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 There is evidence (on the basis of her medical history or other findings) that she is at high risk of developing cervical cancer and her physician (or authorized practitioner) recommends that she have the test performed more frequently than every two years.  High risk factors for cervi cal and vaginal cancer are:   Early onset of sexual activity  (under 16 years of age)  Multiple sexual partners (five or more in a lifetime)  History of sexually transmitted disease (including HIV infection)   Fewer than three negative or any pap smears within the previous seven years; and  DES (diethylstilbestrol) - exposed daughters of women who took DES during pregnancy.  NOTE: Claims for pap smears must indicate the be neficiarys low or high risk status by including the appropriate ICD-9-CM on the line item (Item 24E of the Form CMS-1500).  Definitions   A woman as described in 1861(nn)  of the Act is a woman who is of childbearing age and has had a pap smear test during any of the preceding three years that indicated the presence of cervical or vagi nal cancer or other abnormality, or is at high risk of developing cervical or vaginal cancer.   A woman of childbearing age is one who is premenopausal and has been determined by a physician or other qualified pr actitioner to be of ch ildbearing age, based upon the medical history or other findings.   Other qualified practitioner, as defined in 42 CFR 410.56(a)  includes a certified nurse midwife (as defined in 1861(gg ) of the Act), or a physician assistant, nurse practitioner, or clinical nu rse specialist (as defined in 1861(aa) of the Act) who is authorized under State law to perform the examination.  Screening Pelvic Examination  Section 4102 of the Balanced Budget Act of  1997 provides for coverage of screening pelvic examinations (including a clinical breast examination) for all female beneficiaries, subject to certain frequency and other lim itations.  A screening pelvic examination (including a clinical breast ex amination) should include at least seven of the following eleven elements:   Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge.   Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses.  Pelvic examination (with or  without specimen collection for smears and cultures) including:   External genitalia (for exam ple, general appearance, hair  distribution, or lesions).   Urethral meatus (for example, size,  location, lesions, or prolapse).   Urethra (for example, masses, tenderness, or scarring).   Bladder (for example, fullness, masses, or tenderness).   Vagina (for example, general appearan ce, estrogen effect, discharge lesions, pelvic support, cystoc ele, or rectocele).   Cervix (for example, general a ppearance, lesions, or discharge).   Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support).   Adnexa/parametria (for example, ma sses, tenderness, organomegaly, or nodularity).   Anus and perineum.  This description is from Documentation Guidelines for Evaluation and Management Services, published in May 1997 and was de veloped by the Centers for Medicare & Medicaid Services and the Am erican Medical Association.  230.8 - Non-Implantable Pelvic Floor  Electri cal Stimulator  (Rev. 48, Issued:  03-17-06; Effectiv e/Implementation Dates:  06-19-06) CIM 60-24  Non-im plantable pelvic f loor electrical stim ulators provide neurom uscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor m usculature. S timulation is generally delivered by vaginal or anal probes connected to an extern al puls e generator.  The m ethods of  pelvic f loor ele ctrical stim ulation vary in location, stim ulus frequency (Hz), stim ulus intens ity or am plitude  (mA) , pulse duration (duty cycle), treatm ents per day, num ber of treatm ent days per week, length of  time for each treatm ent session, overall tim e period for device use and between clinic and hom e settings.  In general, the stimulus frequency and other parameters ar e cho sen based on  the patients clin ical diagnosis.  Pelvic floor electrical stimul ation with a non-im plantable stimulator is covered for the treatment of  stres s and/o r urge urin ary incontinen ce in cogn itively in tact p atients who have failed a docum ented trial of pelv ic muscle exercis e (PME) training.  A failed trial of PME training is defined as  no clin ically sign ificant im provem ent in urinary continence after com pleting 4 weeks of an ordered plan of pelvic muscle exercises designed to increase p eriurethral m uscle streng th.  230.19 - Levocarnitine for Use in the Treatment of Carnitine Deficiency in ESRD Patients (Rev. 48, Issued:  03-17-06; Effectiv e/Implementation Dates:  06-19-06) CIM 45-32  Carnitine is a naturally occurring substance that f unctions in the transport of the long-chain fatty acids for energy production by th e body. Deficiency can occur due to a congenital defect in synthesis or utilizati on, or fro m dialysis. Th e causes of carnitine deficiency in hem odialysis patients include  dialy tic loss, r educed renal synthesis and reduced d ietary in take.   