Persius/hicric huggingface dataset:
Respiratory therapy services provided in a facility are usually the
responsibility of the facility's nursing staff and/or respiratory therapy
department.  
  
Payment to a physician may be allowed for respiratory services only when the
services are rendered as an integral, although incidental, part of the
physician's professional services in the course of diagnosis or treatment of
an injury or illness. It is expected that respiratory therapy services will
most often be used in cases of acute respiratory disease or acute exacerbation
of chronic disease. Nevertheless, selected chronic stable conditions could
require respiratory services. Acute disease states are expected to either
subside after a short period of treatment, or, if no response occurs, transfer
the patient to a higher level of care.

  * Respiratory therapy services performed in a nursing facility or office setting may be eligible for payment to a physician if 1 of the following conditions is met: 
    * The service is personally performed by the physician or qualified Non-Physician Practitioner (NPP) if provision of the service is within the scope of his/her license.  
  **or** ,
    * The service is performed by ancillary personnel employed by the physician, under the direct personal supervision of the physician, and is furnished during a course of treatment in which the physician performs an initial service and subsequent service(s), which reflect his/her active participation in and management of the course of treatment.  

 Medically necessary reasons for **pulse oximetry** include:

  * The patient exhibits signs or symptoms of acute respiratory dysfunction such as:
    * Tachypnea
    * Dyspnea
    * Cyanosis
    * Respiratory distress
    * Confusion
    * Hypoxia
  * The patient has chronic lung disease, severe cardiopulmonary disease, or neuromuscular disease involving the muscles of respiration, and oximetry is needed for at least 1 of the following reasons:  
    * Initial evaluation to determine the severity of respiratory impairment
    * Evaluation of an acute change in condition
    * Evaluation of exercise tolerance in a patient with respiratory disease
    * Evaluation to establish medical necessity of an oxygen therapeutic regimen
  * The patient has sustained severe multiple trauma or complains of acute severe chest pain
  * The patient is under treatment with a medication with known pulmonary toxicity and oximetry is medically necessary to monitor for potential adverse effects of therapy

**Note:**

*The results of tests performed by a durable medical equipment (DME) supplier or their employees to qualify patients for home oxygen service are not covered.
This LCD describes Medicare coverage for instrumental assessment of
swallowing. Instrumental assessment of swallowing is indicated for either the
evaluation of a patient with dysphagia who has a pharyngeal dysfunction or who
is at risk for aspiration. Such study is indicated after clinical
(noninstrumental) examination identifies an issue that cannot be resolved
without further assessment.

  
The swallowing study, also known as the Modified Barium Swallow (MBS), is a
videofluoroscopic, radiographic test that differs from the traditional barium
swallow procedures (e.g., pharyngoesophagram and upper gastrointestinal
series) in both procedure and purpose. During the procedure, the patient is
seated in an upright or semi-reclining position and given various quantities
and textures of food and/or liquids mixed with a contrast material. The
procedure includes observation of containment of the food/liquid in the oral
cavity, mastication, tongue mobility during oral bolus transport, elevation
and retraction of the velum, tongue base retraction, upward and forward
movement of the hyoid bone and larynx, laryngeal closure, pharyngeal
contraction, and extent and duration of pharyngoesophageal segment opening.
The presence, timing and cause of penetration or aspiration into the upper
airways are observed. Observations of esophageal clearance in the upright
position, sensation and muscle strength may be measured directly or inferred.
The videofluoroscopic swallowing study is a collaborative study that can be
performed by a speech-language pathologist and a radiologist.  
  
Among the important clinical syndromes that contribute to the presentation of
dysphagia and where **instrumental assessment of swallowing** may be helpful
are:  
  

  * Patients with stroke or other Central Nervous System (CNS) disorder with associated impairment of speech and swallowing.
  * Patients with surgical ablation or radiation due to head and neck cancer with documented difficulty in swallowing.
  * Patients without obvious CNS disorder, but with documented difficulty in swallowing.
  * Patients with generalized debilitation and with difficulty swallowing food.
  * Patients with neuromuscular diseases and rheumatologic diseases known to cause dysphagia.
  * Patients with a clinical history of aspiration or a history of aspiration pneumonia.
  * Patients with head or neck (throat) injury, including peripheral nerve injury from any cause.

