evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: MolDX: HBB Gene Tests (A53493)

CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after 05/03/2013HBB gene testing may be performed during the diagnosis of Sickle cell disease (SCD). Since clinical symptoms and diagnosis usually occur prior to Medicare eligibility and carrier testing is not a covered benefit, the MolDX Team has determined HBB gene testing is a statutorily excluded service. MolDX will also deny panels of tests that include the HBB gene.To receive a HBB gene sequencing service denial, please submit the following claim information:Select the appropriate CPTcode based on gene test:81361  HBB, common variants81362 - HBB, known familiar variants81363 - HBB, duplication/deletion81364 - HBB, full gene sequence81443  Genetic testing for severe inherited conditionsAn 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 modifierEnter DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter DEX Z-Code identifier adjacent to the CPTcode 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 - Glaucoma Screening (A53495)

CMS National Coverage PolicyN/AArticle TextMedicare coverage of glaucoma screenings was implemented with the Benefits Improvement and Protection Act of 2000 (BIPA).A glaucoma screening is defined to include:A dilated eye examination with an intraocular pressure (IOP) measurementA direct ophthalmoscopy examination or a slit-lamp biomicroscopic examinationMedicare covers glaucoma screening for the following persons considered to be at high risk for developing this disease:Individuals with diabetes mellitusIndividuals with a family history of glaucomaAfrican-Americans age 50 or overHispanics-Americans 65 or olderGlaucoma screening frequency limitations and payment information:Medicare pays for this service annually (i.e., at least 11 full months must have passed following the month in which the last Medicare-covered glaucoma screening examination was performed)Services rendered more frequently than allowed under this screening benefit may require that the beneficiary be given an Advance Beneficiary Notice (ABN)The beneficiary will pay 20 percent as the co-payment or coinsurance after meeting the yearly Part B deductibleMedical record documentation requirements:Medical record documentation to support that the beneficiary is a member of one of the high risk groups, as defined aboveDocumentation must support one of the screening defined:A dilated eye examination with IOP measurement and direct ophthalmoscopic examination, or a slit-lamp biomicroscopic examinationProcedure and Diagnosis Code Information:HCPCS CodesHCPCS Code Descriptors/ModifierDiagnosis CodeG0117Glaucoma screening for high risk patient furnished by an optometrist or ophthalmologistZ13.5 (Encounter for Screening for Eye and Ear Disorders)G0118Glaucoma screening for high risk patient furnished under the direct supervision of optometrist or ophthalmologistZ13.5 (Encounter for Screening for Eye and Ear Disorders)
Article - Billing and Coding: Oral Maxillofacial Prosthesis (A53497)

CMS National Coverage PolicyN/AArticle TextImplants, which could be considered dental but are being inserted to secure, attach, or support the maxillofacial prosthesis, will be covered when the prosthesis is to be used secondary to maxillofacial surgery or repair of traumatic injury. Use CPTcode 21299 to bill the implants with an explanation of the intended use. Please note dates of trauma or tumor biopsy/resection, dates of radiation treatment and other pertinent medical history.E0485 to E0486: Oral Devices for Obstructive Sleep ApneaHCPCS codes E0485 and E0486 describe oral devices or appliances used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated (E0485) or custom fabricated (E0486). These devices are typically used to treat obstructive sleep apnea (OSA). Both codes include all fitting and adjustment. These codes are reimbursed as Durable Medical Equipment by the Durable Medical Equipment Medicare Administrative Contractor (DME MAC). The initial assessment and diagnostic services to determine whether an OSA appliance should be used are billable to the Part B contractor up to the time of the decision to order/provide the OSA appliance using the appropriate Evaluation and Management (E&M) CPTcode and other appropriate CPTcodes for diagnostic tests. At the time of the decision to order/provide the OSA appliance, all fittings, adjustments, supplies, and services to provide the appliance to the individual patient is inclusive. Medicare claims related to the fitting, subsequent adjustments and repairs of an oral device should be submitted to the appropriate DME MAC and not as E&M services to the A/B Medicare Administrative Contractor (MAC). Additionally, any radiological or other services performed in order to guide the adjustments of the oral device should not be submitted separately to the A/B MAC, as the Medicare Program payment associated with HCPCS Codes E0485 and E0486 already includes any required adjustments to ensure a properly fitted device.
Article - Billing and Coding: Implantable Miniature Telescope (IMT) for Macular Degeneration (A53501)

