient is on a 14-day dose dense chemotherapy schedule.

Pegfilgrastim-jmdb, pegfilgrastim-cbqv, pegfilgrastim-bmez and pegfilgrastim-apgf are not indicated for the mobilization of peripheral blood progenitor cells for hematopoietic stem cell transplantation. You can find these rules in Local Coverage Determination (LCD) Pegfilgrastim (L33747).

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 radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. You can find this information in the Local Coverage Determination (LCD): Pain Management (L33622).  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 it is standard medical practice for an anesthesia practitioner to perform a patient examination and evaluation prior to surgery. This is considered part of the anesthesia service and is included in the base unit value of the anesthesia code. The evaluation and examination are not reported in the anesthesia time. If a surgery is canceled, subsequent to the preoperative evaluation, payment may be allowed to the anesthesiologist for an Evaluation & Management (E&M) service and the appropriate E&M code may be reported. (A non-medically directed CRNA may also report an E&M code under these circumstances if permitted by state law.) Similarly, routine postoperative evaluation is included in the base unit for the anesthesia service. If this evaluation occurs after the anesthesia practitioner has safely placed the patient under postoperative care, neither additional anesthesia time units nor E&M codes shall be reported for this evaluation. Postoperative E&M services related to the surgery are not separately reportable by the anesthesia practitioner except when an anesthesiologist provides significant, separately identifiable ongoing critical care services. 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(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 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 that the Plan covers only manual manipulation of the spine to correct subluxation. You can find this information on page 64 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 Effective for services performed on or after March 16, 2018, the Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements are met:   a. Patient has: i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and ii. not been previously tested with the same test using NGS for the same cancer genetic content, and iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy).    b. The diagnostic laboratory test using NGS must have:  i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, ii. an FDA-approved or -cleared indication for use in that patient's cancer; and, iii. results provided to the treating physician for management of the patient using a report template to specify treatment options. Effective for services performed on or after January 27, 2020, CMS has determined that NGS as a diagnostic laboratory test is reasonable and necessary and covered nationally for patients with germline (inherited) cancer, when performed in a CLIA-certified laboratory, when ordered by a treating physician and when all of the following requirements are met:    a. Patient has: i. ovarian or breast cancer; and, ii. a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer; and, iii. a risk factor for germline (inherited) breast or ovarian cancer; and iv. not been previously tested with the same germline test using NGS for the same germline genetic content.    b. The diagnostic laboratory test using NGS must have all of the following: i. FDA-approval or clearance; and, ii. results provided to the treating physician for management of the patient using a report template to specify treatment options. You can find this information in the National Coverage Determination (NCD): Next Generation Sequencing (NGS) (90.2).  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 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 doctor's 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 one round trip per month (up to 12 round trips per calendar year) is provided for non-medical purposes. Limit of 20 miles each way. Services must be provided by the Plan-approved transportation provider. You can find this information on page 104 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 a hospital may attest to specific non-diagnostic services as being unrelated to the hospital
Part A claim (that is, the preadmission non-diagnostic services are clinically distinct or independent from the
reason for the beneficiary's admission) by adding a condition code 51. 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 4, Section 10.12.

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 health plan contract says that enrollees must pay a $105 copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). You can find this information in Chapter 4 on pages 4-29 to 4-32 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 the Medicare Advantage Organization (MAO) is responsible for maintaining continuity of
care for its enrollee by ensuring uninterrupted access to the medically necessary covered DME item, including
when the item needs to be repaired or replaced. If necessary, the MAO must purchase or rent a replacement
item for the beneficiary to use. You can find this information in the Centers for Medicare and Medicaid
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, 10.12.
The rules say that the reasonable useful lifetime of durable medical equipment is determined through program
instructions. In the absence of program instructions, carriers may determine the reasonable useful lifetime of
equipment, but in no case can it be less than 5 years. This is seen in the Medicare Benefit Policy Manual
Chapter 15 under Covered Medical and Other Services, Section 110.2.
The rules say that Medicare will pay for durable medical equipment (DME) that is reasonable and necessary for
treatment of an illness or injury, or to improve the functioning of a malformed body part. 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).
The rules say that for durable medical equipment, if equipment or a device is replaced free of charge by the
warrantor, no program payment may be made, since there is no charge involved. You can find this in the
Medicare Benefit Policy Manual Chapter16-GeneralExclusionsFromCoverage, Section 40.4 entitled Items
Covered Under Warranty.
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.