Persius/hicric huggingface dataset:
**

B.   Nationally Covered Indications

**

The following indications are covered for implanted permanent single chamber
or dual chamber cardiac pacemakers:

  1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and
  2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.

**

C.   Nationally Non-Covered Indications

**

The following indications are non-covered for implanted permanent single
chamber or dual chamber cardiac pacemakers:

  1. Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia,
  2. Asymptomatic first degree atrioventricular block,
  3. Asymptomatic sinus bradycardia,
  4. Asymptomatic sino-atrial block or asymptomatic sinus arrest,
  5. Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia,
  6. Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle (a component of the electrical conduction system of the heart),
  7. Syncope of undetermined cause,
  8. Bradycardia during sleep,
  9. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent atrioventricular block,
  10. Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker drug therapy,
  11. Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the control of tachycardia, and
  12. A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated with a reasonable likelihood that pacing needs will become prolonged.

**

D.   Other

**

Medicare Administrative Contractors will determine coverage under section
1862(a)(1)(A) of the Social Security Act for any other indications for the
implantation and use of single chamber or dual chamber cardiac pacemakers that
are not specifically addressed in this national coverage determination.

(This NCD last reviewed August 2013.)
**

B.      Nationally Covered Indications

**

Effective for dates of service on and after February 18, 2014, CMS has
determined that the evidence is sufficient to expand coverage for cardiac
rehabilitation services under 42 CFR 410.49(b)(1)(vii) to beneficiaries with
stable, chronic heart failure, defined as patients with left ventricular
ejection fraction of 35% or less and New York Heart Association (NYHA) class
II to IV symptoms despite being on optimal heart failure therapy for at least
six weeks. Stable patients are defined as patients who have not had recent (
6 weeks) or planned ( 6 months) major cardiovascular hospitalizations or
procedures. (See section A above for other indications covered under 42 CFR
410.49(b)(1)(vii)).

**

C.      Nationally Non-Covered Indications

**

Any cardiac indication not specifically identified in 42 CFR
410.49(b)(1)(vii) or identified as covered in this NCD or any other NCD in
relation to cardiac rehabilitation services is considered non-covered.

**

D.      Other

**

NA

(This NCD last reviewed February 2014.)
**B. Nationally Covered Indications

**

Effective for claims with dates of service on or after February 10, 2022, CMS
has determined that the evidence is sufficient to cover, under Medicare Part
B, a lung cancer screening counseling and shared decision-making visit, and
for appropriate beneficiaries, annual screening for lung cancer with LDCT, as
an additional preventive service benefit under the Medicare program, only if
all of the following eligibility criteria are met.

_Beneficiary Eligibility Criteria

_

Beneficiaries must meet all of the following eligibility criteria:

  * Age 50 - 77 years;
  * Asymptomatic (no signs or symptoms of lung cancer);
  * Tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack =20 cigarettes);
  * Current smoker or one who has quit smoking within the last 15 years; and,
  * Receive an order for lung cancer screening with LDCT.

_

Counseling and Shared Decision-Making Visit

_

Before the beneficiary's first lung cancer LDCT screening, the beneficiary
must receive a counseling and shared decision-making visit that meets all of
the following criteria, and is appropriately documented in the beneficiary's
medical records:

* Determination of beneficiary eligibility;
* Shared decision-making, including the use of one or more decision aids;
* Counseling on the importance of adherence to annual lung cancer LDCT screening, impact of comorbidities and ability or willingness to undergo diagnosis and treatment; and,
* Counseling on the importance of maintaining cigarette smoking abstinence if former smoker; or the importance of smoking cessation if current smoker and, if appropriate, furnishing of information about tobacco cessation interventions.

_Reading Radiologist Eligibility Criteria

_

The reading radiologist must have board certification or board eligibility
with the American Board of Radiology or equivalent organization.

_Radiology Imaging Facility Eligibility Criteria

_

Lung cancer screening with LDCT must be furnished in a radiology imaging
facility that utilizes a standardized lung nodule identification,
classification, and reporting system.

**C. Nationally Non-Covered Indications

**

Preventive services are non-covered by Medicare unless specifically covered in
this NCD, any other NCD, or in statute or regulations.

**D. Other

**

Medicare Part B coinsurance and deductible are waived for this preventive
service.

