Persius/hicric huggingface dataset:
There are no conditions for which colonic irrigation is medically indicated
and no evidence of therapeutic value. Accordingly, colonic irrigation cannot
be considered reasonable and necessary within the meaning of section
1862(a)(1) of the Act.
**

A. Manipulation of the Rib Cage

**

Manual manipulation of the rib cage contributes to the treatment of
respiratory conditions such as bronchitis, emphysema, and asthma as part of a
regimen which includes other elements of therapy, and is covered only under
such circumstances.

**

B. Manipulation of the Head

**

Manipulation of the occipitocervical or temporomandibular regions of the head
when indicated for conditions affecting those portions of the head and neck is
a covered service.
There is no physiological rationale or valid scientific documentation of
effectiveness of diathermy or ultrasound heat treatments for asthma,
bronchitis, or any other pulmonary condition and for such purpose this
treatment cannot be considered reasonable and necessary within the meaning of
section 1862(a)(1) of the Act.
Accordingly, cellular therapy is not considered reasonable and necessary
within the meaning of section 1862(a)(1) of the Act.
Regardless of the medium by which the fever is induced, this modality is not
scientifically accepted for the treatment of any specific disease. Since the
advent of potent antibiotics, the procedure has for all practical purposes
been replaced as a mode of treatment. Therefore, thermogenic therapy is not
considered reasonable and necessary for the treatment of an illness or injury
as required by section 1862(a)(1) of the Act. (Of course, where other covered
services are needed and it would be reasonable and necessary that they be
furnished on an inpatient hospital basis, payment would not be excluded for
the inpatient stay, notwithstanding the fact that reimbursement may not be
made for thermogenic therapy furnished during the hospital stay.)
Carotid body resection is occasionally used to relieve pulmonary symptoms,
including asthma, but has been shown to lack general acceptance of the
professional medical community. In addition, controlled clinical studies
establishing the safety and effectiveness of this procedure are needed.
Therefore, all carotid body resections to relieve pulmonary symptoms must be
considered investigational and cannot be considered reasonable and necessary
within the meaning of section 1862(a)(l) of the Act. No program reimbursement
may be made in such cases.

However, there is one instance where carotid body resection has been accepted
by the medical community as effective. That instance is when evidence of a
mass in the carotid body, with or without symptoms, indicates the need for
surgery to remove the carotid body tumor.

Denervation of a carotid sinus to treat hypersensitive carotid sinus reflex is
another procedure performed in the area of the carotid body. In the case of
hypersensitive carotid sinus, light pressure on the upper part of the neck
(such as might be experienced when turning or raising one's head) results in
symptoms such as dizziness or syncope due to hypotension and slowed heart
rate. Failure of medical therapy and continued deterioration in the condition
of the patient in such cases may indicate need for surgery.

Denervation of the carotid sinus is rarely performed, but when elected as the
therapy of choice with the above indications, this procedure may be considered
reasonable and necessary.
In view of recommendations of authoritative sources in the field of
ophthalmology, the subject technique is viewed as an accepted procedure for
removal of cataracts. Accordingly, program reimbursement may be made for
necessary services furnished in connection with cataract extraction utilizing
the phaco-emulsification procedure.
**

A.      Nationally Covered Conditions

**

  * Payment may be made only where sterilization is a necessary part of the treatment of an illness or injury, e.g., removal of a uterus because of a tumor, removal of diseased ovaries.
  

  * Sterilization of a mentally challenged beneficiary is covered if it is a necessary part of the treatment of an illness or injury (bilateral oophorectomy or bilateral orchidectomy in a case of cancer of the prostate). The Medicare Administrative Contractor denies claims when the pathological evidence of the necessity to perform any such procedures to treat an illness or injury is absent; and
  

  * Monitor such surgeries closely and obtain the information needed to determine whether in fact the surgery was performed as a means of treating an illness or injury or only to achieve sterilization.

**

B.       Nationally Non-Covered Conditions

**

  * Elective hysterectomy, tubal ligation, and vasectomy, if the primary indication for these procedures is sterilization;
  

