evekhm/cms_iom_500 huggingface dataset:
Social Security Act §1862
(B)the trialmeets criteria established by the Secretary to ensure that the trialconforms to appropriate scientific and ethical standards; and(C)in the caseof a trial initiated before January 1, 2010, the device involved inthe trial has been determined by the Secretary to be intended foruse in the diagnosis, monitoring, or treatment of an immediately life-threateningdisease or condition.(n)Requirementof a Surety Bond for Certain Providers of Services and Suppliers.(1)In general.The Secretary may require a provider of services or supplierdescribed in paragraph (2) to provide the Secretary on a continuingbasis with a surety bond in a form specified by the Secretary in anamount (not less than $50,000) that the Secretary determines is commensuratewith the volume of the billing of the provider of services or supplier.The Secretary may waive the requirement of a bond under the precedingsentence in the case of a provider of services or supplier that providesa comparable surety bond under State law.(2)Providerof services or supplier described.Aprovider of services or supplier described in this paragraph is aprovider of services or supplier the Secretary determines appropriatebased on the level of risk involved with respect to the provider ofservices or supplier, and consistent with the surety bond requirementsunder sections 1834(a)(16)(B) and 1861(o)(7)(C).(o)Suspensionof Payments Pending Investigation of Credible Allegations of Fraud.(1)In general.The Secretary may suspend payments to a provider of servicesor supplier under this title pending an investigation of a credibleallegation of fraud against the provider of services or supplier,unless the Secretary determines there is good cause not to suspendsuch payments.(2)Consultation.The Secretary shall consult with the Inspector General of theDepartment of Health and Human Services in determining whether thereis a credible allegation of fraud against a provider of services orsupplier.(3)Promulgationof regulations.The Secretary shall promulgateregulations to carry out this subsection, section 1860D12(b)(7) (includingas applied pursuant to section 1857(f)(3)(D)),[580]and section 1903(i)(2)(C).(4)[581]
Social Security Act §1862
(4)[581]Credible allegation of fraud.In carrying out this subsection, section 1860D12(b)(7) (includingas applied pursuant to section 1857(f)(3)(D)), and section 1903(i)(2)(C), a fraud hotline tip (as defined by the Secretary) without furtherevidence shall not be treated as sufficient evidence for a credibleallegation of fraud.
Social Security Act §1862
[547]See Vol. II, P.L. 108-173, 953(b), with respect tothe annual publication of a list of national coverage determinations.[548]P.L. 112-40, 261(a)(3)(A), struck out utilization andquality control peer review and inserted quality improvement,applicable to contracts entered into or renewed on or after January1, 2012.[549]See Vol. II, P.L. 99-514,1895(b)(16)(C), with respect to deeming approval.[550]See Vol. II, P.L. 110-275, 143(d), with respect toa rule of construction regarding existing regulations and policies.[551]P.L. 110-275,135(a)(2)(A)(iii), added paragraph (23), applicable to advanceddiagnostic imaging services furnished on or after January 1, 2012.[552]P.L. 111148,1104(d)(1), added paragraph (25). Effective March 23, 2010.[553]Current versionavailable at https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/Remittance.html,(October 3, 2018).[554]See Vol. II, P.L. 83-591,5000.[555]August 5, 1997 [P.L. 105-33; 111 Stat. 329].[556]P.L. 112-242, 202(a)(1), struck A primary planand inserted Subject to paragraph (9), a primary plan,effective for years beginning with 2014.[557]P.L. 112-242, 205(a),added this new sentence, applicable with respect to actions broughtand penalties sought on or after 6 months after January 10, 2013.
