Persius/hicric huggingface dataset:
**Abstract:**  
  
External ocular photography is a non-invasive procedure used to photo-document
conditions of the external structures of the eye (e.g., eyelids, lashes,
sclera, conjunctiva and cornea). External photography techniques may also be
used to document conditions related to structures of the anterior segment of
the eye. These would include the anterior chamber, iris, crystalline lens and
filtration angle. External ocular photography is accomplished by using a slit-
lamp-integrated camera, photography through a goniophotography lens or with a
close-up stereo camera. Photographs may be prints, slides, videotapes or
digitally stored.  
  
**Indications:**  
  
This procedure may be indicated when photo-documentation is required to track
the progression or lack of progression of an eye condition, or to document the
progression of a particular course of treatment.  
  
External ocular photography is covered when a special camera is used to obtain
magnified photographs of lesions (e.g., the cornea, iris or lids) for the
purpose of following the patient's condition. Medical quality images may be
digital, Polaroid Macro 3 SLF or equivalent.  
  
**Limitations:**  
  
While many conditions of the eye could be photographed, this procedure should
not be used to simply document the existence of a condition in order to
enhance the medical record.  
  
Photographs for the purpose of documentation for medical legal purposes or
preauthorization (e.g., gross trauma, amount of ptosis or redundant lid tissue
for blepharoplasty) are not separately reportable or reimbursable.  
  
Photography may be reported only once per session, even though multiple views
may be taken.  
  
In addition to the photograph(s), an interpretation and report specific to the
photograph(s) must be contained in the patient's medical record and be
available to the contractor upon request.  
  
External ocular photography without accompanying patient identification and
date permanently affixed to the photograph will be considered not to be
reasonable or necessary and will be denied.  
  
 ** **
A cranial computerized tomographic (CT) scan is a very useful and informative
neurodiagnostic tool. Scanning of the head in successive layers by a narrow
beam of x-rays enables the transmission of x-ray photons in each layer to be
measured. A computer is used to process the accumulated x-ray photon data and
constructs a graphic image of a tomographic slice. Normal intracranial
structures and a wide variety of intracranial disorders may be demonstrated. A
cranial CT scan may be ordered without contrast, with injection of standard
roentgenographic contrast material or without contrast material, followed by
contrast material and further sections. Contrast administration is not without
risk to the patient and for some conditions adds little or no benefit to the
examination.  
  
Cranial CT scans are determined to be reasonable and necessary and are a
covered service when the patient has clinical evidence of an intracranial
disorder or an established intracranial disorder or disease. The general
indications for use of contrast CT scanning are:  
  
1\. To assess perfusion (e.g., cerebrovascular accident [CVA])  
  
2\. To characterize a specific lesion  
  
3\. To detect defects in blood/brain barrier (e.g., infarcts, tumors,
infection, vasculitis)  
  
4\. To detect neovascularity (tumors); or  
  
5\. For staging of known lung cancer, breast cancer, and lymphomas which are
likely to metastasize early to the brain
**Indications:**  
  
Elevated serum levels of the amino acid homocysteine are associated with
increased risk of cardiovascular (CV) and cerebrovascular disease events as
well as an increased risk of osteoporosis. Treatment of the elevated
homocysteine level in the absence of an established causal relationship
between hyperhomocysteinemia and these entities has been empiric
supplementation with vitamin B-6, B-12 and folic acid. Hyperhomocysteinemia
may also be present with vitamin B12 and folate deficiencies associated with
anemia. In these instances the elevated homocysteine confirms the vitamin
deficiency as the source of anemia.  
  
No studies demonstrate that such vitamin supplementation, while lowering the
serum homocysteine levels, also reduces the risks for CV or cerebrovascular
events or osteoporosis. The Heart Outcomes Prevention Evaluation (HOPE) 2
investigators reported that "...combined daily administration...[of the
vitamins] for 5 years had no beneficial effect on major vascular events in a
high risk population with vascular disease." The Norwegian Vitamin Trial
(NORVIT) investigators found that "Treatment with B vitamins did not lower the
risk of recurrent CV disease after acute myocardial infarction. A harmful
effect from combined B vitamin treatment was suggested." In their 2004 report,
Lange H, et. al, reported that B vitamin supplementation to lower homocysteine
levels, after coronary stenting, may increase the risk of in-stent restenosis
and the need for target vessel revascularization.

  * Homocysteine levels will be covered by Medicare to confirm vitamin B12 or folate deficiency.
  * In the absence of evidence that treatment of hyperhomocysteinemia reduces CV events, this test can only be covered in patients with known vascular disease or risk thereof (based upon abnormal lipid metabolism, high blood pressure (BP) or diabetes mellitus (DM)) for the purpose of risk stratification. In this circumstance it will be covered only once per lifetime.