Concerns have been expressed that the use of such services in a mobile setting
lacks evidence of medical effectiveness. Questions of patient safety have yet
to be resolved for these types of procedures to be performed in a Skilled
Nursing Facility (SNF), nursing home or home environment, thus requiring
physician presence during the procedure in such settings.  
  
This procedure will be reimbursed only when medically necessary and performed
in the following places of service:  
  
 Office (11)  
 Off Campus-Outpatient Hospital (19)  
 Inpatient Hospital (21)  
 On Campus-Outpatient Hospital (22)  
 Emergency Room Hospital (23)  
 Comprehensive Inpatient Rehabilitation Facility (61)  
 Comprehensive Outpatient Rehabilitation Facility (62)
**Indications**  
  
Computed Tomography (CT) colonography, also known as virtual colonoscopy,
utilizes helical CT of the abdomen and pelvis along with 2D or 3D
reconstruction to visualize the colon lumen. The test requires colonic
preparation similar to that required for instrument (e.g., fiberoptic, video)
colonoscopy, as well as air or carbon dioxide insufflation to achieve colonic
distention.  
  
Virtual colonoscopy is only indicated in those patients in whom a diagnostic
or surveillance instrument colonoscopy of the entire colon is incomplete due
to an inability to fully pass the colonoscope proximally, and a repeat attempt
is not indicated, or in patients with a valid contraindication to the safe
performance of an instrument colonoscopy. Incomplete colonoscopy must be due
to 1 of the following:

1\. An obstructing neoplasm  
  
2\. Intrinsic scarring, stricture, aberrant anatomy, or obstruction from prior
surgery, radiation, or diverticular disease  
  
3\. Extrinsic compression

There are few absolute contraindications to instrument colonoscopy. Relative
contraindications do not create medical necessity for using CT colonography as
a screening procedure, and the above indications must still be met.  
  
The following relative contraindications to instrument colonoscopy may be
indications for CT colonography if well documented in the medical record:

    * Severe coagulopathy

    * Long-term anticoagulation

    * Increased sedation risk (such as from severe chronic obstructive pulmonary disease (COPD) or previous anesthesia adverse reaction)

**Limitations**  
  
CT colonography is not covered when used for screening, or in the absence of
signs or symptoms of disease, regardless of family history or other risk
factors for the development of colonic disease.  
  
CT colonography is not covered when used as an alternative to instrument
colonoscopy for screening or in the absence of signs or symptoms of disease.  
  
CT colonography is not covered following incomplete colonoscopy if the reason
for the colonoscopy is other than one of those described above.  
  
CT colonography is intended for use in pre-operative planning when imaging of
the non-visualized colon proximal to the obstruction is necessary in making
decisions involving the approach to the patient.
A Wireless Gastrointestinal Motility Monitoring System is an ingestible
capsule with the trade name
[SmartPill](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K092342).
The SmartPill records data enabling the estimation of regional and total
gastrointestinal motility. The device is Food and Drug Administration (FDA)
approved to evaluate patients with suspected delayed gastric emptying and the
evaluation of colonic transit time in patients with chronic idiopathic
constipation. The capsule device measures pH, temperature, and pressure while
traveling through the gastrointestinal (GI) tract, sending the data to a
wireless receiver worn on or near the patient. The data can be used to
determine GI motility, gastric emptying, small bowel transit, colonic transit,
and whole gut transit times. The capsule can also provide pressure patterns
within the GI tract. The study can be done in a physician office after the
patient has discontinued use of all medications that affect the GI tract.  
  
 **Indications**

The Wireless Motility Capsule (WMC) has been studied in many centers. The
capsule does not use radioactive materials and has minimal safety risks.
Palmetto GBA will cover the device when:

  * It is used by a gastroenterologist trained to use and interpret the results.
  * It is used to evaluate and/or treat patients with suspected gastroparesis of any nature.
  * It is used to evaluate colonic transit in patients with chronic idiopathic constipation lasting over 6 months.
  * Basic clinical investigations, including endoscopy, have failed to elucidate a diagnosis.

