Persius/hicric huggingface dataset:
In addition to the traditional surgical/endoscopic techniques for the
treatment of kidney stones, the following lithotripsy techniques are also
covered for services rendered on or after March l5, l985.

**

A. Extracorporeal Shock Wave Lithotripsy

**

Extracorporeal Shock Wave Lithotripsy (ESWL) is a non-invasive method of
treating kidney stones using a device called a lithotriptor. The lithotriptor
uses shock waves generated outside of the body to break up upper urinary tract
stones. It focuses the shock waves specifically on stones under X-ray
visualization, pulverizing them by repeated shocks. ESWL is covered under
Medicare for use in the treatment of upper urinary tract kidney stones.

**

B. Percutaneous Lithotripsy

**

Percutaneous lithotripsy (or nephrolithotomy) is an invasive method of
treating kidney stones by using ultrasound, electrohydraulic or mechanical
lithotripsy. A probe is inserted through an incision in the skin directly over
the kidney and applied to the stone. A form of lithotripsy is then used to
fragment the stone. Mechanical or electrohydraulic lithotripsy may be used as
an alternative or adjunct to ultrasonic lithotripsy. Percutaneous lithotripsy
of kidney stones by ultrasound or by the related techniques of
electrohydraulic or mechanical lithotripsy is covered under Medicare.

The following is covered for services rendered on or after January 16, 1988.

**

C. Transurethral Ureteroscopic Lithotripsy

**

Transurethral ureteroscopic lithotripsy is a method of fragmenting and
removing ureteral and renal stones through a cystoscope. The cystoscope is
inserted through the urethra into the bladder. Catheters are passed through
the scope into the opening where the ureters enter the bladder. Instruments
passed through this opening into the ureters are used to manipulate and
ultimately disintegrate stones, using either mechanical crushing,
transcystoscopic electrohydraulic shock waves, ultrasound or laser.
Transurethral ureteroscopic lithotripsy for the treatment of urinary tract
stones of the kidney or ureter is covered under Medicare.
**B. Nationally Covered Indications**

Effective for services performed on or after July 1, 1999, whole organ
pancreas transplantation is nationally covered by Medicare when performed
simultaneous with or after a kidney transplant. If the pancreas transplant
occurs after the kidney transplant, immunosuppressive therapy begins with the
date of discharge from the inpatient stay for the pancreas transplant.

Effective for services performed on or after April 26, 2006, pancreas
transplants alone (PA) are reasonable and necessary for Medicare beneficiaries
in the following limited circumstances:

  1. PA will be limited to those facilities that are Medicare-approved for kidney transplantation. (Approved centers can be found at http://www.cms.gov/ESRDGeneralInformation/02_Data.asp#TopOfPage
  2. Patients must have a diagnosis of type I diabetes: 
    * Patient with diabetes must be beta cell autoantibody positive; or
    * Patient must demonstrate insulinopenia defined as a fasting C-peptide level that is less than or equal to 110% of the lower limit of normal of the laboratory's measurement method. Fasting C-peptide levels will only be considered valid with a concurrently obtained fasting glucose  225 mg/dL;
  3. Patients must have a history of medically-uncontrollable labile (brittle) insulin-dependent diabetes mellitus with documented recurrent, severe, acutely life-threatening metabolic complications that require hospitalization. Aforementioned complications include frequent hypoglycemia unawareness or recurring severe ketoacidosis, or recurring severe hypoglycemic attacks;
  4. Patients must have been optimally and intensively managed by an endocrinologist for at least 12 months with the most medically-recognized advanced insulin formulations and delivery systems;
  5. Patients must have the emotional and mental capacity to understand the significant risks associated with surgery and to effectively manage the lifelong need for immunosuppression; and,
  6. Patients must otherwise be a suitable candidate for transplantation.

**C. Nationally Non-Covered Indications**

The following procedure is not considered reasonable and necessary within the
meaning of section 1862(a)(1)(A) of the Social Security Act:

  1. Transplantation of partial pancreatic tissue or islet cells (except in the context of a clinical trial (see section[ 260.3.1](https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=286&ncdver=1) of the National Coverage Determinations Manual ).

**D. Other**

Not applicable.

