(Medicare National Coverage Determinations Manual)

Medicare National Coverage Determinations Manual  Chapter 1, Part 3 (Sections 170  190.34) Coverage Determinations   Table of Contents  (Rev. 12112, Issued;  06-29-23)  Transmittals for Chapter  1, Part 3   170 - Nonphysician Practitioner Services (PT/OT/SLP/Audiologists/CRNA ) 170.1 - Institutional and Home Care Patient Education Programs  170.2 - Melodic Intonation Therapy  170.3 - Speech -Language Pathology Services for the Treatment of Dysphagia  180 - Nutrition  180.1 - Medical Nutrition Therapy  (MNT)  180.2 - Enteral and Parenteral Nutritional Therapy  (RETIRED)  190 - Pathology and Laboratory  190.1 - Histocompatibility Testing  190.2 - Diagnostic Pap Smears  190.3 - Cytogenetic Studies  190.4 - Electron Microscope  (RETIRED)  190.5 - Sweat Test  190.6 - Hair Analysis  190.7 - Human Tumor Stem Cell Drug Sensitivity Assays  190.8 - Lymphocyte Mitogen Response Assays  190.9 - Serologic Testing for Acquired Immunodeficiency Syndrome (AIDS)  190.10 - Laboratory Tests - CRD Patients  190.11 - Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring for Anticoagulation Management  (Effective March 19, 2008)  190.12 - Urine Culture, Bacterial  190.13 - Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring)  190.14 - Human Immunodeficiency Virus (HIV) Testing (Diagnosis)  190.15 - Blood Counts  190.16 - Partial Thromboplastin Time (PTT)  190.17 -  Prothrombin Time (PT)  190.18 -  Serum Iron Studies  190.19 -  Collag en Crosslinks, Any Method 190.20 -  Blood Glucose Testing 190.21 -  Glycated Hemoglobin/Glycated Protein  190.22 -  Thyroid Testing 190.23 -  Lipid Testing  190.24 -  Digoxin Therapeutic Drug Assay  190.25 -  Alpha -fetoprotein 190.26 -  Carcinoembryonic Antigen 190.27 -  Human Chorionic Gonadotropin  190.28 -  Tumor Antigen by Immunoassay  CA 125 190.29 -  Tumor Antigen by Immunoassay CA 15- 3/CA 27.29 190.30 -  Tumor Antigen by Immunoass ay CA 19- 9 190.31 -  Prostate Specific Antigen  190.32 -  Gamma Glutamyl Transferase  190.33 -  Hepatitis Panel/Acute Hepatitis Panel 190.34 -  Fecal Occult Blood Test  170 - Nonphysician Practitioner Services (PT/OT/SLP/Audiologists/CRNA (Rev. 1, 10- 03-03)  170.1 - Institutional and Home Care Patient Education Programs  (Rev. 1, 10- 03-03) CIM 80 -1  While the Act does not specifically identify patient education programs as covered services, reimbursement may be made under Medicare for such programs furnished by providers of services (i.e., hospitals, SNFs, HHAs, and OPT providers) to the extent that the programs are appropriate, integral parts in the rendition of covered services which are reasonable and necessary for the treatment of the individuals illness or injury.  For example, educational activities carried out by nurses such as teaching patients to give themselves injections, follow prescribed diets, administer colostomy care, administer medical gases, and carry out other inpatient care activities may be reimbursable as a part of covered routine nursing care.  Also, the teaching by an occupational therapist of compensatory techniques to improve a patients level of independence in the a ctivities of daily living may be reimbursed as a part of covered occupational therapy.  Similarly, the instruction of a patient in the carrying out of a maintenance program designed for him/her by a physical therapist may be reimbursed as part of covered physical therapy.  However, when the educational activities are not closely related to the care and treatment of the patient, such as programs directed toward instructing patients or the public generally in preventive health care activities, reimbursement cannot be made since the Act limits Medicare payment to covered care which is reasonable and necessary for the treatment of an illness or injury.  For example, programs designed to prevent illness by instructing the general public in the importance of good nutritional habits, exercise regimens, and good hygiene are not reimbursable under Medicare.   170.2 - Melodic Intonation Therapy (Rev. 1, 10- 03-03) CIM 35 -67  Melodic intonation therapy is a technique used in language rehabilitation.  Its purpose is to teach aphasic patients to produce useful phrases by intoning them in a melodic pattern with strong rhythmic support.  Limited studies by a few institutions show s ome benefit for a small number of nonfluent aphasic patients otherwise unresponsive to conventional therapy.   Melodic intonation therapy is a covered service only for nonfluent aphasic patients unresponsive to conventional therapy, and only when the condit ions for coverage of speech pathology services are met.  Please refer to the Medicare Benefit Policy, Chapter 15, Covered Medical and Other Health Services, 220; the Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and COR F Services, for these conditions of coverage.   170.3 - Speech -Language  Pathology Services for the Treatment of Dysphagia (Rev. 55, Issued: 05-05- 06, Effective: 10 -01-06, Implementation: 10-02-06)  Dysphagia is a swallowing disorder that may be due to various neurological, structural, and cognitive deficits.  Dysphagia may be the result of head trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, or encephalopathies.  While dysphagia can afflict any age group, it most often appears among the elderly.  Speech- language pathology services are covered under Medicare for the treatment of dysphagia, regardless of the presence of a communication disability.  Patients who are motivated, moderately alert, and have some degree of deglutition and swallowing functions are appropriate candidates for dysphagia therapy.  