evekhm/cms_iom_500 huggingface dataset:
(Medicare National Coverage Determinations Manual)
50.8 - Ultrasonic Surgery  (Rev. 1, 10- 03-03) CIM 35 -4  Reimbursement may be made for ultrasonic surgery when required in the treatment of patients with s evere and recurrent episodes of vertigo due to Menieres syndrome.  This procedure utilizes a machine that produces ultrasonic waves of high intensity and frequency that selectively irradiate certain portions of the inner ear thereby destroying the tissue.   The procedure is usually done under local anesthesia, and requires the services of a surgeon and another individual who is responsible for calibrating the electrical equipment, and who assists in observing certain physical changes (e.g., movement of the eyes, nystagmus") indicative of inner ear reaction to the ultrasonic destruction.  Except in rare instances the desired result is achieved with one treatment.  At present, there are two different approaches being used to apply the ultrasound to the inner ear: one through the lateral semicircular canal and, more recently, a simpler approach from a technical viewpoint, through the round window.  60 - Emergency Medicine  (Rev. 1, 10- 03-03)  No coverage determinations.  70 - Evaluation and Management of Patient s - Office/hospital/home  (Rev. 1, 10- 03-03)  70.1 - Consultations With a Beneficiarys Family and Associates  (Rev. 1, 10- 03-03) CIM 35 -14  In certain types of medical conditions, including when a patient is withdrawn and uncommunicative due to a mental dis order or comatose, the physician may contact relatives and close associates to secure background information to assist in diagnosis and treatment planning.  When a physician contacts his patients relatives or associates for this purpose, expenses of such interviews are properly chargeable as physicians services to the patient on whose behalf the information was secured.  If the beneficiary is not an inpatient of a hospital, Part B reimbursement for such an interview is subject to the special limitation on  payments for physicians services in connection with mental, psychoneurotic, and personality disorders.  A physician may also have contacts with a patients family and associates for purposes other than securing background information.  In some cases, the  physician will provide counseling to members of the household.  Family counseling services are covered only where the primary purpose of such counseling is the treatment of the patients condition.
(Medicare National Coverage Determinations Manual)
For example, two situations where family counseling services would be appropriate are as follows:  (1) where there is a need to observe the patients interaction with family members; and/or (2) where there is a need to assess the capability of and assist the family members in aiding in the management of the pat ient.  Counseling principally concerned with the effects of the patients condition on the individual being interviewed would not be reimbursable as part of the physicians personal services to the patient.  While to a limited degree, the counseling descri bed in the second situation may be used to modify the behavior of the family members, such services nevertheless are covered because they relate primarily to the management of the patients problems and not to the treatment of the family members problems.   Cross -references:   The Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B,20.  The Medicare Claims Processing Manual, Chapter 12, Physician/Practitioner Billing, 10.  The Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, Deductibles, Coinsurance Amounts, and Payment Limitations, 30.   70.2 - Consultation Services Rendered by a Podiatrist in a Skilled Nursing Facility  (Rev. 1, 10- 03-03) CIM 50 -8
(Medicare National Coverage Determinations Manual)
70.2 - Consultation Services Rendered by a Podiatrist in a Skilled Nursing Facility  (Rev. 1, 10- 03-03) CIM 50 -8  Consultation services rendered by a podiatrist in a skilled nursing facility are covered if the services are reasonable and necessary and do not come within any of the specific statutory exclusions.  Section 1862(a)(13)  of the Act excludes payment for the treatment of flat foot conditions, the treatment of subluxations of the foot, and routine foot care.  To determine whether the consultation comes within the foot care exclusions, apply the same rule as for initial diagnostic examinations, i.e., where services are performed in connection with specific symptoms or complaints which suggest the need for, covered services, the services are covered regardless of the resulting di agnosis.  The exclusion of routine physician examinations is also pertinent and would generally exclude podiatric consultation performed on all patients in a skilled nursing facility on a routine basis for screening purposes, except in those cases where a specific foot ailment is involved. Section 1862(a)(7)  of the Act excludes payment for routine physical checkups.  (See the Medicare Benefit Policy Manual, Chapter 16, Ge neral Exclusions from Coverage, 90 and 100.)   70.2.1 - Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy)  (Rev. 1, 10- 03-03) CIM 50 -8.1
(Medicare National Coverage Determinations Manual)
