evekhm/cms_iom_500 huggingface dataset:
Proposed LCD - Cervical Fusion (DL39799)
Yang H, Wang H, Zhang B, Sun Y, Wang L, Lu X. Cervical spine fracture-dislocation in patients with ankylosing spondylitis and severe thoracic kyphosis: Application of halo vest before and during surgical management.Clin Neurol Neurosurg.2021;207:106744.Wang L, Wang H, Wang C, Zhang B, Yang H, Lu X. Comparative study of halo-vest reduction and skull traction reduction in the treatment of cervical fracture dislocation in patients with ankylosing spondylitis.Front Surg.2023;10:1129809.Skeppholm M, Svedmark P, Noz ME, Maguire GQ, Jr., Olivecrona H, Olerud C. Evaluation of mobility and stability in the Discover artificial disc: an in vivo motion study using high-accuracy 3D CT data.J Neurosurg Spine.2015;23(3):383-389.Rustagi T, Mashaly H, Mendel E. Posterior occiput-cervical fixation for metastasis to upper cervical spine.J Craniovertebr Junction Spine.2019;10(2):119-126.Luksanapruksa P, Millhouse PW, Carlson V, Ariyawatkul T, Heller J, Kepler CK. Comparison of Surgical Outcomes of the Posterior and Combined Approaches for Repair of Cervical Fractures in Ankylosing Spondylitis.Asian Spine J.2019;13(3):432-440.Li Z, Li F, Hou S, et al. Anterior discectomy/corpectomy and fusion with internal fixation for the treatment of unstable hangman's fractures: a retrospective study of 38 cases.J Neurosurg Spine.2015;22(4):387-393.Lee JS, Son DW, Lee SH, Ki SS, Lee SW, Song GS. Comparative Analysis of Surgical Outcomes of C1-2 Fusion Spine Surgery between Intraoperative Computed Tomography Image Based Navigation-Guided Operation and Fluoroscopy-Guided Operation.J Korean Neurosurg Soc.2020;63(2):237-247.
Proposed LCD - Cervical Fusion (DL39799)
Lang S, Neumann C, Fiedler L, Alt V, Loibl M, Kerschbaum M. Does Dynamic Anterior Plate Fixation Provide Adequate Stability for Traumatic Subaxial Cervical Spine Fractures at Mid-Term Follow-Up?J Clin Med.2021;10(6).Kong W, Yang X, Li Z, Hu B, Song Y. Analysis of the Cervical Sagittal Alignment in Patients with Unstable Hangman Fracture Under C2 approximately 3 Anterior Discectomy and Fusion.World Neurosurg.2020;137:e1-e8.Kim HS, Cloney MB, Koski TR, Smith ZA, Dahdaleh NS. Management of Isolated Atlas Fractures: A Retrospective Study of 65 Patients.World Neurosurg.2018;111:e316-e322.Bakhsheshian J, Sizdahkhani S, Ohiorhenuan I, Buchanan IA, Strickland B, Pham MH. Transpedicular lag screw placement in traumatic cervical spondylolisthesis: Case report and systematic review of the literature.J Clin Neurosci.2019;63:256-262.Jin C, Xie N, Ren Y, et al. How Does Cervical Sagittal Balance Change After Hangman Fracture Treated with Anterior or Posterior Approach Surgery?World Neurosurg.2020;138:e767-e777.Garrido BJ, Myo GK, Sasso RC. Rigid versus nonrigid occipitocervical fusion: a clinical comparison of short-term outcomes.J Spinal Disord Tech.2011;24(1):20-23.Dagtekin A, Avci E, Hamzaoglu V, et al. Management of occipitocervical junction and upper cervical trauma.J Craniovertebr Junction Spine.2018;9(3):148-155.Clark S, Nash A, Shasti M, et al. Mortality Rates After Posterior C1-2 Fusion for Displaced Type II Odontoid Fractures in Octogenarians.Spine (Phila Pa 1976).2018;43(18):E1077-E1081.