**Limitations**

The WMC should **not** be administered to patients with a history of gastric
bezoar, swallowing disorders, dysphagia, suspected strictures/fistulae in the
GI tract, physiologic GI obstruction, GI surgery within the previous 3 months,
Crohn's disease, diverticulitis, or who have an implanted electromechanical
medical device (such as pacemaker or infusion pump). The capsule is not FDA
approved for use in children.
The implantable pump is a sealed, self-powered system, which is inserted under
the skin by a physician. It provides a continuous controlled infusion of a
drug to a select body site and can be refilled by percutaneous injection. Two
separate ports are available: 1 for bolus injections and 1 for continuous
infusion. Both may be utilized for blood or cerebrospinal fluid (CSF)
withdrawals. An implantable infusion pump is utilized to administer many types
of medications through the intra-arterial, intrathecal or epidural route.  
  
Medicare will consider implantable infusion pumps, and associated services,
medically reasonable and necessary for the conditions listed in the CMS
Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations
Manual, Chapter 1, Part 4, 280.14 Infusion Pumps.

For the indication of opioid drugs used for the treatment of chronic
intractable pain, it is useful to distinguish between pain caused by a
malignancy from which the patient is not expected to recover from those non-
malignant conditions that are longer term in nature. For terminal malignant
conditions, the progression from a non-invasive pain control modality to a
more invasive modality, such as use of an implanted pump, may occur more
rapidly with less emphasis on behavioral approaches to pain control.

Ziconotide
([Prialt](https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/021060s006lbl.pdf))
intrathecal infusion documentation must meet the Food and Drug Administration
(FDA)-approved indication that the patient is intolerant of or refractory to
other treatment, such as systemic analgesics, adjunctive therapies or
intrathecal therapy morphine in the treatment of severe, chronic pain.

  
**_Contraindication_**  
  
The implantation of an infusion pump is contraindicated in the following
patients:

    * Those with a known allergy or hypersensitivity to the drug being used (e.g., oral baclofen and morphine)
    * Those who have an infection
    * Those whose body size is insufficient to support the weight and bulk of the device

In those patients with other implanted programmable devices, since crosstalk
between devices may inadvertently change the prescription, it is recommended
that all devices be checked for possible crosstalk at the time of implantation
of the infusion pump, and that appropriate surveillance for such interactions
be continued.
**Abstract:**  
  
CT colonography, utilizes helical computed tomography of the abdomen and
pelvis to visualize the colon lumen, along with 3-D reconstruction. The test
requires colonic preparation similar to that required for standard colonoscopy
(instrument colonoscopy), and air insufflation to achieve colonic distention.  
  
 **Indications:**  
  
CT colonography is indicated in those patients in whom a diagnostic (performed
for signs/symptoms of disease) optical colonoscopy of the entire colon is
incomplete. Failure to complete the optical colonoscopy may be secondary to
conditions such as, but not limited to, an obstructing neoplasm, stricture,
tortuosity, spasm, redundant colon diverticulitis, extrinsic compression or
aberrant anatomy scarring from prior surgery.  
  
CT colonography is indicated when a board certified or board eligible
gastroenterologist, a surgeon trained in endoscopy or a physician with
equivalent endoscopic training determines from an evaluation of the patient
that optical colonoscopy cannot be safely attempted.  
  
CT colonography is also indicated for the evaluation of a submucosal
abnormality detected on colonoscopy or other imaging study.  
  
CT colonography should be performed soon after the failed standard
colonoscopy, if appropriate, so that the patient will not have to endure
repeat colonic preparation.  
  
**Limitations:**  
  
CT colonography is not reimbursable when used in the absence of signs or
symptoms of disease, regardless of family history or other risk factors for
the development of colonic disease.  
  