Presently, peri pheral neuropathy, or diabetic sensory neuropathy, is the most common factor leading to amputation in people with diabetes.  In diabetes, sensory neuropathy is an anatomically diffuse process primarily affecting sensory and autonomic fibers; however, dista l motor findings may be present in advanced cases.  Long nerves are affected first, with symptoms typically beginning insidiously in the toes and then advancing proximally.  This leads to loss of protective sensation (LOPS), whereby a person is unable to f eel minor trauma from mechanical, thermal, or chemical sources.  When foot lesions are present, the reduction in autonomic nerve functions may also inhibit wound healing.  Diabetic sensory neuropathy with LOPS is a localized illness of the feet and falls w ithin the regulations exception to the general exclusionary rule (see 42 CFR  411.15(l)(1)(i) ).  Foot exams for people with diabetic sensory neuropathy with LOPS are reas onable and necessary to allow for early intervention in serious complications that typically afflict diabetics with the disease.   Effective for services furnished on or after July 1, 2002, Medicare covers, as a physician service, an evaluation (examination and treatment) of the feet no more often than every six months for individuals with a documented diagnosis of diabetic sensory neuropathy and LOPS, as long as the beneficiary has not seen a foot care specialist for some other reason in the interim.  L OPS shall be diagnosed through sensory testing with the 5.07 monofilament using established guidelines, such as those developed by the National Institute of Diabetes and Digestive and Kidney Diseases guidelines.  Five sites should be tested on the plantar surface of each foot, according to the National Institute of Diabetes and Digestive and Kidney Diseases guidelines.  The areas must be tested randomly since the loss of protective sensation may be patchy in distribution, and the patient may get clues if th e test is done rhythmically.  Heavily callused areas should be avoided.  As suggested by the American Podiatric Medicine Association, an absence of sensation at two or more sites out of 5 tested on either foot when tested with the 5.07 Semmes -Weinstein mon ofilament must be present and documented to diagnose peripheral neuropathy with loss of protective sensation.   The examination includes:   1.  A patient history, and
(Medicare National Coverage Determinations Manual)
The examination includes:   1.  A patient history, and   2.  A physical examination that must consist of at least the following elements:    Visual inspection of forefoot and hindfoot (including toe web spaces);   Evaluation of protective sensation;   Evaluation of foot structure and biomechanics;   Evaluation of vascular status and skin integrity;   Evaluation of the need for special footwear; and   3  Patient education.   A.  Treatment includes, but is not limited to:     Local care of superficial wounds;   Debridement of corns and calluses; and   Trimming and debridement of nails.  The diagnosis of diabetic sensory neuropathy with LOPS should be established and documented prior to coverage of foot care.  Other causes of peripheral neuropathy should be considered and investigated by the primary care physician prior to initiating or referring for foot care for persons with LOPS.   70.3 - Physicians Office with in an Institution - Coverage of Services and Supplies Incident to a Physicians Services  (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  Coverage of Services and Supplies Incident to a  Physicians Services
(Medicare National Coverage Determinations Manual)
Where a physician establishes an office within a nursing home or other institution, coverage of services and supplies furnished in the office must be determined in accordance with the incident to a physicians professional service provision (see the Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 20.4.1 or the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 60.1) as in any physicians office. A physicians office within an institution must be confined to a separately identified part of the facility which is used solely as the physicians office and cannot be construed to extend throughout the entire institution.  Thus, services performed outside the office area would be subject to the coverage rules applicable to services furnished outside the office setting.  In order to accurately apply the criteria in the Medicare Benefit Policy Manual, Chapters 6, 20.4.1, or Chapter 15, Covere d Medical and Other Health Services, 60.1, the A/B MAC gives consideration to the physical proximity of the institution and physicians office.  When his office is located within a facility, a physician may not be reimbursed for services, supplies, and use of equipment which fall outside the scope of services commonly furnished in physicians offices generally, even though such services may be furnished in his institutional office. Additionally, make a distinction between the physicians office practice  and the institution, especially when the physician is administrator or owner of the facility.  Thus, for their services to be covered under the criteria in the Medicare Benefit Policy Manual, Chapter 6, 20.4.1, or the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 60.1, the auxiliary medical personnel must be members of the office staff rather than of the institutions staff, and the cost of supplies must represent an expense to the physicians office practice.  Finally, services performed by the employees of the physician outside the office area must be directly supervised by the physician; his presence in the facility as a whole would not suffice to meet this requirement.  (In any setting, of course, supervisi on of auxiliary personnel in and of itself is not considered a physicians professional service to which the services of the auxiliary personnel could be an incidental part, i.e., in addition to
(Medicare National Coverage Determinations Manual)
setting, of course, supervisi on of auxiliary personnel in and of itself is not considered a physicians professional service to which the services of the auxiliary personnel could be an incidental part, i.e., in addition to supervision, the physician must perform or have performed a  personal professional service to the patient to which the services of the auxiliary personnel could be considered an incidental part.)  Denials for failure to meet any of these requirements would be based on 1861(s)(2)(A)  of the Social Security Act.