(This NCD last reviewed February 2022.)
**B. Nationally Covered Indications**

Effective for services performed on or after May 25, 2017, the Centers for
Medicare & Medicaid Services has determined that the evidence is sufficient to
cover SET for beneficiaries with IC for the treatment of symptomatic PAD. Up
to 36 sessions over a 12-week period are covered if all of the following
components of a SET program are met. The SET program must:

  * consist of sessions lasting 30-60 minutes comprising a therapeutic exercise-training program for PAD in patients with claudication;
  * be conducted in a hospital outpatient setting, or a physicians office;
  * be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and
  * be under the direct supervision of a physician (as defined in 1861(r)(1)), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in 1861(aa)(5)) who must be trained in both basic and advanced life support techniques.

Beneficiaries must have a face-to-face visit with the physician responsible
for PAD treatment to obtain the referral for SET. At this visit, the
beneficiary must receive information regarding cardiovascular disease and PAD
risk factor reduction, which could include education, counseling, behavioral
interventions, and outcome assessments.

**C. Nationally Non-Covered Indications**

SET is non-covered for beneficiaries with absolute contraindications to
exercise as determined by their primary physician.

**D. Other**

Medicare Administrative Contractors (MACs) have the discretion to cover SET
beyond the nationally covered 36 sessions over a 12-week period. MACs may
cover an additional 36 sessions over an extended period of time. A second
referral is required for these additional sessions

(This NCD last reviewed May 2017.)
**B.    Nationally Covered Indications**

A.  Effective for services performed on or after August 7, 2019, the Centers
for Medicare & Medicaid Services (CMS) covers autologous treatment for cancer
with T-cells expressing at least one chimeric antigen receptor (CAR) when
administered at healthcare facilities enrolled in the FDA risk evaluation and
mitigation strategies (REMS) and used for a medically accepted indication as
defined at Social Security Act section 1861(t)(2) -i.e., is used for either an
FDA-approved indication (according to the FDA-approved label for that
product), or for other uses when the product has been FDA-approved and the use
is supported in one or more CMS-approved compendia.

**C.    Nationally Non-Covered

**

Effective for services performed on or after August 7, 2019, the use of non-
FDA-approved autologous T-cells expressing at least one CAR is non-covered.
Autologous treatment for cancer with T-cells expressing at least one CAR is
non-covered when the requirements in Section A are not met.

**D. Other

**

Effective for services performed on or after August 7, 2019, routine costs in
clinical trials that use CAR T-cell therapy as an investigational agent that
meet the requirements listed in NCD 310.1 will be covered.

(This NCD last reviewed August 2019.)
Billing and Coding: Bortezomib

This article contains billing and coding guidelines that complement the Local
Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and
Off-Label Uses.

  
**Abstract:**  
  
Bortezomib is an antineoplastic agent which inhibits the activity of the 26S
proteasome. It exhibits cytotoxicity to various malignant cells, including
myeloma and lymphoma cells.  
  
 **Documentation Requirements:**  
  
When modifier -JW is used to report that a portion of the drug is discarded,
the medical record must clearly show the amount administered and the amount
wasted. Effective July 1, 2023 (CR 13056) JZ Modifier is required on all
claims that bill for drugs separately payable under Medicare Part B when there
are no discarded amounts from single-dose containers or single-use packages.

  
**Utilization:**  
  
Dose and frequency should be in accordance with the FDA label or recognized
compendia (for off-label uses). When services are performed in excess of
established parameters, they may be subject to review for medical necessity.  
  
 **FDA and Compendia Review:**  
  
American Society of Health-System Pharmacists, Inc. _AHFS Drug Information ._
Bethesda, MD: 2007.  
  
Clinical Pharmacology Web site. http://www.clinicalpharmacology.com/. Accessed
06/06/2023.  
  
FDA label for Velcade (bortezomib) approval 01/23/2012.  
  
Lexi-Drugs Web site. http://online.lexi.com. Accessed 06/06/2023.  
  
Micromedex DrugDex. http://www.thomsonhc.com/home/dispatch. Accessed
06/06/2023.  
  
National Comprehensive Cancer Network Web site. http://www.nccn.org/index.asp.
Accessed 06/02/2023.  
  
