evekhm/cms_iom_3000 huggingface dataset:
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo

Whittaker Brown SA, Padilla M, et al. Interstitial Lung Abnormalities and Lung Cancer Risk in the National Lung Screening Trial. Chest. 2019 Dec;156(6):1195-1203. doi: 10.1016/j.chest.2019.06.041. PMID: 31404527.Wiener RS, Gould MK, Arenberg DA, et al. An official American Thoracic Society/American College of Chest Physicians policy statement: implementation of low-dose computed tomography lung cancer screening programs in clinical practice. Am J Respir Crit Care Med. 2015 Oct 1;192(7):881-91. doi: 10.1164/rccm.201508-1671ST. PMID: 26426785.Wille MM, Dirksen A, Ashraf H, et al. Results of the Randomized Danish Lung Cancer Screening Trial with Focus on High-Risk Profiling. Am J Respir Crit Care Med. 2016 Mar 1;193(5):542-51. doi: 10.1164/rccm.201505-1040OC. PMID: 26485620.Wilson JMG, Jungner G. Principles and Practice of Screening for Disease. World Health Organization, 1968. Available at: http://whqlibdoc.who.int/php/WHO_PHP_34.pdf.Wood DE et al. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology: Lung Cancer Screening. Version 1.2022  October 26, 2021. Available at https://www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf. Accessed December 21, 2021.Wu FZ, Kuo PL, Huang YL, et al. Differences in lung cancer characteristics and mortality rate between screened and non-screened cohorts. Sci Rep. 2019 Dec 18;9(1):19386. doi: 10.1038/s41598-019-56025-6. PMID: 31852960.Yang H, Varley-Campbell J, et al. Do we know enough about the effect of low-dose computed tomography screening for lung cancer on survival to act? A systematic review, meta-analysis and network meta-analysis of randomised controlled trials. Diagn Progn Res. 2019 Nov 28;3:23. doi: 10.1186/s41512-019-0067-4. eCollection 2019. PMID: 31890897.
NCA - Cardiac Pacemakers: Single-Chamber and Dual-Chamber Permanent Cardiac Pacemakers (CAG-00063R3) - Decision Memo

Lamas, 2002Mode Selection Trial in Sinus Node Dysfunction (MOST)dual chamber (n = 1014) vs programming (ventricular n = 996)median age=74 years;52% men;sinus node dysfunctiondeath any cause or nonfatal stroke; 21.5% vs 23%, respectively;HR 0.93 95% CI 0.78-1.13; p = 0.48.median follow-up = 33 months.all death 19.7% vs 20.5% respectively, HR 0.97 95% CI 0.8-1.18.atrial fibrillation 21.4% vs 27.1% respectively, HR 0.79; 95% CI 0.66-0.94; p = 0.008.perioperative 30d complication rate 4.8% (all patients received dual chamber).Nielsen, 2011Danish Multicenter Randomized Trial on Single Lead Atrial Pacing versus Dual Chamber Pacing in Sick Sinus Syndrome (DANPACE)single lead atrial (n = 707) to dual chamber (n = 708)mean age = 73 years;35% men;sick sinus syndromedeath any cause;29.6% vs 27.3% respectively; HR 1.06 95% CI 0.88-1.29; p = 0.53.mean follow-up = 5.4 years.paroxysmal atrial fib 28.4% vs 23% respectively, HR 1.27 95% CI 1.03-1.56; p = 0.024.chronic atrial fib 11.2% vs 10.7% respectively, HR 1.02 95% CI 0.74-1.39; p = 0.93.stroke and heart failure did not differ.complications not reported.Toff, 2005United Kingdom Pacing and Cardiovascular Events (UKPACE)single ventricular (n = 1009) to dual chamber (n = 1012)mean age=80 years;57% men;2ndAV block 26.1%;complete AV block 73.3%;83% symptomaticdeath all causes;mean annual mortality 7.2% vs 7.4%; respectively, HR 0.96 95% CI 0.83-1.11; p = 0.56.median follow-up = 4.6 years.no significant differences in atrial fib, heart failure, stroke/TIA/thromboembolism.annual rate atrial fib 3.0% vs 2.8% HR 1.05 95% CI 0.78-1.41).procedure complications single 3.5% vs dual 7.8%; p < 0.001.
NCA - Cardiac Pacemakers: Single-Chamber and Dual-Chamber Permanent Cardiac Pacemakers (CAG-00063R3) - Decision Memo