Social Security Act §1862
[558]P.L.112-242, 201(b), added this new clause (vii), effective January10, 2013.[559]P.L.112-242, 201(b), added this new clause (viii), effective January10, 2013.[560]As in original-period missing.[561]See Vol.II, P.L. 83-591, 5000.[562]See Vol. II, P.L. 83-591, 6103(l)(12).[563]See Vol. II, P.L. 83-591,6051.[564]SeeVol. II, P.L. 83-591, 6103(l)(12).[565]P.L. 114-10, 516(a); Insertedsubparagraph (b)(5)(E). Effective April 16, 2015[566]P.L. 115271,4002, amended clause (i) to include subclause (II). EffectiveOctober 24, 2018.[567]P.L.112-242, 204, added these 2 sentences after clause (ii) of 1862(b)(8)(B),effective January 10, 2013.[568]P.L. 112-242, 203(1),struck out shall be subject to a civil money penalty of $1,000for each day of noncompliance with respect to each claimant.and inserted may be subject to a civil penalty of up to $1,000for each day of noncompliance with respect to each claimant.,effective January 10, 2013.[569]P.L.112-242, 203(2), added this new subparagraph (I), effectiveJanuary 10, 2013.[570]P.L. 112-242,202(a)(2), added this new paragraph (9), to be applicable toyears after 2014.[571]P.L. 113-188, 901(d), struck out for a yearand inserted for 2014. Effective November 26, 2014.
Social Security Act §1862
[572]See Vol. II, P.L. 87-781, 103(c)(3).[573]See Vol. II, P.L. 75-717, 505(e).[574]See Vol. II, 21 C.F.R. 310.6.[575]August 18, 1987 [P.L. 100-93; 101 Stat.680].[576]P.L. 112-40, 261(a)(3)(A), struck out utilizationand quality control peer review and inserted qualityimprovement, applicable to contracts entered into or renewedon or after January 1, 2012.[577]See Vol. II, 5 U.S.C. 552.[578]P.L. 75-717.[579]P.L.114-255, 4009(a);inserted new subparagraph (D); Effective with respect to local coveragedeterminations that are proposed or revised on or after the date thatis 180 days after enactment, which was December 13, 2016.[580]P.L. 115271, 2008(c), inserted, section 1860D12(b)(7) (including as applied pursuantto section 1857(f)(3)(D)), after this subsection.Effective with respect to plan years beginning on or after January1, 2020.,[581]P.L. 115271,2008(d), inserted paragraph (4). Effective with respect to planyears beginning on or after January 1, 2020.END CONTENTPAGE FOOTERFooter menuSSA INTERNET BODY SCRIPTS
Article - Billing and Coding: Hemorrhoid Artery Ligation (A53006)
CMS National Coverage PolicyTitle XVIII of the Social Security Act 1833(e)Article TextEffective 08/11/2011, Palmetto GBA will reimburse services for doppler-guided hemorrhoid artery ligation with or without retroanal repair for Grade II or III hemorrhoids that have failed rubber band ligation or conservative treatment, such as behavior modification, high fiber diets to control constipation, and hydrocortisone cream/suppositories.To submit claims for this service, submit code 46948.According to CPTcoding references, it is not appropriate to submit the following codes with a46948 service:46020, 46221, 46250, 46255, 46257, 46258, 46260, 46261, 46262, 46600, 46945, 46946, 76872, 76942, and 76998.
Article - Billing and Coding: Intraocular Bevacizumab (A53008)
CMS National Coverage PolicyN/AArticle TextBevacizumab is not currently packaged and prepared by the manufacturer in doses appropriate for intravitreal injection. Physicians routinely obtain single doses prepared by qualified compounding pharmacies to minimize risk of contamination of the injected drug.Noridian previously considered such use as an "unclassified biologic" and has required claims to reflect HCPCS J3590. The use of HCPCS J7999 will allow for better tracking and recall should a problem arise with a compounded drug. The use of J7999 is not restricted to bevacizumab and shall be used for all compounded injectable drugs.Effective January 1, 2016 Noridian requires that, when billing intravitreal bevacizumab acquired from a compounding source or compounded in the physicians facility/office, the new HCPCS code J7999 be used on the claims submission.Beginning January 1, 2016 claims for compounded bevacizumab for intravitreal use submitted with the HCPCS J3590 will be returned as a billing error.For Part B claims, enter "Intravitreal bevacizumab, [dose] mg" in Item 19 of CMS-1500 claim form or in Loop 2300 or 2400, NTE, 02 for electronic claims.For Part A claims, use HCPCS code C9257. Provide the number of units.When billing CPT code 67028, modifiers RT or LT must be used to indicate the eye treated. When billing bilateral, use modifier 50.When billing J7999, enter '1' in the days/unit field for one eye, or "2" in the days/unit field if both eyes must be treated in the same encounter.The use of scanning computerized ophthalmic diagnostic imaging (e.g., scanning laser) (CPT 92134) is appropriate at four-six week intervals to help evaluate the need for re-treatment. Use of both scanning laser and fundus photography, which are bundled under the NCCI, requires appropriate documentation of medical necessity.
