Persius/hicric huggingface dataset:
Biofeedback therapy is covered under Medicare only when it is reasonable and
necessary for the individual patient for muscle re-education of specific
muscle groups or for treating pathological muscle abnormalities of spasticity,
incapacitating muscle spasm, or weakness, and more conventional treatments
(heat, cold, massage, exercise, support) have not been successful. This
therapy is not covered for treatment of ordinary muscle tension states or for
psychosomatic conditions. (See the [Medicare Benefit Policy
Manual](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673), Chapter
15, for general coverage requirements about physical therapy requirements.)
This policy applies to biofeedback therapy rendered by a practitioner in an
office or other facility setting.

Biofeedback is covered for the treatment of stress and/or urge incontinence in
cognitively intact patients who have failed a documented trial of pelvic
muscle exercise (PME) training. Biofeedback is not a treatment, per se, but a
tool to help patients learn how to perform PME. Biofeedback-assisted PME
incorporates the use of an electronic or mechanical device to relay visual
and/or auditory evidence of pelvic floor muscle tone, in order to improve
awareness of pelvic floor musculature and to assist patients in the
performance of PME.

A failed trial of PME training is defined as no clinically significant
improvement in urinary incontinence after completing 4 weeks of an ordered
plan of pelvic muscle exercises to increase periurethral muscle strength.

Contractors may decide whether or not to cover biofeedback as an initial
treatment modality.

Home use of biofeedback therapy is not covered.
Oxygen (95 percent) and carbon dioxide (5 percent) inhalation therapy for
inner ear disease, such as endolymphatic hydrops and fluctuant hearing loss,
is not reasonable and necessary. The therapeutic benefit deriving from this
procedure is highly questionable.
Blood platelet transplants are safe and effective for the correction of
thrombocytopenia and other blood defects. It is covered under Medicare when
treatment is reasonable and necessary for the individual patient.
Indications

  1. A plasma HIV RNA baseline level may be medically necessary in any patient with confirmed HIV infection.
  2. Regular periodic measurement of plasma HIV RNA levels may be medically necessary to determine risk for disease progression in an HIV-infected individual and to determine when to initiate or modify antiretroviral treatment regimens.
  3. In clinical situations where the risk of HIV infection is significant and initiation of therapy is anticipated, a baseline HIV quantification may be performed. These situations include: 
    1. Persistence of borderline or equivocal serologic reactivity in an at-risk individual.
    2. Signs and symptoms of acute retroviral syndrome characterized by fever, malaise, lymphadenopathy and rash in an at-risk individual.

Limitations

  1. Viral quantification may be appropriate for prognostic use including baseline determination, periodic monitoring, and monitoring of response to therapy. Use as a diagnostic test method is not indicated.
  2. Measurement of plasma HIV RNA levels should be performed at the time of establishment of an HIV infection diagnosis. For an accurate baseline, 2 specimens in a 2-week period are appropriate.
  3. For prognosis including anti-retroviral therapy monitoring, regular, periodic measurements are appropriate. The frequency of viral load testing should be consistent with the most current Centers for Disease Control and Prevention guidelines for use of anti-retroviral agents in adults and adolescents or pediatrics.
  4. Because differences in absolute HIV copy number are known to occur using different assays, plasma HIV RNA levels should be measured by the same analytical method. A change in assay method may necessitate re-establishment of a baseline.
  5. Nucleic acid quantification techniques are representative of rapidly emerging and evolving new technologies. As such, users are advised to remain current on FDA-approval status.

Note: Scroll down for links to the quarterly Covered Code Lists (including
narrative).
Hydrotherapy (whirlpool) treatment for decubitus ulcers is a covered service
under Medicare for patients when treatment is reasonable and necessary.

