(Medicare National Coverage Determinations Manual)

130.6 - Treatment of Drug Abuse (Chemical Dependency)  (Rev. 173, Issued: 09-04- 14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  The Centers for Medicare & Medicaid Services recognizes that there are similarities between the approach to treatment of drug abuse and alcohol detoxification and rehabilitation.  However, the intensity and duration of treatment for drug abuse may vary (depending on the particular substance(s) of abuse, duration of use, and the patients medical and emotional condition) from the duration of treatment or intensity needed to treat alcoholism.  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, Chapte r 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 Benefit Policy Manual, 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 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.)   130.7 - Withdrawal Treatments for Narcotic Addictions  (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  Withdrawal is an accepted treatment for narcotic addiction, and Part B payment can be made for these services if they are provided by the physician directly or under his personal supervision and if they are reasonable and necessary.  In reviewing claims, r easonableness and necessity are determined with the aid of the A/B MAC (B)s medical staff.   Drugs that the physician provides in connection with this treatment are also covered if they cannot be self -administered and meet all other statutory requirements.   Cross -reference:   Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 20.4.1.   130.8 - Hemodialysis for Treatment of Schizophrenia  (Rev. 1, 10- 03-03) CIM 35 -51  Not Covered   Scientific evidence supporting use of hemodialysis as a safe and effective means of treatment for schizophrenia is inconclusive at this time.  Accordingly, Medicare does not cover hemodialysis for treatment of schizophrenia.   140 - Miscellaneous Surgical Procedures  (Rev. 1, 10- 03-03)  140.1 - Abortion  (Rev. 48, Issued:  03- 17-06; Effective/Implementation Dates:  06 -19-06) 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.  140.2 - Breast Reconstruction Following Mastectomy  (Rev. 1, 10-03-03) CIM 35 -47  During recent years, there has been a considerable change in the treatment of diseases of the breast such as fibrocystic disease and cancer.  While extirpation of the disease remains of primary importance, the quality of life following initial treatment is increasingly recognized as of great concern.  The increased use of breast reconstruction procedures is due to several factors:   A change in epidemiology of breast cancer, including an apparent increase in incidence;   Improved surgical skills and techniques;   The continuing development of better prostheses; and   Increasing awareness by physicians of the importance of postsurgical psychological adjustment.  Reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is considered a relatively safe and effective noncosmetic procedure.  Accordingly, program payment may be made for breast reconstruction surgery following removal of a breast for any medical reason.   Program payment may not be made for breast reconstruction for cosmetic reasons. (Cosmetic surgery is excluded from coverage under 1862(a)(10) of the Act.)   140.4 - Plastic Surgery to Correct Moon Face  (Rev. 1, 10-03-03) CIM 35 -12  Not Covered  The cosmetic surgery exclusion precludes payment for any surgical procedure directed at improving appearance.  The condition giving rise to the patients 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).   Cross reference: The Medicare Benefit Policy Manual, Chapter 16, General Exclusions From Coverage, 120.  140.5 - Laser Procedures  (Rev. 173, Issued: 09-04- 14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  Medicare recognizes the use of lasers for many medical indications.  Procedures performed with lasers are sometimes used in place of more conventional techniques.  In the absence of a specific non- coverage instruction, and where a laser has been approved for marketing by the Food and Drug Administration, A/B MAC discretion may be used to determine whether a procedure performed with a laser is reasonable and necessary and, therefore, covered.  The determination of coverage for a procedure performed using a laser is made on the basis that the use of lasers to alter, revise, or destroy tissue is a surgical procedure.  Therefore, coverage of laser procedures is restricted to practitioners with training in the surgical management of the disease or condition being treated.  140.6  Wrong Surgical or Other Invasive Procedure Performed on a Patient (Effective January 15, 2009)  (Rev. 102; Issued:  07- 02-09; Effective Date:  01 -15-09; Implementation Date:  JULY 6, 2009 FOR B MACS AND CARRIERS OCTOBER 5, 2009, FOR A MACS, FIs, AND FISS)   A. General   In 2002, the National Quality Forum (NQF) published Serious Reportable Events in Healthcare: A Consensus Report1, which listed 27 adverse events that were serious, largely preventable and of concern to both the public and health care providers.  These events and subsequent revisions to the list became known as never events.  This concept and need for the proposed reporting led to NQFs Consensus Standards Maintenance Committee on Serious Reportable Events, which maintains and updates the list which currently contains 28 items. Among surgical events on the list is Wrong surgical procedure performed on a patient.  