Article - Billing and Coding: Intraocular Bevacizumab (A53008)
Consistent with the statement of April 2006 of the American Academy of Ophthalmology (AAO) in support of this use of bevacizumab, physicians should provide appropriate informed consent with respect to the off-label use of this drug and maintain it in the patient chart. As always, medical records are subject to post-pay review and must be submitted to Noridian or other Medicare authorized agency, if requested.Current scientific literature published in the peer-reviewed core medical journals supports these uses of this drug. The published experience shows that patients with wet macular degeneration may require regular injections for up to a year if new vessels appear and many may require injections even longer. The most recent clinical trial data now extends out beyond five years and demonstrates that most patients continue to require treatment beyond two years.If and as literature and/or specialty society recommendations warrant, we will add additional covered codes while possibly removing others from this list. Because of the likelihood that frequent changes will be necessary, wedo notplan to incorporate this issue into a Local Coverage Determination (LCD).With regard to the treatment of "wet" macular degeneration, consistent with the NIH-sponsored Comparison of Age-related macular degeneration Treatment Trial (CATT), treatment more frequently than approximately every four weeks (in a given eye) would be expected to be very rare and require explicit documentation justifying that use.With regard to other diagnoses, we anticipate the frequency of administration would be supported by current available literature.
Article - Billing and Coding: Intraocular Bevacizumab (A53009)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Intraocular Bevacizumab (A53009)
Bevacizumab is not currently packaged and prepared by the manufacturer in doses appropriate for intravitreal injection. Physicians routinely obtain single doses prepared by qualified compounding pharmacies to minimize risk of contamination of the injected drug.Noridian previously considered such use as an "unclassified biologic" and has required claims to reflect HCPCS J3590. The use of HCPCS J7999 will allow for better tracking and recall should a problem arise with a compounded drug. The use of J7999 is not restricted to bevacizumab and shall be used for all compounded injectable drugs.Effective January 1, 2016, Noridian requires that, when billing intravitreal bevacizumab acquired from a compounding source or compounded in the physicians facility/office, the new HCPCS code J7999 be used on the claims submission.Beginning January 1, 2016 claims for compounded bevacizumab for intravitreal use submitted with the HCPCS J3590 will be returned as a billing error.For Part B claims, enter "Intravitreal bevacizumab, [dose] mg" in Item 19 of CMS-1500 claim form or in Loop 2300 or 2400, NTE, 02 for electronic claims.For Part A, use HCPCS code C9257. Provide the number of units.When billing CPT code 67028, modifiers RT or LT must be used to indicate the eye treated. When billing bilateral, use modifier 50.When billing J7999, enter '1' in the days/unit field for one eye, or "2" in the days/unit field if both eyes must be treated in the same encounter.The use of scanning computerized ophthalmic diagnostic imaging (e.g., scanning laser) (CPT 92134) is appropriate at four-six week intervals to help evaluate the need for re-treatment. Use of both scanning laser and fundus photography, which are bundled under the NCCI, requires appropriate documentation of medical necessity.
Article - Billing and Coding: Intraocular Bevacizumab (A53009)
Consistent with the statement of April 2006 of the American Academy of Ophthalmology (AAO) in support of this use of bevacizumab, physicians should provide appropriate informed consent with respect to the off-label use of this drug and maintain it in the patient chart. As always, medical records are subject to post-pay review and must be submitted to Noridian or other Medicare authorized agency, if requested.Current scientific literature published in the peer-reviewed core medical journals supports these uses of this drug. The published experience shows that patients with wet macular degeneration may require regular injections for up to a year if new vessels appear and many may require injections even longer. The most recent clinical trial data now extends out beyond five years and demonstrates that most patients continue to require treatment beyond two years.If and as literature and/or specialty society recommendations warrant,we will add additional covered codes while possibly removing others from this list. Because of the likelihood that frequent changes will be necessary, wedo notplan to incorporate this issue into a Local Coverage Determination (LCD).With regard to the treatment of "wet" macular degeneration, consistent with the NIH-sponsored Comparison of Age-related macular degeneration Treatment Trial (CATT), treatment more frequently than approximately every four weeks (in a given eye) would be expected to be very rare and require explicit documentation justifying that use. With regard to other diagnoses, we anticipate the frequency of administration would be supported by current available literature.