Intrav enous levocarnitin e, for one of the fo llowin g indication s, will only be covered f or those ESRD patients who have been on di alysis for a m inimum of three months. Patien ts must have docu mented carnitin e def iciency, def ined as a plasm a free carn itine level < 40 microm ol/L (d eterm ined by a professio nally accepted m ethod as recognized  in curren t literature), along  with signs a nd sym ptoms of :   Erythropoietin -resis tant anem ia (persisten t hematocrit  < 30 p ercent with treatm ent) that has not responded to standa rd erthropoietin dosage (that which is considered clinically appropriate  to treat the particular patient) with iron replacement, and for which other causes have been inves tigated and adequately treated, or   Hypotension  on hemodialysis that interferes with  delivery of the intended dialysis despite application of usual measures deemed  appropriate (e.g., fluid management). Such episodes of hypotension must have  occurred during at least 2 dialysis treatments in a 30-day period.  Continued use of levocarnitine will not be covered if improvement has not been demonstrated within 6 months of initiati on of treatment. All other indications for levocarnitine are noncovered in the ESRD population.  For a patient currently receiving intrave nous levocarnitine, Medicare will cover continued treatment if:   Levocarnitine has been administered to treat erythropoietin-resistent anemia (persistent hematocrit < 30 per cent with treatment) that has not responded to standard erythropoietin dosage (that which is consider ed clinically appropriate to treat the particular patient) with iron replacement,  and for which other causes have been investigated and adequately treated, or hypotension on hemodialysis th at interferes with delivery of the intended dialysis despite  application of usual measures deemed appropriate (e.g., fluid management) and su ch episodes of hypotension occur during at least 2 dialysis treatments  in a 30-day period; and   The patients medical record documents a pre-dialysis plasma free carnitine level < 40 micromol/L prior to the initiation of treatment; or   The treating physician certifies (documents in the medical record) that in his/her judgment, if treatment with th e levocarnitine is discontinued,  the patients pre-dialysis carnitine level would fall below 40 micromo l/L and the patient would have recurrent erythropoietin-resistant-anemia or intradialytic hypotension.  260.1 - Adult Liver Transplantation  (Rev. 48, Issued:  03-17-06; Effectiv e/Implementation Dates:  06-19-06) CIM 35-53  A.   General   Effective July 15, 1996, adult liver transplant ation when performed on beneficiaries with end stage liver disease other than hepatitis B or malignancies is covered under Medicare when performed in a facility which is approved by CMS as meeting institutional coverage criteria.  Effective December 10, 1999, adult liver transp lantation when performed on beneficiaries with end stage liver disease other than malignancies is covered under Medicare when perform ed in a facility which is approved by CMS as m eeting institutional coverage criteria.   Effective Septem ber 1, 2001, Medicare c overs adult liver tr ansplantation f or hepatoce llular ca rcinom a when the f ollowing co nditions are m et:   The patien t is not a cand idate for subtotal live r resection ;  The patien ts tumor(s) is  less th an or equal to 5 c m in diam eter;  There is no m acrovascular invo lvement;  There is no identifiable extrahepatic spr ead of tumor to surrounding lym ph nodes, lungs, abdom inal organs or bone; and  The transp lant is f urnish ed in a f acility tha t is ap proved by CMS as m eeting institutional coverage criteria for liver transplants (see 65 FR 15006).    Adult liv er transplan tation for other m alignancies rem ains excluded from  coverage. Coverage of adult liver transplantation is e ffective as of the date  of the facility s approval, but for applications received before  July 13, 1991, can be effective as early as March 8, 1990.  (See F ederal Regist er 56 FR 15006 dated April 12, 1991.)  B.   Follow -Up Care  Follow-up care or retransplantation required as a result of a covered liver transp lant is covered, p rovided such s ervices are o therw ise reasonable and necessary.  Follow-up care is also covered for patients who have been disch arged from a hospita l after rece iving noncovered liver transplant.  Coverage for fo llow-up care is for item s and services that are reasonable and necessary as determ ined by M edicare guidelines.    C.   Immunosuppressive Drugs  See the Med icare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 50.5. 1 and the Medicare  Claim s Processing Manual, Chapter 17, Drugs and Biologicals,  80.3.  300.1 - Obsolete or Unreliable Diagnostic Tests (Rev. 48, Issued:  03-17-06; Effectiv e/Implementation Dates:  06-19-06) CIM 50-34  A.   Diagno stic Tests   Do not routinely pay for the followin g diagnosti c tests b ecause they are o bsolete and have been replaced by m ore advanced procedures.  The listed tests m ay be paid for only if the medical need for the procedure is satisfactorily jus tified by the physician who perform s it.  When the se rvices are su bject to the Qua lity Im provem ent Organiza tion ( QIO) Review, the QIO is responsible for determ ining that satisfactory m edical jus tification exists.    When the services are no t subject to QIO Review, the in termediary or carrier is responsible for determ ining that satisfactory m edical justification exis ts.  This includes: