(Medicare National Coverage Determinations Manual)

Medicare National Coverage Determinations Manual  Chapter 1, Part 1 (Sections 10  80.12)  Coverage Determinations   Table of Contents  (Rev. 12112, Issued: 06- 29-23)  Transmittals for Chapter 1, Part 1   Foreword -  Purpose for National Coverage Determinations (NCD) Manual  10 - Anesthesia and Pain Management  10.1 -  Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery  10.2 -  Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative Pain  10.3 -  Inpatient Hospital Pain Rehabilitation Programs  10.4 -  Outpatient Hospital Pain Reh abilitation Programs  10.5 -  Autogenous Epidural Blood Graft  10.6 -  Anesthesia in Cardiac Pacemaker Surgery  20 - Cardiovascular System  20.1 -  Vertebral Artery Surgery  20.2 -  Extracranial -  Intracranial (EC -IC) Arterial Byp ass Surgery  20.3 -  Thoracic Duct Drainage (TDD) in Renal Transplants  20.4  Implantable Cardioverter Defibrillators (ICDs)  20.5-  Extracorporeal Immunoadsorption (ECI) Using Protein A Columns   (RETIRED)  20.6 -  Transmyocardial Revascularization (TMR)  20.7 -  Percutaneous Transluminal Angioplasty (PTA)  (Various Effective Dates Below)  20.8 -  Cardiac Pacemakers (Various Effective Dates Below)  20.8.1 -  Cardiac Pacemaker Evaluation Services  20.8.1.1 -  Transtelephonic Monitoring of Cardiac Pacemakers  20.8.2 -  Self-Contained Pacemaker Monitors  20.8.3  Single Chamber and Dual Chamber Permanent Cardiac Pacemakers                         20.8.4 Leadless Pacemakers             20.9 -  Artificial Hearts And Related Devices (RETIRED)   20.9.1 -  Ventricular Assist Devices (Various Effective Dates Below)  20.10 -  Cardiac Rehabilitation Programs (RETIRED)  20.10.1  Cardiac Rehabilitation Programs for Chronic Heart Failure  20.11 -  Intraoperative Ventricular Mapping  20.12 -  Diagnostic Endocardial Electrical Stimulation (Pacing)  20.13 -  HIS Bundle Study 20.14 -  Plethysmography 20.15 -  Electrocardiographic Services  20.16 -  Cardiac Output Monitoring By Thoracic Electrical Bioimpedance (TEB)  Various Effective Dates Below  20.17 -  Noninvasive Tests of Carotid Function  20.18 -  Carotid Body Resection/Carotid Body Denervation  20.19 -  Ambulatory Blood Pressure Monitoring 20.20 -  External Counterpulsation (ECP) Therapy for Severe Angina (Effective March 20, 2006)  20.21 -  Chelation Therapy for Treatment of Atherosclerosis  20.22 -  Ethylenediamine -Tetra- Acetic (EDTA) Chelation Therapy for Treatment of Atherosclerosis  20.23 -  Fabric Wrapping of Abdominal Aneurysms  20.24 -  Displacement Cardiography  20.25 -  Cardiac Catheterization Performed in Other Than a Hospital Setting          (RETIRED)  20.26 -  Partial Ventriculectomy  20.27 -  Cardiointegram (CIG) as an Alternative to Stress Test or Thallium Stress Test 20.28  Therapeutic Embolization  20.29  Hyperbaric Oxygen Therapy  20.30 -  Microvolt T -Wave Alternans (MTWA)  20.31 -  Intensive Cardiac Rehabilitation (ICR) Programs  20.31.1 -  Pritikin Program (Effective August 12, 2010)  20.31.2 -  Ornish Program for Reversing Heart Disease (Effective August 12, 2010 20.31.3  Benson- Henry Institute Cardiac Wellness Program (Effective May 6, 2014)  20.32  Transcatheter Aortic Valve Replacement (TAVR)  20.33 -  Transcatheter Edge -to-Edge Repair (TEER) for Mitral Valve Regurgitation  20.34 -  Percutaneous Left Atrial Appendage Closure (LAAC)  20.35 -  Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery    Disease (PAD)  30 - Complementary and Alternative Medicine  30.1 -  Biofeedback Therapy 30.1.1 -  Biofeedback Therapy for the Treatment of Urinary Incontinence  30.2 -  Thermogenic Therapy 30.3 -  Acupuncture  30.3.1  Acupuncture for Fibromyalgia  30.3.2  Acupuncture for Osteoarthritis  30.3.3  Acupuncture for Chronic Lower Back Pain (cLBP)  30.4 -  Electrosleep Therapy  (RETIRED)  30.5 -  Transcendental Meditation  30.6 -  Intravenous Histamine Therapy  30.7 -  Laetrile and Related Substances  30.8 -  Cellular Therapy  30.9 -  Transillumination Light Scanning, or Diaphanography  40 - Endocrine System and Metabolism  40.1 -  Diabetes Outpati ent Self -Management Training  40.2 -  Home Blood Glucose Monitors  40.3 -  Closed -Loop Blood Glucose Control Device (CBGCD)  40.4 -  Insulin Syringe  40.5  Treatment of Obesity  40.7 -  Outpatient Intravenous Insulin Treatment (Effective December 23, 2009)  50 - Ear, Nose and Throat (ENT)  50.1 -  Speech Generating Devices  50.2 -  Electronic Speech Aids  50.3 -  Cochlear Implantation (Effective April 4, 2005)  50.4 -  Tracheostomy Speaking Valve  50.5 -  Oxygen Treatment of Inner Ear/Carbon Therapy  50.6 -  Tinnitus Masking (RETIRED)  50.7 -  Cochleostomy With Neurovascular Transplant for Menieres Disease  50.8 -  Ultrasonic Surgery  60 - Emergency Medicine 70 - Evaluation and Management of Patients -  Office/hospital/home  70.1 -  Consultations With a Beneficiarys Family and Associates  70.2 -  Consultation Services Rendered by a Podiatrist in a Skilled Nursing Facility  70.3 -  Physicians Office Within an Institution -  Coverage of Services and Supplies Incident to a Physicians Services  70.4 -  Pronouncement of Death  70.5 -  Hospital and Skilled Nursing Facility Admission Diagnostic Procedures  80 - Eye 80.1 -  Hydrophilic Contact Lens for Corneal Bandage  80.2 -  Photodynamic Therapy  80.2.1 -  Ocular Photodynamic Therapy (OPT) -  Effective April 3, 2013 80.3 -  Photosensitive Drugs  80.3.1 -  Verteporfin -  Effective April 3, 2013  80.4 -  Hydrophilic Contact Lenses  80.5 -  Scleral Shell  80.6 -  Intraocular Photography  80.7 -  Refractive Keratoplasty  80.7.1 -  Keratoplasty  80.8 -  Endothelial Cell P hotography  80.9 -  Computer Enhanced Perimetry  80.10 -  Phaco -Emulsification Procedure -  Cataract Extraction  80.11 -  Vitrectomy  80.12 -  Intraocular Lenses (IOLs)  Foreword - Purpose for National Coverage Determinations (NCD) Manual  (Rev.  173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  A. Purpose   The statutory and policy framework within which National Coverage Determinations (NCDs) are made may be found in title XVIII of t he Social Security Act (the Act), and in Medicare regulations and rulings. The NCD Manual describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare.  NCDs have been made on the items addressed in this manual. Decisions that items/services are not covered are generally based on 1862(a)(1)  of the Act (the not reasonable and necessary exclusion) unless otherwise  specifically noted. Where another statutory authority for denial is indicated, that is the authority for denial.  Where an item/service is stated to be covered, but such coverage is explicitly limited to specified indications or specified circumstances, a ll limitations on coverage of the items/services because they do not meet those specified indications or circumstances are based on 1862(a)(1) of the Act. Where coverage of an item/service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item/service is not mentioned at all in the Centers for Medicare & Medicaid Services (CMS) NCD Manual the Medicare Administrative Contractor (MAC) has the discretion to make the coverage decision, in consultation with its medical staff, and with CMS when appropriate, based on the law, regulations, rulings, and general program instructions   The coverage determinations in the manual will be revised based on the most recent medical and other scientific and technical  evidence available to CMS.   Other manuals in this system in which coverage -related instructions may be found are:   Pub 100- 02 (Benefit Policy);  Pub 100- 04 (Claims Processing);  Pub 100- 05 (Medicare Secondary Payer); and  Pub 100- 08 (Program Integrity)   These manuals usually contain more general coverage descriptions and/or claims processing instructions. There should be no inconsistencies among the instructions in any of these manuals and the NCD Manual pertaining to coverage. If any such inc onsistencies are found, bring them to the attention of CMS, Center for Clinical Standards and Quality, Coverage and Analysis Group, Division of Operations and Information Management.   B. Organization   The NCD Manual is organized by categories, e.g., medica l procedures, supplies, diagnostic services.  A table of contents is provided at the beginning of the manual designating coverage determination categories.  Each subject discussed within the category is listed and identified by a number.   The revision transmittal sheet identifies new material and summarizes the principal changes.  When a change in policy or procedure is involved, the background and effective date for the change is provided.  If, at a later date, the reader wishes to refer to the background explanation given on a transmittal sheet, the reader can identify the transmittal by its number which appears on each manual page.   C. CMS Coverage Web site  The CMS Coverage Web page http://www.cms.gov/Center/Special- Topic/Medicare-Coverage -Center.html?redirect=/center/coverage.asp  contains information about pending NCDs and also provides access to a database of NCDs, National Coverage Analyses, and Local Medical review Policies.   10 - Anesthesia and Pain Management  (Rev. 1, 10- 03-03)  10.1 - Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery  A.  Pre- Surgery Evaluations   Cataract surgery with an intraocular lens (IOL) implant is a high volume Medicare procedure.  Along with the surgery, a substantial number of preope rative tests are available to the surgeon.  In most cases, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate pseudophakic power of the IOL are sufficient.  In most cases involving a simpl e cataract, a diagnostic ultrasound A -scan is used.  For patients with a dense cataract, an ultrasound B -scan may be used.   Accordingly, where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye exa mination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A -scan or, if medically justified, a B -scan.  Claims for additional tests are denied as not reasonable and necessary unless there  is an additional diagnosis and the medical need for the additional tests is fully documented.  Because cataract surgery is an elective procedure, the patient may decide not to have the surgery until later, or to have the surgery performed by a physician other than the diagnosing physician.  In these situations, it may be medically appropriate for the operating physician to conduct another examination.  To the extent the additional tests are considered reasonable and necessary by the A/B MAC's medical staff , they are covered.   B.  General Anesthesia   The use of general anesthesia in cataract surgery may be considered reasonable and necessary if, for particular medical indications, it is the accepted procedure among ophthalmologists in the local community to use general anesthesia.