evekhm/cms_iom_500 huggingface dataset:
(Medicare National Coverage Determinations Manual)
A newer treatment for psoriasis uses a psoralen derivative drug in combination with ultraviolet A light, known as PUVA.  PUVA therapy is covered for treatment of intractable, disabling psoriasis, but only after the psoriasis has not responded to more conve ntional treatment.  The A/B MAC (A) or (B) should document this before paying for PUVA therapy.  In addition, reimbursement for PUVA therapy should be limited to amounts paid for other types of photochemotherapy; ordinarily, payment should not be allowed for more than 30 days of treatment, unless improvement is documented.   250.2 - Hemorheograph  (Rev. 1, 10- 03-03) CIM 50 -16  The hemorheograph is a diagnostic instrument which is safe and effective for determining the adequacy of skin perfusion prior to the performance of minor surgical procedures on the extremities, including minor podiatric procedures, and as an adjunct to the  evaluation of patients suspected of having peripheral vascular disease.   Program payment may be made only for those services employing the hemorheograph which are performed for preoperative and postoperative diagnostic evaluation of suspected peripheral artery disease.   NOTE:  This instrument is not a plethysmograph and is not considered as such.  A plethysmograph measures and records changes in the size of a body part as modified by the circulation of blood in that part.  The hemorheograph, on the other hand, measures surface blood flow in the skin; it does not measure total blood flow in a digit or limb.   250.3 - Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases  (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  Intravenous immune globulin (IVIg) is a blood product prepared from the pooled plasma of donors. It has been used to treat a variety of autoimmune diseases, including mucocutaneous blistering diseases.  It has fewer side effects than steroids or immunosuppressive agents.
(Medicare National Coverage Determinations Manual)
Effective October 1, 2002, IVIg is covered for the treatment of biopsy- proven: (1) Pemphigus Vulgaris, (2) Pemphigus Foliaceus, (3) Bullous Pemphigoid, (4) Mucous Membrane Pemphigoid (a.k.a., Cicatricial Pemphigoid), and, (5) Epidermolysis Bullosa Acquisit a for the following patient subpopulations:    Patients who have failed conventional therapy.  A/B MACs (A) and (B) have the discretion to define what constitutes failure of conventional therapy;    Patients in whom conventional therapy is otherwise contraindicated.  conventional therapy; or    Patients with rapidly progressive disease in whom a clinical response could not be affected quickly enough using conventional agents.  In such situations IVIg therapy would be given along with conventional treatment(s) and the IVIg would be used only until  the conventional therapy could take effect.   In addition, IVIg for the treatment of autoimmune mucocutaneous blistering diseases must be used only for short -term therapy and not as a maintenance therapy.  A/B MACs (A) and (B) have the discretion to decide what constitutes short -term therapy.   250.4 - Treatment of Actinic Keratosis  (Rev. 1, 10- 03-03) CIM 35 -101  Actinic keratoses (AKs), also known as solar keratoses, are common, sun- induced skin lesions that are confined to the epidermis and have the potential to become a skin cancer.   Various options exist for treating AKs.  Clinicians should select an appropriate treatment based on the patients medical history, the lesions characteristics, and on the patients preference for a specific treatment.  Commonly performed treatments for AK s include cryosurgery with liquid nitrogen, topical drug therapy, and curettage.  Less commonly performed treatments for AK include dermabrasion, excision, chemical peels, laser therapy, and photodynamic therapy (PDT).  An alternative approach to treating AKs is to observe the lesions over time and remove them only if they exhibit specific clinical features suggesting possible transformation to invasive squamous cell carcinoma (SCC).