  * A sterilization that is performed because a physician believes another pregnancy would endanger the overall general health of the woman is not considered to be reasonable and necessary for the diagnosis or treatment of illness or injury within the meaning of 1862(a)(1) of the Social Security Act. The same conclusion would apply where the sterilization is performed only as a measure to prevent the possible development of, or effect on, a mental condition should the individual become pregnant; and sterilization of a mentally retarded person where the purpose is to prevent conception, rather than the treatment of an illness or injury.
The cosmetic surgery exclusion precludes payment for any surgical procedure
directed at improving appearance. The condition giving rise to the patient's
preoperative appearance is generally not a consideration. The only exception
to the exclusion is surgery for the prompt repair of an accidental injury or
for the improvement of a malformed body member which coincidentally serves
some cosmetic purpose. Since surgery to correct a condition of "moon face"
which developed as a side effect of cortisone therapy does not meet the
exception to the exclusion, it is not covered under Medicare (1862(a)(10) of
the Act).
The medical effectiveness of the above therapies has not been verified by
scientifically controlled studies. Accordingly, reimbursement for these
modalities should be denied on the ground that they are not reasonable and
necessary as required by 1862(a)(1) of the Act.
In certain types of medical conditions, including when a patient is withdrawn
and uncommunicative due to a mental disorder or comatose, the physician may
contact relatives and close associates to secure background information to
assist in diagnosis and treatment planning. When a physician contacts his
patient's relatives or associates for this purpose, expenses of such
interviews are properly chargeable as physician's services to the patient on
whose behalf the information was secured. If the beneficiary is not an
inpatient of a hospital, Part B reimbursement for such an interview is subject
to the special limitation on payments for physicians' services in connection
with mental, psychoneurotic, and personality disorders.

A physician may also have contacts with a patient's family and associates for
purposes other than securing background information. In some cases, the
physician will provide counseling to members of the household. Family
counseling services are covered only where the primary purpose of such
counseling is the treatment of the patient's condition.

For example, two situations where family counseling services would be
appropriate are as follows: (1) where there is a need to observe the patient's
interaction with family members; and/or (2) where there is a need to assess
the capability of and assist the family members in aiding in the management of
the patient. Counseling principally concerned with the effects of the
patient's condition on the individual being interviewed would not be
reimbursable as part of the physician's personal services to the patient.
While to a limited degree, the counseling described in the second situation
may be used to modify the behavior of the family members, such services
nevertheless are covered because they relate primarily to the management of
the patient's problems and not to the treatment of the family member's
problems.
In most cases, postural drainage procedures and pulmonary exercises can be
carried out safely and effectively by nursing personnel. However, in some
cases patients may have acute or severe pulmonary conditions involving complex
situations in which these procedures or exercises require the knowledge and
skills of a physical therapist or a respiratory therapist. Therefore, if the
attending physician determines as part of his/her plan of treatment that for
the safe and effective administration of such services the procedures or
exercises in question need to be performed by a physical therapist, the
services of such a therapist constitute covered physical therapy when provided
as an inpatient hospital service, extended care service, home health service,
or outpatient physical therapy service.

**NOTE:** Physical therapy furnished in the outpatient department of a
hospital is covered under the outpatient physical therapy benefit.

If the attending physician determines that the services should be performed by
a respiratory therapist, the services of such a therapist constitute covered
respiratory therapy when provided as an inpatient hospital service, outpatient
hospital service, or extended care service, assuming that such services are
furnished to the skilled nursing facility by a hospital with which the
facility has a transfer agreement. Since the services of a respiratory
therapist are not covered under the home health benefit, payment may not be
made under the home health benefit for visits by a respiratory therapist to a
patient's home to provide such services. Postural drainage procedures and
pulmonary exercises are also covered when furnished by a physical therapist or
a respiratory therapist as incident to a physician's professional service.
**CIM - 35-16**

Vitrectomy may be considered reasonable and necessary for the following
conditions: vitreous loss incident to cataract surgery, vitreous opacities due
to vitreous hemorrhage or other causes, retinal detachments secondary to
vitreous strands, proliferative retinopathy, and vitreous retraction. See
chapter 23 of the Medicare Claims Processing Manual for how to determine
payment for physician vitrectomy services and the [Medicare Claims Processing
Manual](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912), Chapter
14, "Ambulatory Surgical Centers," 40, for how to determine payment for ASC
facility vitrectomy services. Also, see the [Medicare Claims Processing
Manual](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912), Chapter
23, "Fee Schedule Administration and Coding Requirements," 20.9, to identify
when, for Medicare payment purposes, certain vitrectomy codes are included in
other codes or when codes for other services include vitrectomy codes.
Surgically induced lesions of nerve tracts which involve destruction of nerve
tissue are primarily indicated for controlling the chronic or acute pain
arising from conditions such as terminal cancer or lumbar degenerative
arthritis. Induced lesions of nerve tracts may be produced by surgical cutting
of the nerve (rhizolysis), chemical destruction of the nerve, or by creation
of a radio-frequency lesion (electrocautery). Accordingly, program payment may
be made for these denervation procedures when used in selected cases
(concurred in by the Medicare Administrative Contractors medical staff) to
treat chronic pain.