Article - Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence (A53017)
CMS National Coverage PolicyN/AArticle TextBackgroundSacral Nerve Stimulation for urinary incontinence is covered for the treatment of urinary urge incontinence, urge-frequency syndrome, and urinary retention by the CMS National Coverage Determination (NCD) 230.18, http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf. Direct stimulation of the sacral nerve(s) via an electrode array implanted at the level of the sacrum is the only treatment modality covered by the NCD. In addition, Noridian will cover sacral nerve stimulation by the same modality for the treatment of fecal incontinence, effective March 1, 2012.Indications and LimitationsUrinary IncontinenceSacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent implantation in appropriate candidates. Both the test and the permanent implantation are covered.The NCD describes the following limitations for coverage to all three conditions: Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur. Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded. Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through test stimulation. Improvement is measured through voiding diaries.Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.Fecal IncontinenceNoridian will cover sacral nerve modulation/stimulation for fecal incontinence effective March 1, 2012, when all of the following criteria are met:
Article - Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence (A53017)
Fecal IncontinenceNoridian will cover sacral nerve modulation/stimulation for fecal incontinence effective March 1, 2012, when all of the following criteria are met: Chronic fecal incontinence with greater than two incontinent episodes on average per week and duration of incontinence greater than six months or for more than twelve months after vaginal childbirth; AND Documented failure or intolerance to conventional therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment); AND A successful percutaneous test stimulation, defined as at least 50% sustained (more than one week) improvement in symptoms; AND Condition is not related to anorectal malformation (e.g., congenital anorectal malformation; defects of the external anal sphincter over 60 degrees; visible sequelae of pelvic radiation; active anal abscesses and fistulae) and/or chronic inflammatory bowel disease; AND Incontinence is not related to another neurologic condition such as peripheral neuropathy or complete spinal cord injury.Sacral nerve modulation/stimulation is consideredexperimental, investigational and unproven for the treatment of chronic constipation or chronic pelvic pain.Sources:
Article - Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence (A53017)
Sacral nerve modulation/stimulation is consideredexperimental, investigational and unproven for the treatment of chronic constipation or chronic pelvic pain.Sources:Internet Only Manual (IOM)Medicare National Coverage Determination Manual, Publication 100-03, Section 230.18Sacral Nerve Stimulation for Urinary Incontinence;Abrams P et al. Fourth International Consultation on Incontinence recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence;Neurourol Urodyn. 2010; 29(1):213-40;Annals of Surgery, March 2010, Vol 251, Number 3.Sacral Nerve Stimulation for Fecal Incontinence, Results of a 120-Patient Prospective Multicenter Study;Michelsen H, Thompson-Fawcett M, Lundy L, Krogh K, Laurberg S, Buntzen S;Six Year Experience with Sacral Nerve Stimulation for Fecal Incontinence;Dis Colon Rectum. 2010; 53(4)414-421; Mowatt G, Glazener CMA, Jarrett M. Sacral nerve stimulation for fecal incontinence and constipation in adults (Review);The Cochrane Library. 2009, Issue 1; National Institute for Health and Clinical Excellence. Fecal incontinence: the management of fecal incontinence in adults. NICE Clinical Guideline 49, June 2007;Trailblazer Health Enterprises, Local Coverage Determination forSacral Nerve Stimulation 4S-154AB-R9, Effective March 01, 2008