U.S. Food and Drug Administration approval letter for VELCADETM (bortezomib),
dated May 13, 2003.  
  
U.S. Food and Drug Administration label for bortezomib approved 10/08/2014
accessed on line at http://www.accessdata.fda.gov/scripts/cder/drugsatfda/ on
10/23/2014.  
  
United States Pharmacopoeia (USP), Volume I; Drug Information for the Health
Care Professional, 2007.
Billing and Coding: Ibandronate Sodium

This article contains billing and coding guidelines that complement the Local
Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and
Off-Label Uses.

The intravenous form of ibandronate was approved by the Food and Drug
Administration (FDA) for use every three (3) months.

**Specific coding guidelines for this drug:**

Ibandronate sodium is available in oral and intravenous forms. National
Government Services will consider the intravenous form to be "reasonable and
necessary" only for patients for whom biphosphonate therapy including oral
ibandronate sodium is medically necessary and who cannot tolerate oral
therapy. Documentation must show that the patient cannot tolerate oral
biphosphonates or that they are otherwise medically contraindicated.  
  
 **Coding Information:**  
  

  1. When submitting claims for senile osteoporosis or other osteoporosis, ICD-10-CM code K20.80, K20.81, K20.90, K20.91 or Z87.19 should _only_ be added to claims to indicate that the patient has severe esophagitis and cannot take the oral drugs.  
  

  2. When submitting claims for senile osteoporosis or other osteoporosis, ICD-10-CM code T50.995A-T50.995S, Y63.8, Z91.89 or Z92.89 should _only_ be added to claims to indicate that the patient cannot tolerate oral ibandronate sodium.   
  

  3. For management of hypercalcemia of malignancy (E83.52), the rationale for the use of the drug and the related malignancy must be documented in the patient's medical record.   
  

  4. When submitting claims for patients with osteoporosis as a complication of transplant, the related complication of transplant code as well as T50.995A-T50.995S or Z87.19 is required.  
  

  5. When ibandronate is used to prevent osteoporosis in a postmenopausal woman who is not being treated for osteopenia, the claim should include the -GY modifier which will result in denial of Medicare payment.

**Utilization:**  
  
Dose and frequency should be in accordance with the FDA label or recognized
compendia (for off-label uses). When services are performed in excess of
established parameters, they may be subject to review for medical necessity.  
  
 **FDA and Compendia Review:**  
  
American Society of Health-System Pharmacists, Inc. _AHFS Drug Information ._
Bethesda, MD: 2007.  
  
Clinical Pharmacology Web site. http://www.clinicalpharmacology.com/. Accessed
08/21/2023.

Lexi-Drugs Web site. http://online.lexi.com. Accessed 08/21/2023.  
  
Micromedex DrugDex. http://www.micromedexsolutions.com/home/dispatch.
Accessed 08/21/2023.  
  
National Comprehensive Cancer Network Web site. http://www.nccn.org/index.asp.
Accessed 08/21/2023.  
  
U.S. Food and Drug Administration label approved 01/06/2006 accessed on line
at _http://www.accessdata.fda.gov/scripts/cder/drugsatfda/_ on 11/19/2007.  
  
United States Pharmacopoeia (USP), Volume I; Drug Information for the Health
Care Professional, 2007.
Billing and Coding: Osteopathic Manipulative Treatment

Osteopathic manipulative treatment (OMT) is a treatment employed, primarily by
osteopathic physicians, to facilitate a patient's recovery from somatic
dysfunction, defined under the American Osteopathic Association's Glossary of
Terminology as: impaired or altered function of related components of the
somatic (body framework) system: skeletal, arthroidal and myofascial
structures and related vascular, lymphatic and neuroelements. The positional
and motion aspects of somatic dysfunction are best described using at least
one of three parameters: 1. The position of a body part as determined by
palpation and reference to its adjacent defined structure, 2. The direction in
which motion is freer, and 3. The direction in which motion is restricted.  
  
Osteopathic manipulative treatment includes muscle energy, high velocity-low
amplitude, counterstrain, myofascial release, visceral, and craniosacral. The
chosen treatment will vary depending on patient's age and clinical condition.  
  
  
 **Indications of Coverage**  
  
  
Osteopathic Manipulative Treatment is covered when medically necessary and
performed by a qualified physician, in patients whose history and physical
examination indicate the presence of somatic dysfunction of one or more
regions.  
  