Proposed LCD - Cervical Fusion (DL39799)
Candura D, Perna A, Velluto C, et al. Conservative management of Anderson Type II odontoid fractures in octogenarians: is radiological union what we are searching for?Eur Rev Med Pharmacol Sci.2022;26(1 Suppl):33-42.Aldrian S, Erhart J, Schuster R, et al. Surgical vs nonoperative treatment of Hadley type IIA odontoid fractures.Neurosurgery.2012;70(3):676-682; discussion 682-673.Ghogawala Z, Terrin N, Dunbar MR, et al. Effect of ventral vs dorsal spinal surgery on patient-reported physical functioning in patients with cervical spondylotic myelopathy: a randomized clinical trial.Jama.2021;325(10):942-951.de Dios Perez E. Degenerative cervical myelopathy: Surgical treatment, imaging evaluation, and outcome. 2023.Sattari SA, Ghanavatian M, Feghali J, et al. Anterior cervical discectomy and fusion versus posterior decompression in patients with degenerative cervical myelopathy: a systematic review and meta-analysis.J Neurosurg Spine.2023:1-13.Selph SS SA, Jungbauer RM, Brodt E, et al. Cervical Degenerative Disease Treatment: A Systematic Review. Comparative Effectiveness Review No. 266. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 75Q80120D00006.). AHRQ Publication No. 24-EHC001.Rockville, MD: Agency for Healthcare Research and Quality;. https://effectivehealthcare.ahrq.gov/products/cervical-degenerative-disease/research. Accessed November 28, 2023.
Proposed LCD - Cervical Fusion (DL39799)
Industries. WSDoL. Labor and Industries Industrial Insurance Medical Advisory Committee (IIMAC). Guideline for diagnosis and treatment of cervical radiculopathy and myelopathy. . https://www.lni.wa.gov/patient-care/treating-patients/treatment-guidelines-and-resources/_docs/2014CervicalGuideline-FINAL.pdf [lni.wa.gov]. Updated Effective December 2014, Hyperlinks and minor corrections June 2023. . Accessed November 28, 2023.Cohen SP. Epidemiology, diagnosis, and treatment of neck pain.Mayo Clin Proc.2015;90(2):284-299.Ohnari H, Sasai K, Akagi S, Iida H, Takanori S, Kato I. Investigation of axial symptoms after cervical laminoplasty, using questionnaire survey.Spine J.2006;6(3):221-227.(NASS) NASS. Appropriate Use Criteria: Cervical Fusion (2013) North American Spine Society (NASS). North American Spine Society: Appropriate Use Criteria for Cervical Fusion Web site. https://www.spine.org/Portals/0/assets/downloads/ResearchClinicalCare/CervicalFusionAUC.pdf. Published 2013. Accessed November 14, 2023.van Middelkoop M, Rubinstein SM, Ostelo R, et al. No additional value of fusion techniques on anterior discectomy for neck pain: a systematic review.Pain.2012;153(11):2167-2173.Riew KD, Ecker E, Dettori JR. Anterior cervical discectomy and fusion for the management of axial neck pain in the absence of radiculopathy or myelopathy.Evid Based Spine Care J.2010;1(3):45-50.Carragee EJ, Hurwitz EL, Cheng I, et al. Treatment of neck pain: injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.Spine (Phila Pa 1976).2008;33(4 Suppl):S153-169.
Proposed LCD - Cervical Fusion (DL39799)
Palit M, Schofferman J, Goldthwaite N, et al. Anterior discectomy and fusion for the management of neck pain.Spine (Phila Pa 1976).1999;24(21):2224-2228.Garvey TA, Transfeldt EE, Malcolm JR, Kos P. Outcome of anterior cervical discectomy and fusion as perceived by patients treated for dominant axial-mechanical cervical spine pain.Spine (Phila Pa 1976).2002;27(17):1887-1895; discussion 1895.Whitecloud TS, 3rd, Seago RA. Cervical discogenic syndrome. Results of operative intervention in patients with positive discography.Spine (Phila Pa 1976).1987;12(4):313-316.Simmons EH, Bhalla SK. Anterior cervical discectomy and fusion. A clinical and biomechanical study with eight-year follow-up.J Bone Joint Surg Br.1969;51(2):225-237.Carragee EJ, Hurwitz EL, Cheng I, et al. Treatment of neck pain: injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.J Manipulative Physiol Ther.2009;32(2 Suppl):S176-193.Nystrom B, Svensson E, Larsson S, Schillberg B, Mork A, Taube A. A small group Whiplash-Associated-Disorders (WAD) patients with central neck pain and movement induced stabbing pain, the painful segment determined by mechanical provocation: Fusion surgery was superior to multimodal rehabilitation in a randomized trial.Scand J Pain.2016;12:33-42.Kreiner DS, Shaffer WO, Baisden JL, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update).Spine J.2013;13(7):734-743.Isaac Z, Atlas SJ, K L. Management of non-radicular neck pain in adults. UpToDate. www.uptodate.com. Published 2023. Updated October 4, 2023. Accessed October 30, 2023.