Note that these procedures differ from those employing implanted electrodes
and associated equipment to control pain in that the nerve fibers are ablated
rather than stimulated and no electronic equipment is required by the patient
after the operation.
**30.4 - Electrosleep Therapy (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 Electrosleep Therapy. 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.
However, there is no scientifically valid clinical evidence that histamine
therapy is effective for any condition regardless of the method of
administration, nor is it accepted or widely used by the medical profession.
Therefore, histamine therapy cannot be considered reasonable and necessary,
and program payment for such therapy is not made.
Where electric nerve stimulation is employed to treat motor function
disorders, no reimbursement may be made for the stimulator or for the services
related to its implantation since this treatment cannot be considered
reasonable and necessary.

**NOTE:** For Medicare coverage of deep brain stimulation for essential tremor
and Parkinson's disease, see [160.24](https://www.cms.gov/medicare-coverage-
database/details/ncd-
details.aspx?NCDId=279&ncdver=1&DocID=160.24&kq=true&SearchType=Advanced&bc=EAAAAAgAAAAA&)
of the NCD Manual.
Since pain rehabilitation programs of a lesser scope than that described above
would raise a question as to whether the program could be provided in a less
intensive setting than on an inpatient hospital basis, carefully evaluate such
programs to determine whether the program does, in fact, necessitate a
hospital level of care. Some pain rehabilitation programs may utilize services
and devices which are excluded from coverage, e.g., acupuncture dorsal column
stimulator, and family counseling services. In determining whether the scope
of a pain program does necessitate inpatient hospital care, evaluate only
those services and devices which are covered. Although diagnostic tests may be
an appropriate part of pain rehabilitation programs, such tests would be
covered in an individual case only where they can be reasonably related to a
patient's illness, complaint, symptom, or injury and where they do not
represent an unnecessary duplication of tests previously performed.

An inpatient program of 4 weeks' duration is generally required to modify pain
behavior. After this period it would be expected that any additional
rehabilitation services which might be required could be effectively provided
on an outpatient basis under an outpatient pain rehabilitation program (see
[10.4](https://www.cms.gov/medicare-coverage-database/details/ncd-
details.aspx?NCDId=24&ncdver=1&DocID=10.4&kq=true&SearchType=Advanced&bc=EAAAAAgAAAAA&)
of the NCD Manual) or other outpatient program. The first 7-l0 days of such an
inpatient program constitute, in effect, an evaluation period. If a patient is
unable to adjust to the program within this period, it is generally concluded
that it is unlikely that the program will be effective and the patient is
discharged from the program. On occasions a program longer than 4 weeks may be
required in a particular case. In such a case there should be documentation to
substantiate that inpatient care beyond a 4-week period was reasonable and
necessary. Similarly, where it appears that a patient participating in a
program is being granted frequent outside passes, a question would exist as to
whether an inpatient program is reasonable and necessary for the treatment of
the patient's condition.

An inpatient hospital stay for the purpose of participating in a pain
rehabilitation program would be covered as reasonable and necessary to the
treatment of a patient's condition where the pain is attributable to a
physical cause, the usual methods of treatment have not been successful in
alleviating it, and a significant loss of ability to function independently
has resulted from the pain. Chronic pain patients often have psychological
problems which accompany or stem from the physical pain and it is appropriate
to include psychological treatment in the multidisciplinary approach. However,
patients whose pain symptoms result from a mental condition, rather than from
any physical cause, generally cannot be succesfully treated in a pain
rehabilitation program.
Coverage of services furnished under outpatient hospital pain rehabilitation
programs, including services furnished in group settings under individualized
plans of treatment, is available if the patients pain is attributable to a
physical cause, the usual methods of treatment have not been successful in
alleviating it, and a significant loss of ability by the patient to function
independently has resulted from the pain. If a patient meets these conditions
and the program provides services of the types discussed in 10.3, the
services provided under the program may be covered. Non-covered services
(e.g., vocational counseling, meals for outpatients, or acupuncture) continue
to be excluded from coverage, and A/B Medicare Administrative Contractors
would not be precluded from finding, in the case of particular patients, that
the pain rehabilitation program is not reasonable and necessary under
1862(a)(1) of the Social Security Act for the treatment of their conditions.
Coverage is available for both diagnostic and therapeutic services furnished
for the treatment of alcoholism by the hospital to outpatients subject to the
same rules applicable to outpatient hospital services in general. While there
is no coverage for day hospitalization programs, per se, individual services
which meet the requirements in the [Medicare Benefit Policy
Manual](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673), Chapter
6, 20 may be covered. (Meals, transportation and recreational and social
activities do not fall within the scope of covered outpatient hospital
services under Medicare.)