(Medicare National Coverage Determinations Manual)
Medicare National Coverage Determinations    Manual  Chapter 1, Part 4 (Sections 200  310.1)  Coverage Determinations   Table of Contents  (Rev. 12364, 11- 16-23)  Transmittals for Chapter 1, Part 4
(Medicare National Coverage Determinations Manual)
200 -  Pharmacology  200.1 -  Nesiritide for Treatment of Heart Failure Patients (Effective March 2, 2006)  200.2 -  Nebulized Beta Adrenergic Agonist Therapy for Lung Diseases -  (Effective September 10, 2007)  200.3 -  Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimers Disease (AD)  210 -  Prevention  210.1 -  Prostate Cancer Screening Tests  210.2 -  Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer  210.2.1 Screening for Cervical Cancer with Human Papillomavirus (HPV) Testing (Effective July 9, 2015)  210.3  Colorectal Cancer Screening Tests  210.4  Smoking and Tobacco- Use Cessation Counseling (Effective March 22, 2005)  (RETIRED)  210.4.1  Counseling to Prevent Tobacco Use (Effective August 25, 2010)  210.5 -  Diabetes Screening Tests (Effective January 1, 2005)  210.6 -  Screening for Hepatitis B Virus (HBV)  Infection  210.7  Screening for  Human Immunodeficiency Virus (HIV)  210.8  Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse  (Effective October 14, 2011)  210.9  Screening for Depression in Adults (Effective October 14, 2011)  210.10 -  Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs  210.11 -  Intensive Behavioral Therapy for Cardiovascular Disease  210.12  Intensive Behavioral Therapy for Obesity 210.13 -  Screening for Hepatitis C Virus (HCV) in Adults  210.14  Lung Cancer Screening with Low Dose Computed Tomography (LDCT)  220 -  Radiology 220.1 -  Computed Tomography (CT)  220.2 -  Magnetic Resonance Imaging  (MRI) (Various Effective Dates Below)  220.2.1 -  Magnetic Resonance Spectroscopy  (RETIRED)  220.3 -  Magnetic Resonance Angiography (RETIRED)  220.4 -  Mammograms  220.5 -  Ultrasound Diagnostic Procedures (Effective May 22, 2007)  220.6  Positron Emission Tomography (PET) Scans   (Effective April 6, 2009)  (RETIRED)  220.6.1  PET for Perfusion of the Heart  (Various Effective Dates)   220.6.2  FDG PET for Lung Cance r (RETIRED)  220.6.3  FDG PET for
(Medicare National Coverage Determinations Manual)
(RETIRED)  220.6.1  PET for Perfusion of the Heart  (Various Effective Dates)   220.6.2  FDG PET for Lung Cance r (RETIRED)  220.6.3  FDG PET for Esophageal Cancer  (RETIRED)  220.6.4  FDG PET for Colorectal Cancer  (RETIRED)  220.6.5  FDG PET for Lymphoma  (RETIRED)  220.6.6  FDG PET for Melanoma (RETIRED)  220.6.7  FDG PET for Head and Neck Cancers  (RETIRED)  220.6.8  FDG PET for Myocardial Viability  220.6.9  FDG PET for Refractory Seizures  220.6.10  FDG PET for Breast Cancer  (RETIRED)  220.6.11  FDG PET for Thyroid Cancer  (RETIRED)  220.6.12  FDG PET for Soft Tissue Sarcoma  (RETIRED)  220.6.13  FDG Positron Emission Tomography (PET) for Dementia and Neurodegenerative Diseases (Effective September 15, 2004)  220.6.14  FDG PET for Brain, Cervical, Ovarian, Pancreatic, Small Cell Lung, and Testicular Cancers  (RETIRED)  220.6.15  FDG PET for All Other Cancer Indications Not Previously Specified (RETIRED)  220.6.16 -  FDG PET for Infection and Inflammation (Effective March 19, 2008)  (RETIRED)  220.6.17 -  Positron Emission Tomography (PET) (FDG) for Oncologic Conditions -  (Effective June 11, 2013)  220.6.19 -  Positron Emission Tomography NaF -18 (NaF -18 PET) to Identify Bone Metastasis of Cancer (Effective February 26, 2010)  220.6.20 -  Beta Amyloid Positron Emission Tomography (PET)  in Dementia and Neurodegenerative Disease (RETIRED)  220.7 -  Xenon Scan  (RETIRED)  220.8 -  Nuclear Radiology Procedure  (RETIRED)  220.9 -  Digital Subtraction Angiography (DSA)  220.10 -  Portable Hand -Held X -Ray Instrument  220.11 -  Thermography  220.12 -  Single Photon Emission Computed Tomograph (SPECT)  220.13