Some other methods of treating decubitus ulcers, the safety and effectiveness
of which have not been established, are not covered under the Medicare
program. Some examples of these types of treatments are: ultraviolet light,
low intensity direct current, topical application of oxygen, and topical
dressings with Balsam of Peru in castor oil.
**100.8 - Intestinal Bypass Surgery (RETIRED)  
_(Rev. 11892; Issued: 03-09-23; Effective: 04-10-23; Implementation: 04-10-23)

**_

Please note section 100.8 has been removed from the NCD Manual and
incorporated into NCD 100.1 _effective September 24, 2013._
Fabric wrapping of abdominal aneurysms is not a covered Medicare procedure.
This is a treatment for abdominal aneurysms which involves wrapping aneurysms
with cellophane or fascia lata. This procedure has not been shown to prevent
eventual rupture. In extremely rare instances, external wall reinforcement may
be indicated when the current accepted treatment (excision of the aneurysm and
reconstruction with synthetic materials) is not a viable alternative, but
external wall reinforcement is not fabric wrapping. Accordingly, fabric
wrapping of abdominal aneurysms is not considered reasonable and necessary
within the meaning of 1862(a)(1) of the Act.
Therapeutic embolization is covered when done for hemorrhage, and for other
conditions amenable to treatment by the procedure, when reasonable and
necessary for the individual patient. Renal embolization for the treatment of
renal adenocarcinoma continues to be covered, effective December 15, 1978, as
one type of therapeutic embolization, to:

  * Reduce tumor vascularity preoperatively;
  * Reduce tumor bulk in inoperable cases; or
  * Palliate specific symptoms.
Extracranial-Intracranial (EC-IC) arterial bypass surgery is not a covered
procedure when it is performed as a treatment for ischemic cerebrovascular
disease of the carotid or middle cerebral arteries, which includes the
treatment or prevention of strokes. The premise that this procedure which
bypasses narrowed arterial segments improves the blood supply to the brain and
reduces the risk of having a stroke has not been demonstrated to be any more
effective than no surgical intervention. Accordingly, EC-IC arterial bypass
surgery is not considered reasonable and necessary within the meaning of
1862(a)(1) of the Act when it is performed as a treatment for ischemic
cerebrovascular disease of the carotid or middle cerebral arteries.
**

B. Hemoperfusion

**

This is a process which removes substances from the blood using a charcoal or
resin artificial kidney. When used in the treatment of life threatening drug
overdose, hemoperfusion is a covered service for patients with or without
renal failure. Hemoperfusion generally requires a physician to be present to
initiate treatment and to be present in the hospital or an adjacent medical
office during the entire procedure, as changes may be sudden. Special staff
training and equipment are required.

Develop charges for hemoperfusion in the same manner as for any new or unusual
service. One or two treatments are usually all that is necessary to remove the
toxic compound; document additional treatments. Hemoperfusion may be performed
concurrently with dialysis, and in those cases payment for the hemoperfusion
reflects only the additional care rendered over and above the care given with
dialysis.

The effects of using hemoperfusion to improve the results of chronic
hemodialysis are not known. Therefore, hemoperfusion is not a covered service
when used to improve the results of hemodialysis. In addition, it has not been
demonstrated that the use of hemoperfusion in conjunction with deferoxamine
(DFO), in treating symptomatic patients with iron overload, is efficacious.
There is also a paucity of data regarding its efficacy in treating
asymptomatic patients with iron overload. Therefore, hemoperfusion used in
conjunction with DFO in treating patients with iron overload is not a covered
service; i.e., it is not considered reasonable and necessary within the
meaning of 1862(a)(1) of the Act.

However, the use of hemoperfusion in conjunction with DFO for the treatment of
patients with aluminum toxicity has been demonstrated to be clinically
efficacious and is therefore regarded as a covered service.

**

C. Hemofiltration

**

This is a process which removes fluid, electrolytes and other low molecular
weight toxic substances from the blood by filtration through hollow artificial
membranes and may be routinely performed in 3 weekly sessions. Hemofiltration
(which is also known as diafiltration) is a covered procedure under Medicare
and is a safe and effective technique for the treatment of ESRD patients and
an alternative to peritoneal dialysis and hemodialysis. In contrast to both
hemodialysis and peritoneal dialysis treatments, which eliminate dissolved
substances via diffusion across semipermeable membranes, hemofiltration mimics
the filtration process of the normal kidney. The technique requires an
arteriovenous access. Hemofiltration may be performed either in facility or at
home.