(Medicare National Coverage Determinations Manual)
Establishment of an office within an institution would not modify rules otherwise applicable for determining coverage of the physicians personal professional services within the institution.  However, in view of the opportunity afforded to a physician who maintains such an office for rendering services to a sizable number of patients in a short period of time or for performing frequent services for the same patient, claims f or physicians services rendered under such circumstances would require careful evaluation by the A/B MAC to assure that payment is made only for services that are reasonable and necessary.   Cross -reference:   The Medicare Benefit Policy Manual, Chapter 15,  Covered Medical and Other Health Services.   The Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 20.4.1.  70.4 - Pronouncement of Death  (Rev. 1, 10- 03-03) CIM 50 -19  According to established legal principles, an individual is not considered deceased until there has been official pronouncement of death.  An individual is therefore considered to have expired as of the time he/she is pronounced dead by a person who is legally authorized to make such a pronouncement, usually a physician.  Reasonable and necessary medical services rendered up to and including pronouncement of death by a physician are covered diagnostic or therapeutic services.  70.5 - Hospital and Skilled Nursing Facility Admission Diagnostic Procedures  (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  These instructions describe the application of the reasonable and necessary payment exclusion to diagnostic procedures, such as chest x -rays, urinalysis, etc. provided to patients upon admission to a hospital or skilled nursing facility.  The major factors which support a determination that a diagnostic procedure performed as part of the admitting procedure to a hospital or  skilled nursing facility is reasonable and necessary, are:   A.  The test is specifically ordered by the admitting physician (or a hospital or skilled nursing facility staff physician having responsibility for the patient where there is no admitting physician):  i.e., it is not furnished under the standing orders of  a physician for his patients;  B.  The test is medically necessary for the diagnosis or treatment of the individual patients condition; and
(Medicare National Coverage Determinations Manual)
B.  The test is medically necessary for the diagnosis or treatment of the individual patients condition; and  C.  The test does not unnecessarily duplicate the same test performed on an outpatient basis prior to admission or performed in connection with a recent hospital or skilled nursing facility admission.  Where the A/B MAC has not already done so, consult with the Quality Improvement Organizations (QIOs) to obtain information gathered by the QIOs on a sample basis as to whether x -rays and diagnostic tests are being specifically ordered as described under subsection (A).   80 - Eye (Rev. 1, 10- 03-03)  80.1 - Hydrophilic Contact Lens for Corneal Bandage  (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  Some hydrophilic contact lenses are used as moist corneal bandages for the treatment of acute or chronic corneal pathology, such as bulbous keratopathy, dry eyes, corneal ulcers and erosion, keratitis, corne al edema, descemetocele, corneal ectasis, Moorens ulcer, anterior corneal dystrophy, neurotrophic keratoconjunctivitis, and for other therapeutic reasons.   Payment may be made under 1861(s)(2)  of the Social Security Act for a hydrophilic contact lens approved by the Food and Drug Administration (FDA) and used as a supply incident to a physicians service.  Payment for the lens is included in the payment for the physician s service to which the lens is incident.  A/B MACs are authorized to accept an FDA letter of approval or other FDA published material as evidence of FDA approval.  (See 80.4 for coverage of a hydrophilic contact lens as a prosthetic device.)  See the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, and the Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 20.4.  80.2 - Photodynamic Therapy  (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)
(Medicare National Coverage Determinations Manual)
Photodynamic therapy is a medical procedure which involves the infusion of a photosensitive (light -activated) drug with a very specific absorption peak. This drug is chemically designed to have a unique affinity for the diseased tissue intended for treatme nt. Once introduced to the body, the drug accumulates and is retained in diseased tissue to a greater degree than in normal tissue. Infusion is followed by the targeted irradiation of this tissue with a non -thermal laser, calibrated to emit light at a wave length that corresponds to the drugs absorption peak. The drug then becomes active and locally treats the diseased tissue.   Ocular Photodynamic Therapy (OPT)   Ocular Photodynamic Therapy (OPT) is used in the treatment of ophthalmologic diseases. OPT is only covered when used in conjunction with verteporfin (see section 80.3, Photosensitive Drugs).    Classic Subfoveal Choroidal Neovascular (CNV) Lesions -  OPT is covered with a diagnosis of neovascular age -related macular degeneration (AMD) with predominately classic subfoveal choroidal neovascular (CNV) lesions (where the area of classic CNV occupies 50% of the area of the entire lesion) at the initial visit as determined by a fluorescein angiogram (FA). Subsequent follow -up visits will require either a n optical coherence tomography or an FA to access treatment response. There are no requirements regarding visual acuity, lesion size, and number of re -treatments.    Occult Subfoveal CNV Lesions -  OPT is non- covered for patients with a diagnosis of AMD with occult and no classic CNV lesions.