Since any colonography with abnormal or suspicious findings would require a
subsequent instrument colonoscopy for diagnosis (e.g., biopsy) or for
treatment (e.g., polypectomy), CT colonography is not reimbursable when used
initially as an alternative to an instrument colonoscopy, even though
performed for signs or symptoms of disease.  
  
Irritable bowel syndrome and abdominal pain when representing chronic stable
symptoms rarely represent reasonable indications for colonoscopy and CT
colonography. These conditions have been placed on the list of covered
diagnoses for use when a colonoscopy/colonography exam is normal in the face
of compelling symptoms. When diagnosis codes representing these conditions are
used, the codes must be applicable and the rationale for the
colonoscopy/colonography must be carefully documented in the medical record.
**Abstract:**  
  
Visual field testing detects defects in the field of vision, testing the
function of the retina, optic nerve and optic pathways. Formal visual field
tests are generally performed using automated perimetry, i.e., measurement of
the ability to see points of light at varying locations on a curved surface.  
  
 **Indications:**  
  
Visual field examinations are considered medically necessary for the
conditions listed below:  
  

  1. The patient has a disorder of the eyelid(s) potentially affecting the visual field(s).
  2. The patient has a visual field defect detected on gross visual field testing (e.g., confrontational testing).
  3. The patient has a documented diagnosis of glaucoma.  
It should be noted that the progression of, and effects of treatment on
glaucoma can be monitored only through periodic visual field testing. The
frequency of such examinations is dependent on changes in intraocular pressure
(IOP), retinal damage and changes at the optic disc.

  4. The patient is suspected of having glaucoma; signs include increased intraocular pressure, asymmetric IOP measurements, notching or thinning of the neuroretinal rim, splinter hemorrhages and asymmetric appearance of the discs.
  5. The patient has a documented disorder of the optic nerve, the retina or the neurologic visual pathway.
  6. The patient has a recent intracranial hemorrhage, an intracranial mass or a recent increased intracranial pressure measurement (with or without visual symptoms).
  7. The patient has a recent occlusion / stenosis of cerebral or precerebral arteries.
  8. The patient has a history of a cerebral aneurysm, pituitary or occipital tumor potentially affecting the visual fields.
  9. The patient is being evaluated for buphthalmos, congenital anomalies of the posterior segment or congenital ptosis.
  10. The patient has a disorder of the orbit potentially affecting the visual field.
  11. The patient has sustained a significant eye injury.
  12. The patient has unexplained visual loss.
  13. The patient has a pale or swollen optic nerve on a recent examination.
  14. The patient is having new functional limitations which may be due to visual field loss (e.g., reports by family of patient bumping into objects). 
  15. The patient is taking a medication with a high risk of affecting the visual system (e.g., Plaquenil).
  16. The patient is being evaluated for macular degeneration, or has experienced central vision loss (< 20/70). (Repeated examinations for diagnosis of macular degeneration or central vision loss are not medically necessary unless changes in vision are documented, or to evaluate the results of a surgical intervention).

**Limitations:**  
  
Gross visual field testing (e.g., confrontation testing) is a part of general
ophthalmological service and should not be reported separately.
**Abstract:**  
  
Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and
multiple antigen simultaneous tests are in vitro techniques for determining
whether a patient's serum contains IgE antibodies against specific allergens
of clinical importance. As with any allergy testing, the need for such tests
is based on the findings during a complete history and physical examination of
the patient.  
  
The multiple antigen simultaneous testing technique is similar to the
RAST/FAST techniques in that it depends upon the existence of allergic
antibodies in the blood of the patient being tested. With the multiple antigen
simultaneous test system, several antigens may be used to test for specific
IgE simultaneously.  
  
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of
allergy testing for specific IgE antibodies against allergens. This method is
also a variation of RAST.  
  
 **Limitations:**  
  
The following tests are considered to be not medically necessary and will be
denied.

  * ELISA/Act qualitative antibody testing  
This testing is used to determine in vitro reaction to various foods and
relies on lymphocyte blastogenesis in response to certain food antigens.

  * LMRA (Lymphocyte Mitogen Response Assays) by ELISA/Act
  * IgG ELISA, indirect method
  * Qualitative multi-allergen screen   
This is a non-specific test that does not identify a specific antigen.