**  Limitations:**

  * When used to determine the risk of developing atherosclerotic CV disease, measurement of serum homocysteine levels in the absence of known vascular disease, hyperlipidemia or DM will be denied as screening.
  * Serum homocysteine levels for the evaluation of treatment of hyperhomocysteinemia in patients with CV risk factors will be denied as not medically necessary.
The coverage criteria and definition of Magnetic Resonance Angiography (MRA)
are found in the CMS Internet-only Manual, Pub 100-03, Medicare National
Coverage Determinations Manual, Chapter 1, Part 4, 220.2. MRA is considered
appropriate when it can replace a more invasive test (e.g., contrast
angiography) and reduce risk for beneficiaries. In addition, the services must
be reasonable and necessary for the diagnosis or treatment of the specific
patient involved.
Magnetic Resonance Imaging (MRI) is a noninvasive diagnostic imaging modality
used to diagnose a variety of central nervous system (CNS) disorders. MRI
provides superior tissue contrast when compared to a Computerized Tomography
(CT) scan, is able to image in multiple planes, is not affected by bone
artifact, provides vascular imaging capability, and makes use of safer
contrast media (gadolinium chelate agents). Its major disadvantage over a CT
scan is the longer scanning time required for study, making it less useful for
emergency evaluations. Contraindications include patients with implanted
neurostimulators or cochlear implants. Potential contraindications may include
patients with cardiac pacemakers (refer to the CMS Internet-Only Manual, Pub
100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4,
220.2), metal fragments in the eye, magnetic ocular implants or patients with
older ferromagnetic intracranial aneurysm clips. All of these objects may be
potentially displaced when exposed to the powerful magnetic fields used in
MRI.  
  
MRI of the orbit, face, and/or neck may be considered medically reasonable and
necessary when used to diagnose and characterize pathology of the eye,
nasopharynx, oropharynx, and neck including tumors, infection, soft tissue
pathologies, and congenital abnormalities. In cases involving trauma to the
orbit, face and/or neck, a CT scan is frequently superior to MRI for assessing
injury.  
  
MRI is considered investigational when medical records document the service
was performed only for one of the following:

    * measurement of blood flow and spectroscopy,
    * imaging of cortical bone and calcifications, and
    * procedures involving spatial resolution of bone or calcifications.

  
In some instances, ordering a MRI of the brain in addition to a MRI of the
orbit, face, and/or neck may be medically necessary on the same day. The
medical record should document the medical necessity for these two procedures
being performed on the same day.  
  
Initial imaging of the thyroid should be done with ultrasound or nuclear
medicine, unless there is a known carcinoma present.
**Abstract:**  
  
The Stretta procedure delivers radiofrequency thermal energy to the lower
esophagus as a treatment for gastroesophageal reflux disease (GERD). CGS
Administrators considers the Stretta procedure to be investigational and
therefore non-covered.  
  
 **Limitations:**  
  
An extensive literature review documented the following information:

  * efficacy based on objective physiologic measurements has not been shown;
  * a clear mechanism of action has not been determined, and;
  * significant long-term studies confirming efficacy and safety have not been carried out. The Stretta procedure is considered investigational and is not covered.   
  
**Other Comments:**  
  
For claims submitted to the Part A MAC: this coverage determination also
applies within states outside the primary geographic jurisdiction with
facilities that have nominated CGS to process their claims.  
  
Bill type codes only apply to providers who bill these services to the fiscal
intermediary or Part A MAC. Bill type codes do not apply to physicians, other
professionals and suppliers who bill these services to the carrier or Part B
MAC.  
  
Limitation of liability and refund requirements apply when denials are likely,
whether based on medical necessity or other coverage reasons. The
provider/supplier must notify the beneficiary in writing, prior to rendering
the service, if the provider/supplier is aware that the test, item or
procedure may not be covered by Medicare. The limitation of liability and
refund requirements do not apply when the test, item or procedure is
statutorily excluded, has no Medicare benefit category or is rendered for
screening purposes.  
  
For dates of service prior to April 1, 2010, FQHC services should be reported
with bill type 73X. For dates of service on or after April 1, 2010, bill type
77X should be used to report FQHC services.
Medicare coverage of hospice care depends upon a physician's certification of
an individual's prognosis of a life expectancy of six months or less if the
terminal illness runs its normal course. Recognizing that determination of
life expectancy during the course of a terminal illness is difficult, this A/B
Medicare Administrative Contractor (MAC)(HHH) has established medical criteria
for determining prognosis for non-cancer diagnoses. These criteria form a
reasonable approach to the determination of life expectancy based on available
research, and may be revised as more research is available. Coverage of
hospice care for patients not meeting the criteria in this policy may be
denied. However, some patients may not meet the criteria, yet still be
appropriate for hospice care because of other comorbidities or rapid decline.
Coverage for these patients may be approved on an individual consideration
basis.  
  