The procedure is most advantageous when applied to high-risk unstable
patients, such as older patients with cardiovascular diseases or diabetes,
because there are fewer side effects such as hypotension, hypertension or
volume overload.
Intraocular photography is covered when used for the diagnosis of such
conditions as macular degeneration, retinal neoplasms, choroid disturbances
and diabetic retinopathy, or to identify glaucoma, multiple sclerosis and
other central nervous system abnormalities. Make Medicare payment for the use
of this procedure by an opthalmologist in these situations when it is
reasonable and necessary for the individual patient to receive these services.
High energy pulsed wave diathermy machines have been found to produce some
degree of therapeutic benefit for essentially the same conditions and to the
same extent as standard diathermy. Accordingly, where the Medicare
Administrative Contractor's medical staff has determined that the pulsed wave
diathermy apparatus used is one which is considered therapeutically effective,
the treatments are considered a covered service, but only for those conditions
for which standard diathermy is medically indicated and only when rendered by
a physician or incident to a physician's professional services.

(This NCD last reviewed June 2006.)
Withdrawal is an accepted treatment for narcotic addiction, and Part B payment
can be made for these services if they are provided by the physician directly
or under his personal supervision and if they are reasonable and necessary. In
reviewing claims, reasonableness and necessity are determined with the aid of
the B/Medicare Administrative Contractors medical staff.

Drugs that the physician provides in connection with this treatment are also
covered if they cannot be self-administered and meet all other statutory
requirements.
**A. Pre-Surgery Evaluations**

Cataract surgery with an intraocular lens (IOL) implant is a high volume
Medicare procedure. Along with the surgery, a substantial number of
preoperative tests are available to the surgeon. In most cases, a
comprehensive eye examination (ocular history and ocular examination) and a
single scan to determine the appropriate pseudophakic power of the IOL are
sufficient. In most cases involving a simple cataract, a diagnostic ultrasound
A-scan is used. For patients with a dense cataract, an ultrasound B-scan may
be used.

Accordingly, where the only diagnosis is cataract(s), Medicare does not
routinely cover testing other than one comprehensive eye examination (or a
combination of a brief/intermediate examination not to exceed the charge of a
comprehensive examination) and an A-scan or, if medically justified, a B-scan.
Claims for additional tests are denied as not reasonable and necessary unless
there is an additional diagnosis and the medical need for the additional tests
is fully documented.

Because cataract surgery is an elective procedure, the patient may decide not
to have the surgery until later, or to have the surgery performed by a
physician other than the diagnosing physician. In these situations, it may be
medically appropriate for the operating physician to conduct another
examination. To the extent the additional tests are considered reasonable and
necessary by A/B Medicare Administrative Contractor's medical staff, they are
covered.

**B. General Anesthesia**

The use of general anesthesia in cataract surgery may be considered reasonable
and necessary if, for particular medical indications, it is the accepted
procedure among ophthalmologists in the local community to use general
anesthesia.
**20.25 - Cardiac Catheterization Performed in Other Than a Hospital Setting
(RETIRED)  
(Rev. 11892; Issued: 03-09-23; Effective: 04-10-23; Implementation:04-10-23)**

_This section of the NCD Manual was repealed January 12, 2006._
Reconstruction of the affected and the contralateral unaffected breast
following a medically necessary mastectomy is considered a relatively safe and
effective noncosmetic procedure. Accordingly, program payment may be made for
breast reconstruction surgery following removal of a breast for any medical
reason.

Program payment may not be made for breast reconstruction for cosmetic
reasons. (Cosmetic surgery is excluded from coverage under l862(a)(l0) of the
Act.)
Local hyperthermia is covered under Medicare when used in connection with
radiation therapy for the treatment of primary or metastatic cutaneous or
subcutaneous superficial malignancies. It is not covered when used alone or in
connection with chemotherapy.
While there are two recognized surgical procedures used in treating Meniere's
disease (decompression of the endolymphatic hydrops and labyrinthectomy),
there is no scientific evidence supporting the safety and effectiveness of
cochleostomy with neurovascular transplant in treatment of Meniere's syndrome.
Accordingly, Medicare does not cover cochleostomy with neurovascular
transplant for treatment of Meniere's disease.
Scientific evidence supporting use of hemodialysis as a safe and effective
means of treatment for schizophrenia is inconclusive at this time.
Accordingly, Medicare does not cover hemodialysis for treatment of
schizophrenia.
Medicare recognizes the use of lasers for many medical indications. Procedures
performed with lasers are sometimes used in place of more conventional
techniques. In the absence of a specific noncoverage instruction, and where a
laser has been approved for marketing by the Food and Drug Administration,
Medicare Administrative Contractor discretion may be used to determine whether
a procedure performed with a laser is reasonable and necessary and, therefore,
covered.