Similar to any other patient population, Medicare beneficiaries experience serious injury and/or death if wrong surgeries are performed and may require additional healthcare in order to correct adverse outcomes resulting from such errors.  B. Nationally Covered Indications  N/A  C. Nationally Non- covered Indications   The CMS does not cover a particular surgical or other invasive procedure to treat a particular medical condition when a practitioner erroneously performs a different procedure on a Medicare beneficiary because that particular surgical or other invasive procedure is not a reasonable and necessary treatment for the Medicare beneficiarys particular medical condition.   A surgical or other invasive procedure is considered to be the wrong procedure if it is not consistent with the correctly documented informed consent for that patient.  Emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining informed consent are not considered erroneous under this decision.  Also, the event is not intended to capture changes in the plan upon surgical entry into the patient due to the discovery of pathology in close proximity to the intended site when the risk of a second surgery outweighs the benefit of patient consultation; or the discovery of an unusual physical configuration (e.g., adhesions, spine level/extra vertebrae).  Surgical and other invasive procedures are defined as operative procedures in which skin or mucous membranes and connective tissue are incised or an instrument is introduced through a natural body orifice.  Invasive procedures include a range of procedures from minimally invasive dermatological procedures (biopsy, excision, and deep cryotherapy for malignant lesions) to extensive multi-organ transplantation.  They include all procedures described by the codes in the surgery section of the Current Procedural Terminology (CPT) and other invasive procedures such as percutaneous transluminal angioplasty and cardiac catheterization.  They include minimally invasive procedures involving biopsies or placement of probes or catheters requiring the entry into a body cavity through a needle or trocar.  They do not include use of instruments such as otoscopes for examinations or very minor procedures such as drawing blood.  D. Other ) (Rev. 102; Issued: 02-07- 09; Effect   1 http://www.qualityforum.org/pdf/reports/sre.pdf    N/A  (NCD last reviewed January 2009.)  140.7  Surgical or Other Invasive Procedure Performed on the Wrong Body Part (Effective January 15, 2009 ive Date:  01-15-09; Implementation Date:  JULY 6, 2009 FOR B MACS AND CARRIERS OCTOBER 5, 2009, FOR A MACS, FIs, AND FISS)   A. General   In 2002, the National Quality Forum (NQF) published Serious Reportable Events in Healthcare: A Consensus Report2, which listed 27 adverse events that were serious, largely preventable and of concern to both the public and health care providers.  These events and subsequent revisions to the list became known as never events.  This concept and need for the proposed reporting led to NQFs Consensus Standards Maintenance Committee on Serious Reportable Events, which maintains and updates the list which currently contains 28 items.  Among surgical events on the list is Surgery performed on the wrong body part.  Similar to any other patient population, Medicare beneficiaries experience serious injury and/or death if wrong surgeries are performed and may require additional healthcare in order to correct adverse outcomes resulting from such errors.  B. Nationally Covered Indications  N/A  C. Nationally Non- covered Indications   The CMS does not cover a particular surgical or other invasive procedure to treat a particular medical condition when a practitioner erroneously performs the procedure on the wrong body part because that particular surgical or other invasive procedure is not a reasonable and necessary treatment for the Medicare beneficiarys particular medical condition.  A surgical or other invasive procedure is considered to have been performed on the wrong body part if it is not consistent with the correctly documented informed consent for that patient including surgery on the right body part, but on the wrong location of the body; for example, left versus right (appendages and/or organs), or at the wrong level (spine).  Emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining informed consent are not considered erroneous under this decision.  Also, the event is not intended to capture changes in the plan upon surgical entry into the patient due to the discovery of pathology in close proximity to the intended site when the risk of a second surgery outweighs the benefit of patient consultation; o r the discovery of an unusual physical configuration (e.g., adhesions, spine level/extra vertebrae).   Surgical and other invasive procedures are defined as operative procedures in which skin or mucous membranes and connective tissue are incised or an instrument is introduced through a natural body orifice.  Invasive procedures include a range of procedures from minimally invasive dermatological procedures (biopsy, excision, and deep cryotherapy for malignant lesions) to extensive multi-organ transplantation.  They include all procedures described by the codes in the surgery section of the Current Procedural Terminology (CPT) and other invasive procedures such as percutaneous transluminal angioplasty and cardiac catheterization.  They include minimally invasive procedures involving biopsies or placement of probes or catheters requiring the entry into a body cavity through a needle or trocar.  They do not include use of instruments such as otoscopes for examinations or very minor procedures such as drawing blood.  D. Other