Patients will be considered to be in the terminal stage of liver disease (life
expectancy of 6 months or less) if they meet the following criteria (1 and 2
must be present; factors from 3 will lend supporting documentation):  
  
1\. The patient should show both a and b:

a. Prothrombin time prolonged more than 5 seconds over control, or
International Normalized Ratio (INR)> 1.5

        b. Serum albumin <2.5 gm/dl

 2\. End stage liver disease is present and the patient shows at least one of
the following:

       a. Ascites, refractory to treatment or patient non-compliance

       b. Spontaneous bacterial peritonitis

       c. Hepatorenal syndrome (elevated creatinine and blood urea nitrogen (BUN) with oliguria (<400 ml/day) urine and sodium concentration <10 mEq/l)

       d. Hepatic encephalopathy, refractory to treatment, or patient non-compliance

       e. Recurrent variceal bleeding, despite intensive therapy

 3\. Documentation of the following factors will support eligibility for
hospice care:

       a. Progressive malnutrition

       b. Muscle wasting with reduced strength and endurance

       c. Continued active alcoholism (> 80 gm ethanol/day)

       d. Hepatocellular carcinoma

       e. Hepatitis B virus surface antigen (HBsAg)positivity

       f. Hepatitis C refractory to interferon treatment.

Patients awaiting liver transplant who otherwise fit the above criteria may be
certified for the Medicare hospice benefit, but if a donor organ is procured,
the patient must be discharged from hospice.
Surface electrical stimulation in the treatment of dysphagia is being used by
some Medicare providers as an adjunct to "usual care". There is insufficient
scientific or clinical evidence to consider this device as reasonable and
necessary for the treatment of dysphagia within the meaning of 1862(a)(1)(A)
of the Social Security Act (SSA)and will not be covered by this A/B HHH
Medicare Administrative Contractor (MAC).
Medicare coverage of hospice care depends upon a physician's certification of
an individual's prognosis of a life expectancy of 6 months or less, if the
terminal illness runs its normal course. Recognizing that determination of
life expectancy during the course of a terminal illness is difficult, this A/B
HHH Medicare Administrative Contractor (MAC) has established medical criteria
for determining prognosis for non-cancer diagnoses. These criteria form a
reasonable approach to the determination of life expectancy based on available
research and may be revised as more research is available. Coverage of hospice
care for patients not meeting the criteria in this policy may be denied.
However, some patients may not meet the criteria, yet still be appropriate for
hospice care because of other comorbidities or rapid decline. Coverage for
these patients may be approved on an individual consideration basis.  
  
Patients will be considered to be in the terminal stage of their illness (life
expectancy of 6 months or less) if they meet the following criteria:

**  Human Immunodeficiency Virus (HIV) Disease** (1 **and** 2 must be present;
factors from 3 will add supporting documentation)

 1\. Clusters of differentiation 4 (CD4) + Count 100,000 copies/ml, plus **1**
of the following:

a. Central Nervous System (CNS) lymphoma b. Untreated, or not responsive to
treatment, wasting (loss of 33% lean body mass) c. Mycobacterium avium complex
bacteremia, untreated, unresponsive to treatment, or treatment refused d.
Progressive multifocal leukoencephalopathy e. Systemic lymphoma, with advanced
HIV disease and partial response to chemotherapy f. Visceral Kaposi's sarcoma
unresponsive to therapy g. Renal failure in the absence of dialysis h.
Cryptosporidium infection i. Toxoplasmosis, unresponsive to therapy

 2\. Decreased performance status as measured by the Karnofsky Performance
Status (KPS) scale, of  50.  
  
 3\. Documentation of the following factors will support eligibility for
hospice care:

a. Chronic persistent diarrhea for 1 year b. Persistent serum albumin < 2.5 c.
Concomitant, active substance abuse d. Age > 50 years e. Absence of
antiretroviral, chemotherapeutic and prophylactic drug therapy related
specifically to HIV disease f. Advanced acquired immunodeficiency syndrome
(AIDS) dementia complex g. Toxoplasmosis h. Congestive heart failure (CHF),
symptomatic at rest
Retroperitoneal ultrasound (US) studies represent the ultrasonic imaging of
retroperitoneal organs for the diagnosis and management of abnormalities that
occur within the retroperitoneum. A complete retroperitoneal US study
visualizes all the structures or organs within the anatomic description of
that study. A limited study involves an imaging of only a single quadrant, a
single diagnostic problem, or an evaluation of a specific organ of interest.
Retroperitoneal ultrasonography may be considered reasonable and necessary for
the diagnosis and treatment of the following organs and retroperitoneal
structures:

1\. Pancreas

2\. Abdominal aorta- US is accurate for aortic measurement and may be used to
follow patients with aortic aneurysms.