(This NCD last reviewed April 2006.)
Twenty-four hour ambulatory pH monitoring is covered by Medicare for patients
who are suspected of having gastric reflux, but only if the patient presents
diagnostic problems associated with atypical symptoms or the patient's
symptoms are suggestive of reflux, but conventional tests have not confirmed
the presence of reflux.
**160.4  Stereotactic Cingulotomy as a Means of Psychosurgery (RETIRED)  
_(Rev. 11892; Issued: 03-09-23; Effective: 04-10-23; Implementation:
04-10-23)**

_

Effective December 18, 2014, NCD 160.4 is _retired._
**100.11  Gastric Balloon for Treatment of Obesity (RETIRED)  
_(Rev. 11892; Issued: 03-09-23; Effective: 04-10-23; Implementation:
04-10-23)**_

Please note section 100.11 has been removed from the NCD Manual and
incorporated into NCD 100.1 _effective September 24, 2013._
**20.5 - Extracorporeal Immunoadsorption (ECI) Using Protein A Columns
(RETIRED)**  
_(Rev. 11892; Issued: 03-09-23; Effective: 04-10-23; Implementation:04-10-23)_

Effective January 1, 2021, the Centers for Medicare & Medicaid Services
determined that no national coverage determination (NCD) is appropriate at
this time for Extracorporeal Immunoadsorption (ECI) Using Protein A Columns.
In the absence of an NCD, coverage determinations will be made by the Medicare
Administrative Contractors under 1862(a)(1)(A) of the Social Security Act.
Laparoscopic cholecystectomy is a covered surgical procedure in which a
diseased gall bladder is removed through the use of instruments introduced via
cannulae, with vision of the operative field maintained by use of a high-
resolution television camera-monitor system (video laparoscope). For inpatient
claims, report the diagnosis code for laparoscopic cholecystectomy. For all
other claims, report the appropriate CPT code for laparoscopy, surgical;
cholecystectomy (any method), and the appropriate CPT code for laparoscopy,
surgical: cholecystectomy with cholangiography.
After review of this issue, CMS has concluded that the evidence concerning the
medical efficacy of TM is incomplete at best and does not demonstrate
effectiveness and that a professional level of skill is not required for the
training of patients to engage in TM.

Although many articles have been written about application of TM for patients
with certain forms of hypertension and anxiety, there are no rigorous
scientific studies that demonstrate the effectiveness of TM for use as an
adjunct medical therapy for such conditions. Accordingly, neither TM nor the
training of patients for its use are covered under the Medicare program.
**

Indications

**

CEA may be medically necessary for follow-up of patients with colorectal
carcinoma. It would however only be medically necessary at treatment decision-
making points. In some clinical situations (e.g. adenocarcinoma of the lung,
small cell carcinoma of the lung, and some gastrointestinal carcinomas) when a
more specific marker is not expressed by the tumor, CEA may be a medically
necessary alternative marker for monitoring. Preoperative CEA may also be
helpful in determining the post-operative adequacy of surgical resection and
subsequent medical management. In general, a single tumor marker will suffice
in following patients with colorectal carcinoma or other malignancies that
express such tumor markers.

In following patients who have had treatment for colorectal carcinoma, ASCO
guideline suggests that if resection of liver metastasis would be indicated,
it is recommended that post-operative CEA testing be performed every two to
three months in patients with initial stage II or stage III disease for at
least two years after diagnosis.

For patients with metastatic solid tumors which express CEA, CEA may be
measured at the start of the treatment and with subsequent treatment cycles to
assess the tumor's response to therapy.

**

Limitations

**

Serum CEA determinations are generally not indicated more frequently than once
per chemotherapy treatment cycle for patients with metastatic solid tumors
which express CEA or every two months post-surgical treatment for patients who
have had colorectal carcinoma. However, it may be proper to order the test
more frequently in certain situations, for example, when there has been a
significant change from prior CEA level or a significant change in patient
status which could reflect disease progression or recurrence.

Testing with a diagnosis of an in situ carcinoma is not reasonably done more
frequently than once, unless the result is abnormal, in which case the test
may be repeated once.