Article - Billing and Coding: Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee – Medical Policy Article (A52369)
CMS National Coverage PolicyN/AArticle TextArthroscopy is a surgical procedure that allows the direct visualization of the interior joint space. In addition to providing visualization, arthroscopy enables the process of joint cleansing through the use of lavage or irrigation. Lavage alone may involve either large or small volume saline irrigation of the knee by arthroscopy. Although generally performed to reduce pain and improve function, current practice does not recognize the benefit of lavage alone for the reduction of mechanical symptoms. Arthroscopy also permits the removal of any loose bodies from the interior joint space, a procedure termed debridement.(CMS Publication 100-03,Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Section 150.9).In June, 2004 CMS issued a national coverage determination (NCD) for non-covered arthroscopic procedures for patients with osteoarthritis. This NCD specified that medical necessity decisions for coverage of debridement procedures in patients without severe osteoarthritis of the knee who presented with symptoms in addition to pain were at the discretion of the Medicare contractor (carrier or intermediary). This article reiterates non-coverage instructions in CMS Publication 100-03,Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Section 150.9 and provides coding and billing guidelines for arthroscopic lavage and debridement procedures. All language quoted from Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout this article.Indications:Not applicableLimitation:CMS does not consider the following procedures to be reasonable or necessary in the treatment of the osteoarthritic knee and is considered non-covered by the Medicare program:Arthroscopic lavage used alone for the osteoarthritic knee; orArthroscopic debridement for osteoarthritic patients presenting with knee pain only; or,Arthroscopic debridement and lavage with or without debridement for patients presenting with severe osteoarthritis
Article - Billing and Coding: Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee – Medical Policy Article (A52369)
Patients without severe osteoarthritis of the knee who present with symptoms other than pain alone; i.e., (1) mechanical symptoms that include, but are not limited to, locking, snapping, or popping (2) limb and knee joint alignment, and (3) less severe and/or early degenerative arthritis, remain at local contractor discretion. Medicare contractors may require submission of one or all of the following documents to define the patients knee condition:Operative notes,Reports of standing x-rays, or,Arthroscopy results.Coding Information: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.Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines (for outpatient services):An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 30, revised 09/05/2008, for complete instructions.Specific coding information for this policyThe physician/provider performing the procedure is responsible for identifying those patients for whom Medicare does not consider the procedure reasonable or necessary.Report CPT code 29999 (Unlisted procedure, arthroscopy) for arthroscopic lavage of the knee for treatment of osteoarthritis and/or arthroscopic debridement and lavage for patients with severe osteoarthritis.Report CPT code 29877 (Arthroscopy, knee, surgical; debridement/shaving of articular cartilage [chrondroplasty]) for arthroscopic debridement with presentation of knee pain only, or arthroscopic debridement without lavage for patients with severe osteoarthritis.
Article - Billing and Coding: Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee – Medical Policy Article (A52369)
Report HCPCS code G0289 for arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee.For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.