Note:

  * Osteopathic Manipulative Treatment(OMT) specifically encompasses only the procedure itself.
  * Evaluation and management(E&M)services may be reported seperately using modifier -25 if the patient's condition requires a significant and identifiable E&M service which is above and beyond the usual pre and post service work associated with the OMT procedure; and it is appropriately documented.
  * While the E&M service may be caused or prompted by the same symptoms or condition for which the OMT service was provided; documentation for the E&M must support this was a distinct and seperate purpose from the OMT evaluation and treatment.
  * Different diagnoses are not required for the reporting of the OMT and E&M on the same date.

  
  
**Limitations of Coverage**  
  
Osteopathic Manipulative Treatment is not covered when the indication of
Coverage is not met, and conventional documentation of somatic dysfunction is
not present in the patient's medical record  
  
 **Note: No E &M service is warranted for planned follow-up OMT treatments
unless a new condition occurs or the patient's condition has changed
substantially, necessitating an overall reassessment.**
Billing and Coding: Paclitaxel (e.g., Taxol/Abraxane )

This article contains billing and coding guidelines that complement the Local
Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and
Off-Label Uses.  
  
 **Abstract:**  
  
Paclitaxel is a natural product with antitumor (antineoplastic) activity
obtained via a semi-synthetic process from Taxus baccata. Paclictaxel is
administered as an intravenous agent and inhibits the replication of cells by
interfering with mitosis (cellular division).

**Documentation Requirements:**  
  
For any claims submitted for albumin-bound paclitaxel, documentation should be
included in the patient's medical record showing prior therapy included an
anthracycline unless clinically contraindicated.

When modifier -JW is used to report that a portion of the drug is discarded,
the medical record must clearly show the amount administered and the amount
wasted. Effective July 1, 2023 (CR 13056) JZ Modifier is required on all
claims that bill for drugs separately payable under Medicare Part B when there
are no discarded amounts from single-dose containers or single-use packages.

  **Utilization:  
**  
Dose and frequency should be in accordance with the FDA label or recognized
compendia (for off-label uses). When services are performed in excess of
established parameters, they may be subject to review for medical necessity.  
  
 **Coding Information:**

When billing for metastatic (secondary) disease, only use the code for the
primary malignancy if still present, and only use the related "personal
history of" Z code if not.  
  
 **FDA and Compendia Review** **:**  
  
American Society of Health-System Pharmacists, Inc. _AHFS Drug Information ._
Bethesda, MD: 2007.  
  
Clinical Pharmacology Web site. http://www.clinicalpharmacology.com/. Accessed
06/06/2023.  
  
Lexi-Drugs Web site. http://online.lexi.com. Accessed 06/06/2023.  
  
Micromedex DrugDex. http://www.thomsonhc.com/home/dispatch. Accessed
06/06/2023.  
  
National Comprehensive Cancer Network Web site. http://www.nccn.org/index.asp.
Accessed 06/02/2023.  
  
U.S. Food and Drug Administration label Drugs@FDA Web site.
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/. Accessed 02/01/2008.
Billing and Coding: Ranibizumab and biosimilars, Aflibercept, Aflibercept HD,
Brolucizumab-dbll and Faricimab-svoa

This article contains billing and coding guidelines that complement the Local
Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and
Off-Label Uses.

**Abstract:**  
  
Ranibizumab, a recombinant humanized immunoglobin G, kappa monoclonal antibody
fragment, is a vascular endothelial growth factor A (VEGF-A) antagonist used
as an intravitreal injection.  
  
Aflibercept is a recombinant fusion protein consisting of portions of human
VEGF receptors 1 and 2 extracellular domains fused to the Fc portion of human
IgG1 formulated as an iso-osmotic solution for intravitreal administration.

Brolucizumab-dbll is a human vascular endothelial growth factor (VEGF)
inhibitor used as an intravitreal injection.

Faricimab-svoa is a vascular endothelial growth factor (VEGF) inhibitor and
angiopoietin-2 (Ang-2) inhibitor.

Ranibizumab-eqrn is a vascular endothelial growth factor (VEGF) inhibitor
interchangeable to Lucentis (ranibizumab).