3\. Inferior vena cava - US is useful in the detection of invasion by adjacent
tumors and identification of obstruction levels.

4\. Kidneys, ureter, and bladder:

       a) Kidneys-

          i) May confirm scarred or small kidneys in chronic renal cortical disease (but may be of no use in detecting early or mild cortical disorders or to categorize specific types of cortical diseases).

          ii) May be useful in detecting and following renal cysts and localizing solid masses.

          iii) May be useful as a primary diagnostic tool in patients with suspected renal disease.

       b) Ureter- Normal ureters are usually not well visualized by US, especially in their mid-portions. Renal US is the primary mode of diagnosis of a renal obstruction  which is demonstrated by dilated ureters. It may be helpful in identifying filling defects or a mass, in its most proximal or distal portions. US has no role in vesicular ureteral reflux.        

       c) Bladder- Tumors of the bladder are most efficiently followed by cystoscopy and urography. However, US is useful in following intraluminal bladder tumors with or without  extraluminal extension, including evaluation of bladder wall thickness and irregularity and evaluating post void residual at the bedside. 

5\. Renal transplants- US is indicated to detect urinary obstruction, fluid
collection, and complications of renal transplants and is considered a primary
tool in this endeavor. The presence or absence of signs and symptoms dictate
utilization frequency of this modality for renal transplants.

6\. Adenopathy- Computed tomography (CT) is far more accurate than US in
detecting and delineating adenopathy. US in this instance should be considered
secondary and rarely utilized in the detection or follow up of nodal disease.

7\. Prostate- Evaluation of the prostate is primarily done transrectally by
US.

8\. Adrenal Gland- US is of little value since a CT scan is considered more
accurate.

9\. Organs located in the retroperitoneal region- US may be helpful in the
evaluation of wounds, contusions, and lacerations of organs located in the
retroperitoneal region.
Surface electrical stimulation in the treatment of dysphagia is being used by
some Medicare providers as an adjunct to usual care. There is insufficient
scientific or clinical evidence to consider this device as reasonable and
necessary for the treatment of dysphagia within the meaning of 1862(a)(1)(A)
of the Social Security Act (SSA) and will not be covered by this A/B MAC.
**Abstract:**  
  
Reduction mammaplasty is the surgical removal of a substantial portion of the
breast, including the skin and underlying glandular tissue, until a clinically
normal size is obtained. Breasts are pair organs, and breast hypertrophy
generally affects both sides, therefore, bilateral surgery is usually
performed.  
  
Reduction mammaplasty is performed to reduce the size of the breasts and help
ameliorate symptoms caused by the hypertrophy and to reduce the size of a
normal breast to bring it into symmetry with a breast reconstructed after
cancer surgery.  
  
**Indications:**  
Reduction mammaplasty is considered medically necessary:

  1. When the patient has significant symptoms that have interfered with normal daily activities, despite conservative management, for at least 6 months, including at least one of the following criteria:

  * History of back and/or shoulder pain which adversely affects activities of daily living (ADLs) unrelieved by, e.g.:  

    * conservative analgesia (e.g., such as NSAID, compresses, massage, etc.)
    * supportive measures (e.g., such as garments, back brace, etc.),
    * physical therapy
    * correction of obesity
  * History of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity, e.g.: 
    * Signs and symptoms of ulnar paresthesias
    * Cervicalgia
    * Torticollis
    * Acquired kyphosis

Signs and symptoms of:

  * intertrigonous maceration or infection of the inframammary skin (e.g., hyperpigmentation, bleeding, chronic moisture, and evidence of skin breakdown), refractory to dermatologic measures, or
  * shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by appropriate supporting garment



AND

Considerable attention has been given to the amount of breast tissue removed
in differentiating between cosmetic and medically necessary reduction
mammoplasty. To be considered a non-cosmetic procedure it is expected that at
least a minimal amount of breast tissue will be removed. Yet, arbitrary
minimum weight breast tissue removed criteria do not consistently reflect the
consequences of mammary hypertrophy in individuals with a unique body habitus.
There are wide variations in the range of height, weight, and associated
breast size that cause symptoms. The amount of tissue that must be removed in
order to relieve symptoms will vary and depend upon these variations.

The following are guidelines (not rules) that address the patient's body
surface area (BSA) and the amount of breast tissue removed  
BSA 1.35-1.45 199-238  
BSA 1.46-1.55 239-284  
BSA 1.56-1.69 285-349  
Equal to or greater than 350g

  
  
**Limitations of Coverage:**

1\. Cosmetic surgery to reshape the breasts to improve appearance is not a
Medicare benefit.  
2\. Indications of Coverage must be met.  
  
Note: Reconstruction of the affected and the contralateral unaffected breast
following a medically necessary mastectomy is considered a non-cosmetic
procedure. National coverage provides for payment of breast reconstruction
surgery following removal of a breast for any medical reason.