Article - Billing and Coding: Bevacizumab and biosimilars (A52370)
CMS National Coverage PolicyN/AArticle TextThis article contains billing and coding guidelines that complement the Local Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and Off-Label Uses.Coding Information:When billing for metastatic (secondary) disease, only use the code for the primary malignancy if still present, and only use the related personal history of Z code if not.For claims submitted to the Part B MAC:NON-OPHTHALMOLOGIC GUIDELINESBevacizumab should be reported with HCPCS code J9035 (injection, bevacizumab, 10 mg). The number of services should reflect multiples of 10 mg provided.Bevacizumab-awwb should be reported with HCPCS code Q5107 (injection, bevacizumab-awwb, biosimilar, (MVASI), 10 mg).Bevacizumab-bvzr should be reported with HCPCS code Q5118 (injection, bevacizumab-bvzr, biosimilar, (ZIRABEV), 10 mg).Effective 01/01/2023, HCPCS code Q5126 should be used to report bevacizumab-maly, biosimilar, (ALYMSYS1), 10 mg. Effective 10/01/2022 through 12/31/2022, bevacizumab-maly should be reported with HCPCS code C9142 (injection, bevacizumab-maly, biosimilar, (ALYMSYS), 10 mg).Effective 04/01/2023, HCPCS code Q5129 should be used to report bevacizumab-adcd (Vegzelma). Effective 09/27/2022 through 03/31/2023 HCPCS code J3590 should be reported.OPHTHALMOLOGIC GUIDELINESClaims for small dose bevacizumab and biosimilars for the treatment of approved ophthalmologic indications, for providers who bill the Part B MAC, should be submitted using HCPCS code C9142, J9035, Q5107 or Q5118 (bill one unit per eye).
Article - Billing and Coding: Bevacizumab and biosimilars (A52370)
HCPCS code C9257 (injection, bevacizumab, 0.25 mg) should be reported for treatment of approved ophthalmologic indications when billed in an ambulatory surgical center setting.The claim for the intravitreal injection should be coded using CPT code 67028. The appropriate site modifier (RT, LT or 50) must be appended to indicate if the service was performed unilaterally or bilaterally. Claims without a modifier will be returned to the provider unprocessed.If the drug is denied as not reasonable and necessary, the associated injection code will also be denied.For claims submitted to the Part A MAC:NON-OPHTHALMOLOGIC GUIDELINESBevacizumab should be reported with HCPCS code J9035 (injection, bevacizumab, 10 mg). The number of services should reflect multiples of 10 mg provided.Bevacizumab-awwb should be reported with HCPCS code Q5107 (injection, bevacizumab-awwb, biosimilar, (MVASI), 10 mg).Bevacizumab-bvzr should be reported with HCPCS code Q5118 (injection, bevacizumab-bvzr, biosimilar, (ZIRABEV), 10 mg).Effective 01/01/2023, HCPCS code Q5126 should be used to report bevacizumab-maly, biosimilar, (ALYMSYS1), 10 mg. Effective 10/01/2022 through 12/31/2022, bevacizumab-maly should be reported with HCPCS code C9142 (injection, bevacizumab-maly, biosimilar, (ALYMSYS), 10 mg).Effective 04/01/2023, HCPCS code Q5129 should be used to report bevacizumab-adcd (Vegzelma). Effective 09/27/2022 through 03/31/2023 HCPCS code J3590 should be reported.OPHTHALMOLOGIC GUIDELINES
Article - Billing and Coding: Bevacizumab and biosimilars (A52370)
OPHTHALMOLOGIC GUIDELINESFor providers who bill the Part A MAC, claims for bevacizumab should be reported using HCPCS code C9257 (injection, bevacizumab, 0.25 mg) for treatment of approved ophthalmologic indications.Bevacizumab-awwb should be reported with HCPCS code Q5107 (injection, bevacizumab-awwb, biosimilar, (MVASI), 10 mg).Bevacizumab-bvzr should be reported with HCPCS code Q5118 (injection, bevacizumab-bvzr, biosimilar, (ZIRABEV), 10 mg).Effective 01/01/2023, HCPCS code Q5126 should be used to report bevacizumab-maly, biosimilar, (ALYMSYS1), 10 mg. Effective 10/01/2022 through 12/31/2022, bevacizumab-maly should be reported with HCPCS code C9142 (injection, bevacizumab-maly, biosimilar, (ALYMSYS), 10 mg).The claim for the intravitreal injection should be coded using CPT code 67028. The appropriate site modifier (RT, LT or 50) must be appended to indicate if the service was performed unilaterally or bilaterally. Claims without a modifier will be returned to the provider unprocessed.If the drug is denied as not reasonable and necessary, the associated injection code will also be denied.Utilization:Dose and frequency should be in accordance with the FDA label or recognized compendia (for off-label uses). When services are performed in excess of established parameters, they may be subject to review for medical necessity.FDA and Compendia ReviewAmerican Society of Health-System Pharmacists, Inc.AHFS Drug Information.Bethesda, MD:2007.Clinical Pharmacology Web site. http://www.clinicalpharmacology.com. Accessed 06/06/2023.Lexi-Drugs Web site. http://online.lexi.com. Accessed 06/06/2023.