Aflibercept HD is a vascular endothelial growth factor (VEGF) inhibitor used
as an intravitreal injection.

  
**Utilization:**  
  
The dose and frequency of administration should be consistent with the FDA
approved package insert. When dose and/or frequency are different from the FDA
approved package insert, literature support for the specific schedule chosen
should be available.  
  
 **Coding Information:**  
  
The administration for ranibizumab, ranibizumab-nuna, ranibizumab-eqrn,
aflibercept, aflibercept HD, brolucizumab-dbll or faricimab-svoa must be
billed on the same claim as the drug, with CPT code 67028 (intravitreal
injection of a pharmacologic agent).  
  
The appropriate site modifier (RT, LT or 50) must be appended to CPT code
67028 to indicate if the service was performed unilaterally or bilaterally.
Claims without a modifier will be returned to the provider unprocessed.

If the drug is denied as not reasonable and necessary, the associated
injection code will also be denied.  
  
 **For claims submitted to the Part A and Part B MAC:**  
  
Ranibizumab should be reported with HCPCS code J2778.  
  
Aflibercept should be reported with HCPCS code J0178.

Brolucizumab-dbll should be reported with HCPCS code J0179.

Ranibizumab-nuna should be reported with HCPCS code Q5124.

Faricimab-svoa should be reported with HCPCS code J2777.

Ranibizumab-eqrn should be reported with HCPCS codes Q5128.

Aflibercept HD should be reported with HCPCS code C9161.  
  
 **FDA and Compendia Review:**  
  
American Society of Health-System Pharmacists, Inc. _AHFS Drug Information ._
Bethesda, MD: 2014.  
  
Clinical Pharmacology Web site. http://www.clinicalpharmacology.com/. Accessed
03/08/222.

FDA Web site. https://www.accessdata.fda.gov/scripts/cder/daf/  
  
Lexi-Drugs Web site. http://online.lexi.com/lco/action/home. Accessed
03/08/2022.  
  
Micromedex DrugDex Thomson Web site. http://www.thomsonhc.com/home/dispatch.
Accessed 03/08/2022.  
  
National Comprehensive Cancer Network Web site. http://www.nccn.org/index.asp.
Accessed 03/08/2022.
Self-Administered Drug Exclusion List: and Biologicals Excluded from Coverage
- Medical Policy Article

The table below lists drugs that are not covered by Medicare, the effective
date of non-coverage, and the rationale. (Please see "Process for Determining
Self-Administered Drug Exclusions - Medical Policy Article") The column,
"Brand Names," provides one or more examples but not all. Information about
drugs not separately reimbursed or not covered for reasons other than "usually
self-administered," is found in other Part A and Part B MAC publications and
sites.  
  
In the interest of consistent Medicare, the CGS Administrators Part A MAC will
follow the coverage decision for self-administered drugs as determined by the
Part B MAC in each respective state. HCPCS codes for the same drugs that apply
only to providers that bill the Part A MAC (e.g., HCPCS codes used for drugs
billable under the Outpatient Prospective Payment System [OPPS]) are included
when applicable.

The use of the JA and JB modifiers is required for drugs which have one HCPCS
Level II (J or Q) code but multiple routes of administration. Drugs that fall
under this category will be marked with an asterisk (*) and must be billed
with the JA modifier for the intravenous infusion of the drug or billed with
the JB modifier for the subcutaneous injection form of administration. Claims
billed with the JA modifier are not part of the SAD exclusion. The Contractor
will process claims with the JA modifier applying the policy that not only the
drug is medically reasonable and necessary, but also that the route of
administration is medically reasonable and necessary. Subcutaneously
administered drugs listed on the Usually Self-Administered list will be denied
as a benefit exclusion. Claims for drugs marked with an asterisk (*) billed
without either a JA or JB modifier will also be denied.

And mark all applicable drugs with *.
Traumeel Injections

CGS has determined that the injection of Traumeel, a homeopathic formulation,
into the soft tissues, ligaments or other structures of the foot or ankle is
not medically necessary. There are no published studies on Traumeel injections
in humans in the peer-reviewed literature.

  * CPT codes 20550-20553 will be denied if the material injected is determined to be Traumeel.
  * HCPCS code J3490 will be denied when used to denote Traumeel.