The determination of coverage for a procedure performed using a laser is made
on the basis that the use of lasers to alter, revise, or destroy tissue is a
surgical procedure. Therefore, coverage of laser procedures is restricted to
practitioners with training in the surgical management of the disease or
condition being treated.
**

B. Nationally Covered Indications

**

Effective July 15, 1996, adult liver transplantation when performed on
beneficiaries with end- stage liver disease other than hepatitis B or
malignancies is covered under Medicare when performed in a facility which is
approved by the Centers for Medicare & Medicaid Services (CMS) as meeting
institutional coverage criteria.

Effective December 10, 1999, adult liver transplantation when performed on
beneficiaries with end-stage liver disease other than malignancies is covered
under Medicare when performed in a facility which is approved by CMS as
meeting institutional coverage criteria.

Effective September 1, 2001, Medicare covers adult liver transplantation for
hepatocellular carcinoma when the following conditions are met:

  * The patient is not a candidate for subtotal liver resection;
  * The patients tumor(s) is less than or equal to 5 cm in diameter;
  * There is no macrovascular involvement;
  * There is no identifiable extrahepatic spread of tumor to surrounding lymph nodes, lungs, abdominal organs or bone; and,
  * The transplant is furnished in a facility that is approved by CMS as meeting institutional coverage criteria for liver transplants (see 65 FR 15006).

Effective June 21, 2012, Medicare Adminstrative Contractors acting within
their respective jurisdictions may determine coverage of adult liver
transplantation for the following malignancies: (1) extrahepatic unresectable
cholangiocarcinoma (CCA); (2) liver metastases due to a neuroendocrine tumor
(NET); and, (3) hemangioendothelioma (HAE).

1\. Follow-Up Care

Follow-up care or re-transplantation required as a result of a covered liver
transplant is covered, provided such services are otherwise reasonable and
necessary. Follow-up care is also covered for patients who have been
discharged from a hospital after receiving non-covered liver transplant.
Coverage for follow-up care is for items and services that are reasonable and
necessary as determined by Medicare guidelines.

2\. Immunosuppressive Drugs

See the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other
Health Services, 50.5.1 and the Medicare Claims Processing Manual, Chapter
17, Drugs and Biologicals, 80.3.

**

C. Nationally Non-Covered Indications

**

Adult liver transplantation for other malignancies remains excluded from
coverage.

**

D. Other

**

Coverage of adult liver transplantation is effective as of the date of the
facilitys approval, but for applications received before July 13, 1991, can
be effective as early as March 8, 1990. (See 56 FR 15006 dated April 12,
1991.)

(This NCD last reviewed June 2012.)
Liver transplantation is covered for children (under age 18) with extrahepatic
biliary atresia or any other form of end stage liver disease, except that
coverage is not provided for children with a malignancy extending beyond the
margins of the liver or those with persistent viremia.

Liver transplantation is covered for Medicare beneficiaries when performed in
a pediatric hospital that performs pediatric liver transplants if the hospital
submits an application which CMS approves documenting that:

The hospital's pediatric liver transplant program is operated jointly by the
hospital and another facility that has been found by CMS to meet the
institutional coverage criteria in the "Federal Register" notice of April 12,
1991;

  * The unified program shares the same transplant surgeons and quality assurance program (including oversight committee, patient protocol, and patient selection criteria); and
  * The hospital is able to provide the specialized facilities, services, and personnel that are required by pediatric liver transplant patients.
The correction of common refractive errors by eyeglasses, contact lenses or
other prosthetic devices is specifically excluded from coverage. The use of
radial keratotomy and/or keratoplasty for the purpose of refractive error
compensation is considered a substitute or alternative to eye glasses or
contact lenses, which are specifically excluded by 1862(a)(7) of the Act
(except in certain cases in connection with cataract surgery). In addition,
many in the medical community consider such procedures cosmetic surgery, which
is excluded by section 1862(a)(10) of the Act. Therefore, radial keratotomy
and keratoplasty to treat refractive defects are not covered.