  * IgG and IgG subclass antibody tests for food allergy do not have clinical relevance, are not validated, lack sufficient quality control, and should not be performed.
**Abstract:**  
  
Ultrasound of the extremity is a non-invasive imaging technique that uses
high-frequency sound waves to evaluate the extremities (arms and legs),
providing real-time, two-dimensional images. Longitudinal, transverse and
oblique images of the area of interest are obtained. Ultrasound, echography
and sonography are all terms that may be used interchangeably to describe this
particular imaging technique. This LCD identifies the indications and
limitations of Medicare coverage and reimbursement for these services.  
  
 **Indications:**  
  
Extremity ultrasound is indicated for the following conditions:

  1. To detect cysts, abscesses, tumors (including evaluation of size of tumors) and effusion;
  2. To distinguish solid tumors from fluid-filled cysts;
  3. To evaluate tendons (including tears, tendonitis and tenosynovitis), joints, plantar fascia, ligaments, soft tissue masses, ganglion cysts, intermetatarsal neuroma and stress fractures of the metatarsals;
  4. To aid in the diagnosis of and surgical removal of foreign bodies.

**Limitations:**

  1. Extremity ultrasound must be performed by qualified and knowledgeable physicians and/or technicians (sonographers) under the general supervision of a physician.
  2. Extremity ultrasound is limited to studies of the arms and legs.
  3. Extremity ultrasound is considered not medically necessary for the routine diagnosis or management of the following conditions:  
\- bunions;  
\- cellulitis;  
\- neuromas (where the clinical impression is obvious and ultrasound is not
likely to add further information);  
\- paronychia;  
\- plantar warts; or  
\- superficial abscesses.

  4. Bilateral studies are allowed only if there is pathology of both extremities dictating medical necessity for two distinct examinations. It is not reasonable and necessary to perform the contralateral extremity as a "control."
  5. Extremity ultrasound is considered not medically necessary for diagnosis or management of neuromas, superficial ganglia, bursae and abscesses unless there is documented evidence of some clinical presentation that obscures the clinician's ability to establish these simple clinical diagnoses.
  6. Extremity ultrasound is considered not medically necessary in the initial determination (diagnosis) of plantar fasciitis. A single diagnostic extremity ultrasound may be medically necessary for plantar fasciitis when the diagnosis is still uncertain after a failed course of conservative management. Repeated extremity ultrasound is not medically necessary in plantar fasciitis.
  7. Extremity ultrasound of the same extremity more than two times in six months is rarely medically reasonable and necessary (see the "Documentation Requirements" and "Utilization Guidelines" sections below).
Panretinal laser photocoagulation (PRP) involves extensive treatment with an
argon or diode laser to the peripheral and middle portions of the retina.
Photocoagulation is designed to burn and seal unwanted blood vessels, thus
preventing hemorrhage. Panretinal laser photocoagulation targets the ablation
of ischemic retina which in turn reduces the production of various cytokines,
such as vascular endothelial growth factor (VEGF), thereby causing regression
of neovascularization. Panretinal photocoagulation may also be used to ablate
small areas of neovascularization on the retina. The initial treatment usually
consists of approximately 1500-2000 spots of laser per eye. This is
accomplished in two or more sessions. This local coverage determination (LCD)
documents the indications and limitations of coverage for use of panretinal
laser photocoagulation.  
  
 **Indications:**  
  
Panretinal laser photocoagulation is indicated for the treatment or management
of patients with proliferative or pre-proliferative diabetic retinopathy and
patients with severe levels of diabetic macular edema associated with pre-
proliferative retinopathy, and other proliferative retinopathies.  
  
While panretinal laser photocoagulation greatly reduces the risk of visual
loss in all states of proliferative retinopathy, treatment is withheld until
the risk of visual loss outweighs the risks and side effects of the treatment.  
  
**Limitations:**  
  
Medicare coverage of panretinal laser photocoagulation using a laser is
limited to management of proliferative or pre-proliferative retinopathies.