CMS National Coverage PolicyN/AArticle TextThe Implantable Miniature Telescope (IMT) is a prosthetic device in the form of a miniature telescope, implanted monocularly to enlarge the retinal image of the central visual field and reduce the impact of untreatable, severe-to-profound vision-impairing central scotomas associated with end stage age related macular degeneration (ARMD).The implantable miniature telescope is considered medically reasonable and necessary only for patients who meet ALL of the following criteria: 65 years of age or older; and Diagnosis of stable, untreatable, severe-to-profound central vision impairment caused by blind spots (bilateral central scotoma) associated with end stage ARMD as determined by fluorescein angiography (findings of geographic atrophy or disciform scar with foveal involvement); and Evidence of a visually significant cataract (grade 2 or higher); and Corrected distance Snellen visual acuity poorer than 20/160 but no worse than 20/800; and No active wet ARMD (no sign of active choroidal neovascularization in either eye); and Have no sign of eye disease other than well controlled glaucoma; and Have not been treated for wet ARMD in the previous 6 months; and Achieve at least a 5 letter improvement on the Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity chart in the eye scheduled for surgery using an external telescope; and Agree to undergo 2 to 4 pre-surgical training sessions with a low vision specialist (optometrist or occupational therapist); and Agree to participate in postoperative visual rehabilitation with a low vision specialist; and Complete and agree to the 'Acceptance of Risk and Informed Consent Agreement' provided in the device labeling documentation.Note:Palmetto GBA expects performing providers to obtain adequate training prior to procedure performance. Medical records may be subject to review and/or denial if criteria are not documented and IMT contraindications are identified.
Article - Billing and Coding: MolDX: BCR-ABL (A53531)

CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after 4/15/13Breakpoint testing for BCR-ABL1 is commonly performed as a combination or panel of tests(major, minor and other breakpoints). To report multiple tests assigned a single ID, submit CPTcode 81479. This guideline includes the following CPTcode combinations:81206 and 8120781206, 81207, and 81208CPTcodes 81206, 81207, and 81208 may only be reported when performed as a single test.To submit a claim for BCR-ABL translocation analysis by NGS, use CPT81479 and one (1) UOS with the assigned DEX Z-code.To report the FDA-approved MRDx BCR-ABL Test use the CPTcode 0040U.Refer toBilling and Coding: MolDX: Testing of Multiple Genes A57503for additional information regarding single-gene and panel testing of genes.
Article - Billing and Coding: MolDX: ENG and ACVRL1 Gene Tests (A53536)

CMS National Coverage PolicyN/AArticle TextHereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder with variable clinical presentation. Most common manifestations are epistaxis, recurrent gastrointestinal bleeding, iron deficiency anemia, and mucocutaneous telangectasias. Arteriovenous malformations (AVMs), of various organs (lung, liver, brain) are common.The two most prevalent forms of HHT, Type 1 and Type 2, are caused by mutations in the endoglin (ENG) or the ACVRL1 gene respectively. Although identification of these gene mutations can confirm the diagnosis of HHT, these tests are not necessary in many cases. HHT is generally established using well vetted consensus criteria (most often the International Curaao Criteria (ICC)). The ICC uses the clinical characteristics of epistaxis, cutaneous or mucosal telangectasias, visceral AVMs, and a first-degree relative with HHT to judge likelihood of a given patient having HHT. A 'definite' diagnosis is established when a patient has 3 or 4 of these criteria. Genetic testing for ENG/ACVRL1 is not warranted. A patient with 0 to 1 criteria is 'unlikely' to have HHT, and similarly would not be a candidate for genetic testing. Patients with 2 or 3 Curaao criteria are defined as suspected of HHT and are candidates for ENG/ACVRL1 testing.Since screening of patients without signs or symptoms of HHT, who have a first-degree relative with HHT, is not a Medicare benefit, the MolDX Team has determined ENG and/or ACVRL1 genetic testing and panels of tests that include ENG/ACVRL1 are statutorily excluded services.EXCEPTIONS:For patients with suspected HHT in which diagnosis confirmation would demonstrate an improved outcome, approval will be made on a case-by-case basis through the appeal process.For tests that include ENG and ACVRL1 registered and assigned a single Z-Code Identifier, submit CPTcode 81479.To receive an ENG and/or ACVRL1 gene test denial, please submit the following claim information:Select appropriate CPTcode for test81405-ENG, Duplication/deletion81406-ENG, full gene sequence81479-ACVRL181479-ACVRL1 and ENGAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierFor CPTnon-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode 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: SULT4A1 Genetic Testing (A53538)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextSulfotransferase 4A1 (SULT4A1) is an enzyme found in the brain that interacts with numerous neuroactive molecules, including some catecholamines and neural steroids. Findings suggest the SULT4A1-1 haplotype of SULT4A1 is associated with enhanced response to antipsychotic drug therapy. At present there is insufficient evidence to support SULT4A1 genotyping to determine medical management. Therefore, the MolDX Team has determined SULT4A1 genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests that include the SULT4A1 gene as a statutorily excluded service.To receive a SULT4A1 test denial, please submit the following claim information:CPTcode 81479An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX HCPCS modifierTo indicate a statutorily excluded service, append with a GY HCPCS modifierFor CPTnon-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode 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: BLM Gene Analysis (A53540)

CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after July 30, 2014The clinical diagnosis of Bloom (BLM syndrome, BSyn), characterized by severe pre and postnatal growth deficiency, highly characteristic sparseness of subcutaneous fat tissue in infants and children, is confirmed through cytogenetic testing. Molecular genetic testing identifies BLM gene mutation carriers at risk for conceiving offspring with the disease. Therefore, BLM genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests that include the BLM gene as a statutorily excluded service.To receive a BLM gene test service denial, please submit the followingCPTcode 81209or CPTcode 81443An 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 modifierEnter DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter DEX Z-Code identifier adjacent to the CPTcode 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: GBA Genetic Testing (A53542)

CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after July 30, 2013.Mutations found in glucosidase, beta, acid (GBA) are associated with Gaucher disease (GD), which encompasses a continuum of clinical findings. Since GBA genetic testing is used to confirm the clinical findings to diagnose GD, the MolDX Team has determined that GBA genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests that include the GBA gene as a statutorily excluded service.To receive a GBA test denial, please submit the following claim information:CPTcode 81251- GBA, common variantsAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX HCPCS modifierTo indicate a statutorily excluded service, append with a GY HCPCS modifierFor CPTnon-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode 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: myPap™ (A53544)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextThe myPAP DNA test, developed to complement a Papanicolaou (Pap) test, confirms a Pap specimen belongs to the patient evaluated for treatment. The MolDX Team agrees the healthcare community should define and follow strict procedures regarding patient and patient specimen identification and handling. Tests performed to measure the quality or control of a process and do not provide information to diagnose or treat a patient illness or injury do not meet the criteria for a Medicare benefit. Therefore, the myPAP test is a statutorily excluded test. Although an Advance Beneficiary Notice (ABN) is not required for a statutory exclusion, providers supplying this test (directly or through a purchased service) should ensure patients understand the test is not a covered benefit.Providers must register for a DEX Z-Code identifier prior to claim submission. To access the MolDX registry, go to the DEX Diagnostics Exchange located at: https://app.dexzcodes.com/login. Once an ID has been obtained, please submit the following claim information to receive a myPap Medicare service denial:CPTcode 84999  unlisted chemistry procedureAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded serviceFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierEnter DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter DEX Z-Code identifier adjacent to the CPTcode 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 formIf you believe your practice has submitted claims and received reimbursement in error, you may take the following corrective actions:Complete a Self-AuditIdentify incorrect submissionsContain further claim submission errorsConsider Self-Disclosure ProtocolSelf-disclosure guidelines
Article - Billing and Coding: MolDX: VEGFR2 Tests (A53548)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextEffective for dates of service on and after 05/03/2013.Vascular endothelial growth factor, subtype 2, (VEGFR2) receptor has been found to be oncogenic. Current studies have targeted VEGFR2 as a potential therapeutic option. However, at present there is insufficient evidence to establish a clear association between VEGFR2 mutations and treatment response. Therefore, the MolDX Team has determined VEGFR2 testing is a statutorily excluded service. MolDX will also deny panels of tests that include the VEGFR2 receptor.To receive a VEGFR2 service denial, please submit the following claim information:CPTcode 81479An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierEnter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode 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: ATP7B Gene Tests (A53550)

CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after July 24, 2013ATP7B gene mutations have been primarily associated with Wilson Disease, a disorder of copper metabolism. However, serology remains the gold standard for testing and treating the signs and symptoms of this condition. At present the literature does not support that ATP7B gene testing changes physician treatment or improves patient outcomes. Therefore, the MolDX Team has determined ATP7B gene testing is a statutorily excluded service. MolDX will also deny panels of tests that include the ATP7B gene.To receive an ATP7B gene test denial, please submit the following claim information:Select the appropriate CPTcode for the performed service:81406 - ATP7B, fgs81443 - Genetic Testing for severe genetic conditions81479 - Unlisted molecular pathology procedureAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierEnter DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter DEX Z-Code identifier adjacent to the CPTcode 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: know error® (A53554)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextThe know error DNA Specimen Provenance Assay is a forensic assay to confirm that a surgical specimen belongs to the patient evaluated for treatment. Although MolDX agrees the healthcare community should define and follow strict procedures regarding patient and patient specimen identification and handling, tests performed to measure the quality of a process do not provide information to diagnose or treat a patient illness or injury as defined in the Medicare benefit category. Therefore, the know error DNA Specimen Provenance Assay is a statutorily excluded test. Although an Advance Beneficiary Notice (ABN) is not required for a statutory exclusion, providers supplying this test (directly or through a purchased service) should ensure patients understand the test is not a covered benefit.To receive a DNA Specimen Provenance Assay service denial, please submit the following claim information:CPT code 84999  unlisted chemistry procedureFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifier. An Advance Beneficiary Notice (ABN) is not required for statutorily excluded serviceSelect the appropriate diagnosis for the patientIf you believe your practice has submitted claims and received reimbursement in error, you may take the following corrective actions:Complete a Self-Auditidentify incorrect submissionscontain further claim submission errorsConsider Self-Disclosure Protocolself-disclosure guidelines available @ the following pathway: http://www.oig.hhs.gov/compliance/self-disclosure-info/index.asp