Elements of the therapy program can include thermal stimulation to heighten the sensitivity of the swallowing reflex, exercises to improve oral-motor control, training in laryngeal adduction and compensatory swallowing techniques, and positioning and dietary modifications.  Design all programs to ensure swallowing safety of the patient during oral feedings and maintain adequate nutrition.  Cross -reference:   The Medicare Benefit Policy, Chapter 15, Covered Medical and Other Health Services, 220 and 230.3.  180 - Nutrition  (Rev. 1, 10-03-03)  180.1 - Medical Nutrition  Therapy  (MNT)  (Rev. 11426; Issued: 05-20- 22; Effective: 01 -01-22; Implementation: 07 -05-22)  A. General   Section 1861(s)(2)(V) of the Social Security Act  authorizes Medicare part B coverage of medical  nutrition therapy services (MNT)  for certain beneficiaries who have diabetes or  a renal  disease.  Regulations for MNT  were  established  on January 2, 2002, at 42 CFR 410.130 - 410.134.  This national coverage determination (NCD) establishes the duration and frequency limits for  the MNT  benefit  and coordinates MNT  and diabetes outpatient self- management training (DSMT)  as an NCD.   B. Nationally Covered   Effective  January 1, 2022, basic coverage of MNT,  for the first  year a beneficiary receives MNT, with either  a diagnosis of renal disease or diabetes as defined at  42 CFR 410.130  is three hours of administration.  Basic coverage in subsequent years for renal disease or diabetes is two hours. The dietitian/nutritionist may  choose how many units are administered per  day as long as all of  the other requirements  in this NCD and 42 CFR 410.130-410.134 are met.  Pursuant to the exception at 42 4CFR 410.132(b)(5), additional hours are considered to be medically necessary  and covered if the physician  determines that there  is a change in medical condition, diagnosis, or treatment regimen that requires a  change in MNT  and orders additional hours during that episode of care.   If the physician determines that receipt  of both MNT and DSMT is medically  necessary  in the same episode of care, Medicare will cover  both DSMT and MNT initial and subsequent years without decreasing either benefit as long as DSMT  and MNT are not provided on the same date of service.  The dietitian/nutritionist may  choose how many  units are performed per day  as long as all of the other requirements in the NCD  and 42 CFR 410.130-410.134  are met.  Pursuant to the exception at 42 CFR 410.132(b)(5), additional hours are considered  to be medically necessary  and covered if the physician determines that there  is a change in medical condition, diagnosis, or treatment regimen that requires a  change in MNT  and orders additional hours during that episode of care.   C. Nationally Non- Covered   N/A  D. Other   N/A  (This NCD last reviewed December 2021.)    180.2 - Enteral and Parenteral Nutritional Therapy  (RETIRED)  (Rev. 11892; Issued: 03-09- 23; Effective: 04 -10-23; Implementation:04 -10-23)   Effective January 1, 2022, the Centers for Medicare & Medicaid Services determined  that no national coverage determination (NCD) is appropriate at this time for Enteral  and Parenteral  Nutritional 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.   190 - Pathology and Laboratory  (Rev. 1, 10-03-03)  190.1 - Histocompatibility Testing  (Rev.  12112; Issued: 06-29- 23; Effective: 07 - 31-23; Implementation: 07-31- 23)   Histocompatibility testing involves the matching or typing of the human leucocyte  antigen (HLA). This testing is safe and effective when it is performed on patients:   A.  In preparation for a ki dney transplant;         B .  In preparation for bone marrow transplantation;   C.  In preparation for blood platelet transfusions (particularly where multiple              infusions are involved; or         D .  Who are suspected of having ankylosing spondyliti s.     This testing is covered under Medicare when used for any of the indications listed in A, B, and C  and if it is reasonable and necessary for the patient.   It is covered for ankylosing spondylitis in cases where other methods of diagnosis would not be  appropriate or have yielded inconclusive results. Request documentation supporting the medical necessity of the test from the physician in all cases where ankylosing spondylitis  is indicated as the reason for the test.    190.2 - Diagnostic Pap Smears  (Rev. 48, Issued:  03- 17-06; Effective/Implementation Dates:  06 -19-06) CIM 50 -20, CIM 50 -20.1  A diagnostic pap smear and related medically necessary services are covered under Medicare Part B when ordered by a physician under one of the following conditions:    Previous 4cancer of the cervix, uterus, or vagina that has been or is presently being treated;    Previous abnormal pap smear;    Any abnormal findings of the vagina, cervix, uterus, ovaries, or adnexa;    Any significant complaint by the patient referable to the female reproductive system; or    Any signs or symptoms that might in the physicians judgment reasonably be related to a gynecologic disorder.   Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer.  (See section 210.2.)   190.3 - Cytogenetic Studies (Rev. 1, 10- 03-03) CIM 50 -29  The term cytogenetic studies is used to describe the microscopic examination of the physical appearance of human chromosomes.  Medicare covers these tests when they are reasonable and necessary for the diagnosis or treatment of the following conditions:   Genetic disorders (e.g., mongolism) in a fetus (See the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 20.1   Failure of sexual development; or   Chronic myelogenous leukemia.