All services must be reasonable and necessary for diagnosis or treatment of
the patient's condition (see the [Medicare Benefit Policy
Manual](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673), Chapter
16 20). Thus, educational services and family counseling would only be
covered where they are directly related to treatment of the patient's
condition. The frequency of treatment and period of time over which it occurs
must also be reasonable and necessary.
Accordingly, when it is medically necessary for a patient to receive
detoxification and/or rehabilitation for drug substance abuse as a hospital
inpatient, coverage for care in that setting is available. Coverage is also
available for treatment services that are provided in the outpatient
department of a hospital to patients who, for example, have been discharged
from an inpatient stay for the treatment of drug substance abuse or who
require treatment but do not require the availability and intensity of
services found only in the inpatient hospital setting. The coverage available
for these services is subject to the same rules generally applicable to the
coverage of outpatient hospital services. (See the [Medicare Benefit Policy
Manual (BPM)](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673), Chapter
6, Hospital Services Covered Under Part B, 20.) The services must also be
reasonable and necessary for treatment of the individuals condition. (See the
[Medicare BPM](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673), Chapter
16, General Exclusions from Coverage, 90.) Decisions regarding
reasonableness and necessity of treatment, the need for an inpatient hospital
level of care and length of treatment, should be `made by A/B Medicare
Administrative Contractors (MACs) based on accepted medical practice with the
advice of their medical consultant. (In hospitals under Quality Improvement
Organization (QIO) review, QIO determinations of medical necessity of services
and appropriateness of the level of care at which services are provided are
binding on A/B MACs for purposes of adjudicating claims for payment.)
Coverage is available for alcoholism or drug abuse treatment services (such as
drug therapy, psychotherapy, and patient education) that are provided incident
to a physician's professional service in a freestanding clinic to patients
who, for example, have been discharged from an inpatient hospital stay for the
treatment of alcoholism or drug abuse or to individuals who are not in the
acute stages of alcoholism or drug abuse but require treatment. The coverage
available for these services is subject to the same rules generally applicable
to the coverage of clinic services. Of course, the services also must be
reasonable and necessary for the diagnosis or treatment of the individual's
alcoholism or drug abuse. The Part B psychiatric limitation would apply to
alcoholism or drug abuse treatment services furnished by physicians to
individuals who are not hospital inpatients.
Available evidence indicates that chemical aversion therapy may be an
effective component of certain alcoholism treatment programs, particularly as
part of multi-modality treatment programs which include other behavioral
techniques and therapies, such as psychotherapy. Based on this evidence, the
Centers for Medicare & Medicaid Services medical consultants have recommended
that chemical aversion therapy be covered under Medicare. However, since
chemical aversion therapy is a demanding therapy which may not be appropriate
for all Medicare beneficiaries needing treatment for alcoholism, a physician
should certify to the appropriateness of chemical aversion therapy in the
individual case. Therefore, if chemical aversion therapy for treatment of
alcoholism is determined to be reasonable and necessary for an individual
patient, it is covered under Medicare.

When it is medically necessary for a patient to receive chemical aversion
therapy as a hospital inpatient, coverage for care in that setting is
available. (See 130.1 regarding coverage of multi-modality treatment
programs.) Follow-up treatments for chemical aversion therapy can generally be
provided on an outpatient basis. Thus, where a patient is admitted as an
inpatient for receipt of chemical aversion therapy, there must be
documentation by the physician of the need in the individual case for the
inpatient hospital admission.

Decisions regarding reasonableness and necessity of treatment and the need for
an inpatient hospital level of care should be made by A/MACs based on accepted
medical practice with the advice of their medical consultant. (In hospitals
under Quality Improvement Organization (QIO) review, QIO determinations of
medical necessity of services and appropriateness of the level of care at
which services are provided are binding on A/MACs for purposes of adjudicating
claims for payment.)
Electrical aversion therapy has not been shown to be safe and effective and
therefore is excluded from coverage.
Program payment may be made for diagnosis and treatment of sexual impotence.
Since causes and, therefore, appropriate treatment vary, if abuse is suspected
it may be necessary to request documentation of appropriateness in individual
cases. If treatment is furnished to patients (other than hospital inpatients)
in connection with a mental condition, apply the psychiatric service
limitation described in the [Medicare General Information, Eligibility, and
Entitlement Manual](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS050111), Chapter
3.
**20.10 - Cardiac Rehabilitation Programs (RETIRED)  
(Rev. 11892; Issued: 03-09-23; Effective: 04-10-23; Implementation:04-10-23)**

This section of the NCD Manual was repealed February 22, 2010, as a result of
section 144 of the Medicare Improvements for Patients and Providers Act.
Instead, refer to Pub. 100-04, chapter 32, section 140.
Please note section 40.5 has been removed from the NCD Manual and incorporated
into NCD [100.1](https://www.cms.gov/medicare-coverage-database/details/ncd-
details.aspx?NCDId=57&ncdver=5&DocID=100.1&kq=true&SearchType=Advanced&bc=EAAAAAgAAAAA&).