Appendix DECG Grid:  Waves, Intervals, and SegmentsClinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition.  Walker HK, Hall WD, Hurst JW, editors.  Boston: Butterworths; 1990.  Copyright  1990, Butterworth Publishers, a division of Reed Publishing.  NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.Figure 33.3ECG grid. Waves, intervals, segments.From: Chapter 33, ElectrocardiographyAppendix ENASPE/BPEG Generic Code for Antibradycardia, Adaptive-Rate, and Multisite PacingBritish Pacing and Electrophysiology Group. Recommendations for pacemaker prescription for symptomatic bradycardia. Report of a working party of the British Pacing and Electrophysiology Group.  Br Heart J. 1991 Aug;66(2):185-91.Bernstein AD, Daubert JC, Fletcher RD, Hayes DL, Lderitz B, Reynolds DW, Schoenfeld MH, Sutton R.  NASPE Position Statement:  The Revised NASPE/BPEG Generic Code for Antibradycardia, Adaptive-Rate, and Multisite Pacing.  J of Pacing and Clinical Electrophysiology.  Vol. 25, No. 2, February 2002.Appendix FHRS/ACCF Expert Consensus Statement Classification of RecommendationsReproduced from:Gillis AM, Russo AM, Ellenbogen KA, Swerdlow CD, Olshansky B, Al-Khatib SM, Beshai JF, McComb JM, Nielsen JC, Philpott JM, Shen WK; Heart Rhythm Society; American College of Cardiology Foundation. HRS/ACCF expert consensus statement on pacemaker device and mode selection. Developed in partnership between the Heart Rhythm Society (HRS) and the American College of Cardiology Foundation (ACCF) and in collaboration with the Society of Thoracic Surgeons. Heart Rhythm. 2012 Aug;9(8):1344-65. doi: 10.1016/j.hrthm.2012.06.026.Bibliography
NCA - Cardiac Pacemakers: Single-Chamber and Dual-Chamber Permanent Cardiac Pacemakers (CAG-00063R3) - Decision Memo

Nielsen JC, Kristensen L, Andersen HR, Mortensen PT, Pedersen OL, Pedersen AK.  A randomized comparison of atrial and dual-chamber pacing in 177 consecutive patients with sick sinus syndrome: echocardiographic and clinical outcome. J Am Coll Cardiol. 2003 Aug 20;42(4):614-23.Nielsen JC, Thomsen PE, Hjberg S, Mller M, Vesterlund T, Dalsgaard D, Mortensen LS, Nielsen T, Asklund M, Friis EV, Christensen PD, Simonsen EH, Eriksen UH, Jensen GV, Svendsen JH, Toff WD, Healey JS, Andersen HR; DANPACE Investigators.  A comparison of single-lead atrial pacing with dual-chamber pacing in sick sinus syndrome. Eur Heart J. 2011 Mar;32(6):686-96. doi: 10.1093/eurheartj/ehr022. Epub 2011 Feb 7.Nowak B, Misselwitz B, Erdogan A, et al.  Do gender differences exist in pacemaker implantation? results of an obligatory external quality control program. Europace. 2010; 12: 210-5.Rosenqvist M, Nordlander R.  Survival in patients with permanent pacemakers.  Cardiol Clin.  1992 Nov;10(4):691-703.Silberbauer J, Veasey RA, Freemantle N, Arya A, Boodhoo L, Sulke N.  The relationship between high-frequency right ventricular pacing and paroxysmal atrial fibrillation burden. Europace. 2009 Nov;11(11):1456-61. doi: 10.1093/europace/eup218. Epub 2009 Aug 6.Toff WD, Camm AJ, Skehan JD; United Kingdom Pacing and Cardiovascular Events Trial Investigators.  Single-chamber versus dual-chamber pacing for high-grade atrioventricular block.  N Engl J Med. 2005 Jul 14;353(2):145-55.Vardas PE, Auricchio A, Blanc JJ, Daubert JC, Drexler H, Ector H, Gasparini M, Linde C, Morgado FB, Oto A, Sutton R, Trusz-Gluza M; European Society of Cardiology; European Heart Rhythm Association.  Guidelines for cardiac pacing and cardiac resynchronization therapy: The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology.  Developed in collaboration with the European Heart Rhythm Association. Eur Heart J. 2007 Sep;28(18):2256-95. Epub 2007 Aug 28.Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Michel MC, Dalquist JE, Corley SD; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators.   A comparison of rate control and rhythm control in patients with atrial fibrillation.   N Engl J Med.  2002 Dec 5:347(23):1825-33.Zhan C, Baine WB, Sedrakyan A, Steiner C.  Cardiac device implantation in the United States from 1997 through 2004:  a population-based analysis.  J Gen Intern Med.  2008 Jan;23 Suppl 1:13-9.  doi:  10.1007/s11606-007-0392-0.
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54969)

II. Reasons for Denial in addition to those stated in LCD1. Narrative reports alluding to "normal" or abnormal" results without supporting numerical data.2. Descriptions of F-wave without reference to corresponding motor conduction data; pattern-setting unilateral H-reflex measurements; separate E/M charges without documentation requested from the referral source.3. Surface and/or macro EMGs will not be paid.4. Failure to submit, upon request or when requesting a review, a clinical history indicating the need for testing.5. Absence of a clinical history, preferably written by the referral source, indicating the need for the test.6. Absence of documentation to support repeated testing on the same beneficiary.7. Testing every beneficiary referred for pain.Needle electromyographic (EMG) codes 95860-95872, and 95885-95887 have the designation of 6A for the technical portion of the test. Therefore, if authorized by state law Physical Therapists are allowed the technical portion of the test according to the description of 6A. Definitions below:6A = Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.66 = May be personally performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.III. Comments1. Certain less than optimal practices are discouraged, and may invite review. These include: exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions; definitive diagnostic conclusions based on paraspinal EMG in regions bearing scar of past surgeries (e.g., previous laminectomies); pattern-setting limited limb muscle examinations, without paraspinal muscle testing for diagnosis of radiculopathies, narrative reports without data, and premature EMG testing after trauma when EMG changes are unlikely to have taken place.2. There are situations in which EMG and nerve conduction studies can be valuable in a relatively acute situation with or without trauma, even though full-blown EMG changes may not yet have taken place. An example is, to assess the presence of pre-existing injury or disease after trauma or in the evaluation of some non-traumatic conditions, such as suspected Guillain-Barre syndrome. The clinical record must distinctly document such a need.3. Frequency of testing is a difficult issue to answer. Documented clinical justification, rather than an algorithm, should be the determinant in these instances. While this removes any recipe-style limits, it also calls for clear responsible and evidence-based documentation for any repeat study. Such a guideline applies to all studies including those for patients (i) under medical, surgical or rehabilitative treatment, (ii) for neuropathy and (iii) for patients with chronic renal failure and/or dialysis.
Article - Billing and Coding: MolDX: Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) Testing (A54975)

CMS National Coverage PolicyN/AArticle TextARVD/C, characterized by fatty replacement of heart cells predominantly in the right ventricle of the heart, is most often inherited as an autosomal dominant disease that may be associated with testing in at least seven genes (RYR2, TMEM43, DSP, PKP2, DSG2, DSC2 and JUP). Genetic testing may be performed in panels of 5-7 of these genes and disease-causing mutation is expected to be identified in 42-55% of cases. Testing would be performed to confirm an established diagnosis or on individuals already diagnosed with ARVD/C to identify family members at risk. Therefore, MolDX has determined that testing for ARVD/C is a statutorily excluded test.To receive an ARVD/C panel test denial, please submit the following claim information:An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter the DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem19 for paper claimEnter the DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: MolDX: Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) Testing (A54976)

CMS National Coverage PolicyN/AArticle TextARVD/C, characterized by fatty replacement of heart cells predominantly in the right ventricle of the heart, is most often inherited as an autosomal dominant disease that may be associated with testing in at least seven genes (RYR2, TMEM43, DSP, PKP2, DSG2, DSC2 and JUP). Genetic testing may be performed in panels of 5-7 of these genes and disease-causing mutation is expected to be identified in 42-55% of cases. Testing would be performed to confirm an established diagnosis or on individuals already diagnosed with ARVD/C to identify family members at risk. Therefore, MolDX has determined that testing for ARVD/C is a statutorily excluded test.To receive an ARVD/C panel test denial, please submit the following claim information:An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter the DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem19 for paper claimEnter the DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54992)

II. Reasons for Denial in addition to those stated in LCD1. Narrative reports alluding to "normal" or abnormal" results without supporting numerical data.2. Descriptions of F-wave without reference to corresponding motor conduction data; pattern-setting unilateral H-reflex measurements; separate E/M charges without documentation requested from the referral source.3. Surface and/or macro EMGs will not be paid.4. Failure to submit, upon request or when requesting a review, a clinical history indicating the need for testing.5. Absence of a clinical history, preferably written by the referral source, indicating the need for the test.6. Absence of documentation to support repeated testing on the same beneficiary.7. Testing every beneficiary referred for pain.Needle electromyographic (EMG) codes 95860-95872, and 95885-95887 have the designation of 6A for the technical portion of the test. Therefore, if authorized by state law Physical Therapists are allowed the technical portion of the test according to the description of 6A. Definitions below:6A = Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.66 = May be personally performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.III. Comments1. Certain less than optimal practices are discouraged, and may invite review. These include: exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions; definitive diagnostic conclusions based on paraspinal EMG in regions bearing scar of past surgeries (e.g., previous laminectomies); pattern-setting limited limb muscle examinations, without paraspinal muscle testing for diagnosis of radiculopathies, narrative reports without data, and premature EMG testing after trauma when EMG changes are unlikely to have taken place.2. There are situations in which EMG and nerve conduction studies can be valuable in a relatively acute situation with or without trauma, even though full-blown EMG changes may not yet have taken place. An example is, to assess the presence of pre-existing injury or disease after trauma or in the evaluation of some non-traumatic conditions, such as suspected Guillain-Barre syndrome. The clinical record must distinctly document such a need.3. Frequency of testing is a difficult issue to answer. Documented clinical justification, rather than an algorithm, should be the determinant in these instances. While this removes any recipe-style limits, it also calls for clear responsible and evidence-based documentation for any repeat study. Such a guideline applies to all studies including those for patients (i) under medical, surgical or rehabilitative treatment, (ii) for neuropathy and (iii) for patients with chronic renal failure and/or dialysis.
Article - Billing and Coding: Urine Drug Testing (A55001)

CMS National Coverage PolicyN/AArticle TextThis article contains coding that complements the Local Coverage Determination (LCD) for Urine Drug Testing.Coding Guidelines:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Article - Billing and Coding: Lab: Bladder/Urothelial Tumor Markers (A55028)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub 100-4, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Bladder/Urothelial Tumor Markers (L36678).Noridian will only cover bladder tumor marker fluorescence in situ hybridization (FISH) testing services when performed using validated assays. To date, UroVysion Bladder Cancer Kit is the only Federal Drug Administration (FDA) approved assay that is designed to detect aneuploidy for chromosomes 3, 7, 17 and loss of the 9p21 locus via FISH. The assay is performed on urine specimens from persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis of bladder carcinoma and subsequent monitoring for tumor recurrence in patient previously diagnosed with bladder cancer. UroVysion Bladder Kit services may only be billed by a CLIA certified lab.To bill UroVysion Bladder Kit services, submit the following claim information:Select CPT code 88120 or 88121 as appropriate.Laboratories reporting only the technical component for a UroVysion service should append the appropriate code 88120 or 88121 with the TC modifier.Select CPTcode 88120 or 88121 as appropriate.Note:Physicians may NOT submit claims for a code 88120 and 88121 professional components when the interpretive information is provided by a lab technician or scientist. Per Chapter 10 in the NCCI Policy Manual for Medicare Services, Version 16.3, the physician work component requires a physician to read, quantitate and interpret the tissues/cells stained with the probes(s). Physicians who knowingly report and interpretation based on the documented results of another professional may be subject to additional corrective action including Recovery Audit Contractor (RAC) or fraud referrals.To report a Bladder/Urothelial Tumor Marker service, please submit the following claim information:Select the appropriate CPTcode.Enter 1 unit of service (UOS)Select the appropriate ICD-10 code.
Article - Billing and Coding: Lab: Bladder/Urothelial Tumor Markers (A55029)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub 100-4, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Bladder/Urothelial Tumor Markers (L36680).Noridian will only cover bladder tumor marker fluorescence in situ hybridization (FISH) testing services when performed using validated assays. To date, UroVysion Bladder Cancer Kit is the only Federal Drug Administration (FDA) approved assay that is designed to detect aneuploidy for chromosomes 3, 7, 17 and loss of the 9p21 locus via FISH. The assay is performed on urine specimens from persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis of bladder carcinoma and subsequent monitoring for tumor recurrence in patient previously diagnosed with bladder cancer. UroVysion Bladder Kit services may only be billed by a CLIA certified lab.To bill UroVysion Bladder Kit services, submit the following claim information:Select CPTcode 88120 or 88121 as appropriate.Laboratories reporting only the technical component for a UroVysion service should append the appropriate code 88120 or 88121 with the TC modifier.All other services that meet the code 88120 or 88121 definition performed by any provider type MUST bill the following claim information.Select CPTcode 88120 or 88121 as appropriate.Note:Physicians may NOT submit claims for a code 88120 and 88121 professional components when the interpretive information is provided by a lab technician or scientist. Per Chapter 10 in the NCCI Policy Manual for Medicare Services, Version 16.3, the physician work component requires a physician to read, quantitate and interpret the tissues/cells stained with the probes(s). Physicians who knowingly report and interpretation based on the documented results of another professional may be subject to additional corrective action including Recovery Audit Contractor (RAC) or fraud referrals.To report a Bladder/Urothelial Tumor Marker service, please submit the following claim information:Select the appropriate CPTcode.Enter 1 unit of service (UOS)Select the appropriate ICD-10 code.
Article - Billing and Coding: Urine Drug Testing (A55030)

CMS National Coverage PolicyN/AArticle TextThis article contains coding that complements the Local Coverage Determination (LCD) for Urine Drug Testing.Coding Guidelines:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the results of the test if known; otherwise the symptoms prompting the performance of the test should be reported.