Note: Scroll down for links to the quarterly Covered Code Lists (including
narrative).
CMS therefore covers TMR as a late or last resort for patients with severe
(Canadian Cardiovascular Society classification Classes III or IV) angina
(stable or unstable), which has been found refractory to standard medical
therapy, including drug therapy at the maximum tolerated or maximum safe
dosages. In addition, the angina symptoms must be caused by areas of the heart
not amenable to surgical therapies such as percutaneous transluminal coronary
angioplasty, stenting, coronary atherectomy or coronary bypass.

Coverage is further limited to those uses of the laser used in performing the
procedure which have been approved by the Food and Drug Administration for the
purpose for which they are being used.

Patients would have to meet the following additional selection guidelines:

  * An ejection fraction of 25% or greater;
  * Have areas of viable ischemic myocardium (as demonstrated by diagnostic study) which are not capable of being revascularized by direct coronary intervention; and
  * Have been stabilized, or have had maximal efforts to stabilize acute conditions such as severe ventricular arrhythmias, decompensated congestive heart failure or acute myocardial infarction.

Coverage is limited to physicians who have been properly trained in the
procedure. Providers of this service must also document that all ancillary
personnel, including physicians, nurses, operating room personnel and
technicians, are trained in the procedure and the proper use of the equipment
involved. Coverage is further limited to providers which have dedicated
cardiac care units, including the diagnostic and support services necessary
for care of patients undergoing this therapy. In addition, these providers
must conform to the standards for laser safety set by the American National
Standards Institute, ANSIZ1363.
Indications

AFP is useful for the diagnosis of hepatocellular carcinoma in high-risk
patients (such as alcoholic cirrhosis, cirrhosis of viral etiology,
hemochromatosis, and alpha 1-antitrypsin deficiency) and in separating
patients with benign hepatocellular neoplasms or metastases from those with
hepatocellular carcinoma and, as a non-specific tumor associated antigen,
serves in marking germ cell neoplasms of the testis, ovary, retroperitoneum,
and mediastinum.

Note: Scroll down for links to the quarterly Covered Code Lists (including
narrative).
Since the mortality rate is high and there are no published scientific
articles or clinical studies regarding partial ventriculectomy, this procedure
cannot be considered reasonable and necessary within the meaning of
1862(a)(1) of the Act. Therefore, partial ventriculectomy is not covered by
Medicare.
Cryosurgery of the prostate as a salvage therapy is not covered for any
services performed prior to June 30, 2001.

Salvage Cryosurgery of Prostate After Radiation Failure. Salvage cryosurgery
of the prostate for recurrent cancer is medically necessary and appropriate
only for those patients with localized disease who:

  1. Have failed a trial of radiation therapy as their primary treatment; and
  2. Meet one of the following conditions: Stage T2B or below, Gleason score <9, PSA <8 ng/mL.

Cryosurgery as salvage therapy is therefore not covered under Medicare after
failure of other therapies as the primary treatment. Cryosurgery as salvage is
only covered after the failure of a trial of radiation therapy, under the
conditions noted above.
There is insufficient scientific data to support the benefits of this
technique. Therefore, VAX-D is not covered by Medicare.
Human Chorionic Gonadotropin (hCG) is useful for monitoring and diagnosis of
germ cell neoplasms of the ovary, testis, mediastinum, retroperitoneum, and
central nervous system. In addition, hCG is useful for monitoring pregnant
patients with vaginal bleeding, hypertension and/or suspected fetal loss.

It is not reasonable and necessary to perform hCG testing more than once per
month for diagnostic purposes. It may be performed as needed for monitoring of
patient progress and treatment. Qualitative hCG assays are not appropriate for
medically managing patients with known or suspected germ cell neoplasms.

Note: Scroll down for links to the quarterly Covered Code Lists (including
narrative).
**CIM 35-99**

Abortions are not covered Medicare procedures except:

  1. If the pregnancy is the result of an act of rape or incest; or
  2. In the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.
**Ocular photodynamic therapy (OPT)**

Ocular Photodynamic Therapy (OPT) is used in the treatment of ophthalmologic
diseases. OPT is only covered when used in conjunction with verteporfin (see
section 80.3, "Photosensitive Drugs").

  * Classic Subfoveal Choroidal Neovascular (CNV) Lesions - OPT is covered with a diagnosis of neovascular age-related macular degeneration (AMD) with predominately classic subfoveal choroidal neovascular (CNV) lesions (where the area of classic CNV occupies  50% of the area of the entire lesion) at the initial visit as determined by a fluorescein angiogram (FA). Subsequent follow-up visits will require either an optical coherence tomography or an FA to access treatment response. There are no requirements regarding visual acuity, lesion size, and number of re-treatments. 
  * Occult Subfoveal CNV Lesions - OPT is non-covered for patients with a diagnosis of AMD with occult and no classic CNV lesions.

Other Conditions - Use of OPT with verteporfin for other types of AMD (e.g.,
patients with minimally classic CNV lesions, atrophic, or dry AMD) is non-
covered. OPT with verteporfin for other ocular indications such as pathologic
myopia or presumed ocular histoplasmosis syndrome, is eligible for coverage
through individual Medicare Administrative Contractor discretion.
Effective for services performed on and after November 26, 2001, Medicare
covers the destruction of actinic keratoses without restrictions based on
lesion or patient characteristics.
**

Indications

**

CA 125 is a high molecular weight serum tumor marker elevated in 80% of
patients who present with epithelial ovarian carcinoma. It is also elevated in
carcinomas of the fallopian tube, endometrium, and endocervix. An elevated
level may also be associated with the presence of a malignant mesothelioma _or
primary peritoneal carcinoma_.

A CA125 level may be obtained as part of the initial pre-operative work-up for
women presenting with a suspicious pelvic mass to be used as a baseline for
purposes of post-operative monitoring. Initial declines in CA 125 after
initial surgery and/or chemotherapy for ovarian carcinoma are also measured by
obtaining three serum levels during the first month post treatment to
determine the patient's CA 125 half-life, which has significant prognostic
implications.

The CA 125 levels are again obtained at the completion of chemotherapy as an
index of residual disease. Surveillance CA125 measurements are generally
obtained every 3 months for 2 years, every 6 months for the next 3 years, and
yearly thereafter. CA 125 levels are also an important indicator of a
patient's response to therapy in the presence of advanced or recurrent
disease. In this setting, CA 125 levels may be obtained prior to each
treatment cycle.

**

Limitations

**

These services are not covered for the evaluation of patients with signs or
symptoms suggestive of malignancy. The service may be ordered at times
necessary to assess either the presence of recurrent disease or the patient's
response to treatment with subsequent treatment cycles.

The CA 125 is specifically not covered for aiding in the differential
diagnosis of patients with a pelvic mass as the sensitivity and specificity of
the test is not sufficient. In general, a single "tumor marker" will suffice
in following a patient with one of these malignancies.

_(This NCD last reviewed November 2005)_

Note: Scroll down for links to the quarterly Covered Code Lists (including
narrative).
**

A. Nationally Covered Indications

**

The use of ES and electromagnetic therapy for the treatment of wounds are
considered adjunctive therapies, and will only be covered for chronic Stage
III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous
stasis ulcers. Chronic ulcers are defined as ulcers that have not healed
within 30 days of occurrence. ES or electromagnetic therapy will be covered
only after appropriate standard wound therapy has been tried for at least 30
days and there are no measurable signs of improved healing. This 30-day period
may begin while the wound is acute.

Standard wound care includes: optimization of nutritional status, debridement
by any means to remove devitalized tissue, maintenance of a clean, moist bed
of granulation tissue with appropriate moist dressings, and necessary
treatment to resolve any infection that may be present. Standard wound care
based on the specific type of wound includes: frequent repositioning of a
patient with pressure ulcers (usually every 2 hours), offloading of pressure
and good glucose control for diabetic ulcers, establishment of adequate
circulation for arterial ulcers, and the use of a compression system for
patients with venous ulcers.

Measurable signs of improved healing include: a decrease in wound size (either
surface area or volume), decrease in amount of exudates, and decrease in
amount of necrotic tissue. ES or electromagnetic therapy must be discontinued
when the wound demonstrates 100% epitheliliazed wound bed.

ES and electromagnetic therapy services can only be covered when performed by
a physician, physical therapist, or incident to a physician service.
Evaluation of the wound is an integral part of wound therapy. When a
physician, physical therapist, or a clinician incident to a physician,
performs ES or electromagnetic therapy, the practitioner must evaluate the
wound and contact the treating physician if the wound worsens. If ES or
electromagnetic therapy is being used, wounds must be evaluated at least
monthly by the treating physician.

**

B. Nationally Non-Covered Indications

**

1\. ES and electromagnetic therapy will not be covered as an initial treatment
modality.

2\. Continued treatment with ES or electromagnetic therapy is not covered if
measurable signs of healing have not been demonstrated within any 30-day
period of treatment.

3\. Unsupervised use of ES or electromagnetic therapy for wound therapy will
not be covered, as this use has not been found to be medically reasonable and
necessary.

**

C. Other

**

All other uses of ES and electromagnetic therapy not otherwise specified for
the treatment of wounds remain at local Medicare Administrative Contractor
discretion.

(This NCD last reviewed March 2004.)
Medical supplies are covered under 1861(s)(2)(A) of the Act only when they
are furnished incident to a physician's professional services. To be covered
under this provision an insulin syringe must have been used by the physician
or under his/her direct personal supervision, and the insulin injection must
have been given in an emergency situation (e.g., diabetic coma).

The use of an insulin syringe by a diabetic would not meet the requirements of
1861(s)(2)(A) of the Act.
**

Indications

**

Multiple tumor markers are available for monitoring the response of certain
malignancies to therapy and assessing whether residual tumor exists post-
surgical therapy.

CA 15-3 is often medically necessary to aid in the management of patients with
breast cancer. Serial testing must be used in conjunction with other clinical
methods for monitoring breast cancer. For monitoring, if medically necessary,
use consistently either CA 15-3 or CA 27.29, not both.

CA 27.29 is equivalent to CA 15-3 in its usage in management of patients with
breast cancer.

**

Limitations

**

These services are not covered for the evaluation of patients with signs or
symptoms suggestive of malignancy. The service may be ordered at times
necessary to assess either the presence of recurrent disease or the patient's
response to treatment with subsequent treatment cycles.

Note: Scroll down for links to the quarterly Covered Code Lists (including
narrative).
Vitamin B12 injections to strengthen tendons, ligaments, etc., of the foot are
not covered under Medicare because (1) there is no evidence that vitamin B12
injections are effective for the purpose of strengthening weakened tendons and
ligaments, and (2) this is nonsurgical treatment under the subluxation
exclusion. Accordingly, vitamin B12 injections are not considered reasonable
and necessary within the meaning of 1862(a)(1) of the Act.
Payment may be made under 1861(s)(2) of the Social Security Act for a
hydrophilic contact lens approved by the Food and Drug Administration (FDA)
and used as a supply incident to a physicians service. Payment for the lens
is included in the payment for the physicians service to which the lens is
incident. Medicare Administrative Contractors are authorized to accept an FDA
letter of approval or other FDA published material as evidence of FDA
approval. (See 80.4 for coverage of a hydrophilic contact lens as a
prosthetic device.)
The FDA has determined that neither Laetrile nor any other drug called by the
various terms mentioned above, nor any other product which might be
characterized as a "nitriloside" is generally recognized (by experts qualified
by scientific training and experience to evaluate the safety and effectiveness
of drugs) to be safe and effective for any therapeutic use. Therefore, use of
this drug cannot be considered to be reasonable and necessary within the
meaning of 1862(a)(1) of the Act and program payment may not be made for its
use or any services furnished in connection with its administration.

A hospital stay only for the purpose of having laetrile (or any other drug
called by the terms mentioned above) administered is not covered. Also,
program payment may not be made for laetrile (or other drug noted above) when
it is used during the course of an otherwise covered hospital stay.
Autogenous epidural blood grafts are considered a safe and effective remedy
for severe headaches that may occur after performance of spinal anesthesia,
spinal taps or myelograms, and are covered.
Porcine (pig) skin dressings are covered, if reasonable and necessary for the
individual patient as an occlusive dressing for burns, donor sites of a
homograft, and decubiti and other ulcers.

Gradient pressure dressings are Jobst elasticized heavy duty dressings used to
reduce hypertrophic scarring and joint contractures following burn injury.
They are covered when used for that purpose.