Keratoplasty that treats specific lesions of the cornea, such as
phototherapeutic keratectomy that removes scar tissue from the visual field,
deals with an abnormality of the eye and is not cosmetic surgery. Such cases
may be covered under 1862(a)(1)(A) of the Act.

The use of lasers to treat ophthalmic disease constitutes opthalmalogic
surgery. Coverage is restricted to practitioners who have completed an
approved training program in ophthalmologic surgery.
**240.6 - Transverse (Catheter) Pulmonary Embolectomy (RETIRED)  
(Rev. 11892; Issued: 03-09-23; Effective: 04-10-23; Implementation:
04-10-23)**

Effective _October 28, 2021,_ the Centers for Medicare & Medicaid Services
removed the national coverage determination (NCD) for Transvenous (Catheter)
Pulmonary Embolectomy (TPE). In the absence of an NCD, coverage determinations
will be made by the Medicare Administrative Contractors under section
1862(a)(1)(A) of the Social Security Act.
**Indications**

  1. The PTT is most commonly used to quantitate the effect of therapeutic unfractionated heparin and to regulate its dosing. Except during transitions between heparin and warfarin therapy, in general both the PTT and PT are not necessary together to assess the effect of anticoagulation therapy. PT and PTT must be justified separately.
  2. A PTT may be used to assess patients with signs or symptoms of hemorrhage or thrombosis. For example: abnormal bleeding, hemorrhage or hematoma petechiae or other signs of thrombocytopenia that could be due to disseminated intravascular coagulation; swollen extremity with or without prior trauma.
  3. A PTT may be useful in evaluating patients who have a history of a condition known to be associated with the risk of hemorrhage or thrombosis that is related to the intrinsic coagulation pathway. Such abnormalities may be genetic or acquired. For example: dysfibrinogenemia; afibrinogenemia (complete); acute or chronic liver dysfunction or failure, including Wilson's disease; hemophilia; liver disease and failure; infectious processes; bleeding disorders; disseminated intravascular coagulation; lupus erythematosus or other conditions associated with circulating inhibitors, e.g., Factor VIII Inhibitor, lupus-like anticoagulant, etc.; sepsis; von Willebrand's disease; arterial and venous thrombosis, including the evaluation of hypercoagulable states; clinical conditions associated with nephrosis or renal failure; other acquired and congenital coagulopathies as well as thrombotic states.
  4. A PTT may be used to assess the risk of thrombosis or hemorrhage in patients who are going to have a medical intervention known to be associated with increased risk of bleeding or thrombosis. An example is as follows: evaluation prior to invasive procedures or operations of patients with personal or family history of bleeding or who are on heparin therapy.

**

Limitations

**

  1. The PTT is not useful in monitoring the effects of warfarin on a patient's coagulation routinely. However, a PTT may be ordered on a patient being treated with warfarin as heparin therapy is being discontinued. A PTT may also be indicated when the PT is markedly prolonged due to warfarin toxicity.
  2. The need to repeat this test is determined by changes in the underlying medical condition and/or the dosing of heparin.
  3. Testing prior to any medical intervention associated with a risk of bleeding and thrombosis (other than thrombolytic therapy) will generally be considered medically necessary only where there are signs or symptoms of a bleeding or thrombotic abnormality or a personal history of bleeding, thrombosis or a condition associated with a coagulopathy. Hospital/clinic-specific policies, protocols, etc., in and of themselves, cannot alone justify coverage.

Note: Scroll down for links to the quarterly Covered Code Lists (including
narrative).
Use of fluidized therapy dry heat is covered as an acceptable alternative to
other heat therapy modalities in the treatment of acute or subacute traumatic
or nontraumatic musculoskeletal disorders of the extremities.