(Medicare National Coverage Determinations Manual)
 Occult Subfoveal CNV Lesions -  OPT is non- covered for patients with a diagnosis of AMD with occult and no classic CNV lesions.   Other Conditions -  Use of OPT with verteporfin for other types of AMD (e.g., patients with minimally classic CNV lesions, atrophic, or dry AMD) is non- covered. OPT with verteporfin for other ocular indications such as pathologic myopia or presumed ocular histoplasmosis syndrome, is eligible for coverage through individual A/B MAC discretion.  80.2.1 - Ocular Photodynamic Therapy (OPT) - Effective April 3, 2013  (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation:  of ICD -10, Implementation: Upon Implementation of ICD -10)  A. General   Ocular Photodynamic Therapy (OPT) is used in the treatment of ophthalmologic diseases; specifically, for age- related macular degeneration (AMD), a common eye disease among the elderly . OPT involves the infusion of an intravenous photosensitizing drug called verteporfin followed by exposure to a laser. OPT is only covered when used in conjunction with verteporfin.   Effective July 1, 2001, OPT with verteporfin was approved for a diagnos is of neovascular AMD with predominately classic subfoveal choroidal neovascularization (CNV) lesions (where the area of classic CNV occupies 50% of the area of the entire lesion) at the initial visit as determined by a fluorescein angiogram (FA).   On Oct ober 17, 2001, the Centers for Medicare & Medicaid Services (CMS) announced its intent to cover OPT with verteporfin for AMD patients with occult and no classic subfoveal CNV as determined by an FA. The October 17, 2001, decision was never implemented.   On March 28, 2002, after thorough review and reconsideration of the October 17, 2001, intent to cover policy, CMS determined that the current non- coverage policy for OPT for verteporfin for AMD patients with occult and no classic subfoveal CNV as determine d by an FA should remain in effect.
(Medicare National Coverage Determinations Manual)
Effective August 20, 2002, CMS issued a non- coverage instruction for OPT with verteporfin for AMD patients with occult and no classic subfoveal CNV as determined by an FA.   B. Nationally Covered Indications   Effective April 1, 2004, OPT with verteporfin c ontinues to be approved for a diagnosis of neovascular AMD with predominately classic subfoveal CNV lesions (where the area of classic CNV occupies 50% of the area of the entire lesion) at the initial visit as determined by an FA. (CNV lesions are compris ed of classic and/or occult components.) Subsequent follow -up visits require either an optical coherence tomography (OCT) (effective April 3. 2013) or an FA (effective April 1, 2004) to access treatment response. There are no requirements regarding visual acuity, lesion size, and number of re -treatments when treating predominantly classic lesions.   In addition, after thorough review and reconsideration of the August 20, 2002, non-coverage policy, CMS determines that the evidence is adequate to conclude that  OPT with verteporfin is reasonable and necessary for treating:   1.  Subfoveal occult with no classic CNV associated with AMD; and,   2.  Subfoveal minimally classic CNV (where the area of classic CNV occupies <50% of the area of the entire lesion) associ ated with AMD.   The above 2 indications are considered reasonable and necessary only when:   1. The lesions are small (4 disk areas or less in size) at the time of initial treatment or within the 3 months prior to initial treatment; and,   2.  The lesions have shown evidence of progression within the 3 months prior to initial treatment. Evidence of progression must be documented by deterioration of visual acuity (at least 5 letters on a standard eye examination chart), lesion growth (an increase in at least  1 disk area), or the appearance of blood associated with the lesion.  C. Nationally Non -Covered Indications   Other uses of OPT with verteporfin to treat AMD not already addressed by CMS will continue to be non- covered. These include, but are not limited to, the following AMD indications:
(Medicare National Coverage Determinations Manual)
C. Nationally Non -Covered Indications   Other uses of OPT with verteporfin to treat AMD not already addressed by CMS will continue to be non- covered. These include, but are not limited to, the following AMD indications:    Juxtafoveal or extrafoveal CNV lesions (lesions outside the fovea),   Inability to obtain a fluorescein angiogram,   Atrophic or dry AMD.   D. Other  The OPT with verteporfin for other ocular indications, such as pathologic myopia or presumed ocular histoplasmosis syndrome, continue to be eligible for local coverage determinations through individual A/B MAC discretion.  80.3 - Photosensitive Drugs  (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)