Article - Billing and Coding: Bevacizumab and biosimilars (A52370)
Lexi-Drugs Web site. http://online.lexi.com. Accessed 06/06/2023.Micromedex DrugDex. http://www.micromedexsolutions.com/home/dispatch. Accessed 06/06/2023.National Comprehensive Cancer Network Web site. http://www.nccn.org/index.asp. Accessed 06/02/2023.U.S. Food and Drug Administration (FDA) Web site. http://www.accessdata.fda.gov/scripts/cder/daf/. Accessed 08/07/2019.United States Pharmacopoeia (USP), Volume I; Drug Information for the Health Care Professional, 2007.
Article - Billing and Coding: Bortezomib (A52371)
CMS National Coverage PolicyN/AArticle TextThis article contains billing and coding guidelines that complement the Local Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and Off-Label Uses.Abstract:Bortezomibis an antineoplastic agent which inhibits the activity of the 26S proteasome. It exhibits cytotoxicity to various malignant cells, including myeloma and lymphoma cells.Documentation Requirements:When modifier JW is used to report that a portion of the drug is discarded, the medical record must clearly show the amount administered and the amount wasted.Effective July 1, 2023 (CR 13056) JZ Modifier is required on all claims that bill for drugs separately payable under Medicare Part B when there are no discarded amounts from single-dose containers or single-use packages.Utilization:Dose and frequency should be in accordance with the FDA label or recognized compendia (for off-label uses). When services are performed in excess of established parameters, they may be subject to review for medical necessity.FDA and Compendia Review:American Society of Health-System Pharmacists, Inc.AHFS Drug Information.Bethesda, MD: 2007.Clinical Pharmacology Web site. http://www.clinicalpharmacology.com/. Accessed 06/06/2023.FDA label for Velcade (bortezomib) approval 01/23/2012.Lexi-Drugs Web site. http://online.lexi.com. Accessed 06/06/2023.Micromedex DrugDex. http://www.thomsonhc.com/home/dispatch. Accessed 06/06/2023.National Comprehensive Cancer Network Web site. http://www.nccn.org/index.asp. Accessed 06/02/2023.U.S. Food and Drug Administration approval letter for VELCADE (bortezomib), dated May 13, 2003.U.S. Food and Drug Administration label for bortezomib approved 10/08/2014 accessed on line at http://www.accessdata.fda.gov/scripts/cder/drugsatfda/ on 10/23/2014.
Article - Billing and Coding: Bortezomib (A52371)
United States Pharmacopoeia (USP), Volume I; Drug Information for the Health Care Professional, 2007.
Article - Billing and Coding: CPT Code 87641 (Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique) (A52379)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Code of Federal Regulations:42 CFR Sections 409 et al include the Medicare Program Prospective Payment System for Hospital Outpatient Services Final Rule published in the FR Vol. 65, No. 68, April 7, 2000.CMS Publications:CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 1:6060.1.1 Required Hospital Notice to BeneficiariesArticle TextThe purpose of this article is to alert providers that National Government Services considers CPT code 87641 to be a test used for screening purposes for which payment will not be allowed.Screening tests are statutorily non-covered based on Title VIII of the Social Security Act, Section 1862(a)(1)(A) which excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Background:Methicillin-resistant S. aureus (MRSA) was first described in 1961 and now constitutes more than 50% of S. aureus isolates that cause infections in the hospital setting.