(Medicare National Coverage Determinations Manual)
Effective for services performed on and after November 26, 2001, Medicare covers the destruction of actinic keratoses without restrictions based on lesion or patient characteristics.   250.5 - Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS) - Effective March 23, 2010  (Rev. 122, Issued: 06- 04-10, Effective: 03 -23-10, Implementation: 07- 06-10)  A. General   Treatment of persons infected with the human immunodeficiency virus (HIV) or persons who have Acquired Immune Deficiency Syndrome (AIDS) may include highly active antiretroviral therapy (HAART).  Drug reactions commonly associated with long- term use of HAART include metabolic complications such as, lipid abnormalities, e.g., hyperlipidemia, hyperglycemia, diabetes , lipodystrophy, and heart disease.  Lipodystrophy is characterized by abnormal fat distribution in the body.   The LDS is often characterized by a loss of fat that results in a facial abnormality such as severely sunken cheeks.  The patients physical appearance may contribute to psychological conditions (e.g., depression) or adversely impact a patients adherence to antiretroviral regimens (therefore jeopardizing their health) and both of these are important health- related outcomes of interest in this population.  Therefore, improving a patients physical appearance through the use of dermal injections could improve these health -related outcomes.   B. Nationally Covered Indications   Effective for claims with dates of service on and after March 23, 2010, dermal injections for LDS are only reasonable and necessary using dermal fillers approved by the Food and Drug Administration (FDA) for this purpose, and then only in HIV -infected bene ficiaries when LDS caused by antiretroviral HIV treatment is a significant contributor to their depression.   C. Nationally Non -Covered Indications   1. Dermal fillers that are not approved by the FDA for the treatment of LDS.  2. Dermal fillers that are used for any indication other than LDS in HIV -infected individuals who manifest depression as a result of their antiretroviral HIV treatments.   D. Other  N/A  (This NCD last reviewed March 2010.)   260 - Transplantation - Solid Organ Transplants  (Rev. 1, 10- 03-03)
(Medicare National Coverage Determinations Manual)
D. Other  N/A  (This NCD last reviewed March 2010.)   260 - Transplantation - Solid Organ Transplants  (Rev. 1, 10- 03-03)  260.1 - Adult Liver Transplantation  (Rev. 146, Issued: 08- 03-12, Effective: 06 -21-12, Implementation; 09- 04-12)  A. General   Liver transplantation, which is in situ replacement of a patients liver with a donor liver, in certain circumstances, may be an accepted treatment for patients with end -stage liver disease due to a variety of causes.  The procedure is used in selected pat ients as a treatment for malignancies, including primary liver tumors and certain metastatic tumors, which are typically rare but lethal with very limited treatment options.  It has also been used in the treatment of patients with extrahepatic perihilar ma lignancies.  Examples of malignancies include extrahepatic unresectable cholangiocarcinoma (CCA), liver metastases due to a neuroendocrine tumor (NET), and, hemangioendothelioma (HAE).  Despite potential short - and long- term complications, transplantation may offer the only chance of cure for selected  patients while providing meaningful palliation for some others.   B. Nationally Covered Indications   Effective July 15, 1996, adult liver transplantation when performed on beneficiaries with end-  stage liver disease other than hepatitis B or malignancies is covered under Medicare when performed in a facility which is approved by the Centers for Medicare & Medicaid Services (CMS) as meeting institutional coverage criteria.   Effective December 10, 1999, adult liver transplantation when performed on beneficiaries with end-stage liver disease other than malignancies is covered under Medicare when performed in a facility which is approved by CMS as meeting institutional coverage criteria.   Effective September 1, 2001, Medicare covers adult liver transplantation for hepatocellular carcinoma when the following conditions are met:
(Medicare National Coverage Determinations Manual)
Effective September 1, 2001, Medicare covers adult liver transplantation for hepatocellular carcinoma when the following conditions are met:    The patient is not a candidate for subtotal liver resection;   The patients tumor(s) is less than or equal to 5 cm in diameter;   There is no macrovascular involvement;   There is no identifiable extrahepatic spread of tumor to surrounding lymph nodes, lungs, abdominal organs or bone; and,   The transplant is furnished in a facility that is approved by CMS as meeting institutional coverage criteria for liver  transplants (see 65 FR 15006).  Effective June 21, 2012, A/B MACs (A) and (B)  acting within their respective jurisdictions may determine coverage of adult liver transplantation for the following malignancies: (1) extrahepatic unresectable cholangiocarcinoma (CCA); (2) liver metastases due to a neuroendocrine tumor (NET); and, (3) he mangioendothelioma (HAE).   1.  Follow -Up Care   Follow -up care or re -transplantation required as a result of a covered liver transplant is covered, provided such services are otherwise reasonable and necessary. Follow -up care is also covered for patients who have been discharged from a hospital after re ceiving non- covered liver transplant.  Coverage for follow -up care is for items and services that are reasonable and necessary as determined by Medicare guidelines.   2.  Immunosuppressive Drugs   See the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 50.5.1 and the Medicare Claims Processing Manual, Chapter 17, Drugs and Biologicals, 80.3.  C. Nationally Non -Covered Indications   Adult liver transplantation for other malignancies remains excluded from coverage.   D. Other  Coverage of adult liver transplantation is effective as of the date of the facilitys approval, but for applications received before July 13, 1991, can be effective as early as March 8, 1990.  (See 56 FR 15006 dated April 12, 1991.)   (This NCD last reviewed June 2012.)   260.2 - Pediatric Liver Transplantation  (Rev. 1, 10- 03-03) CIM 35 -53.1
(Medicare National Coverage Determinations Manual)
(This NCD last reviewed June 2012.)   260.2 - Pediatric Liver Transplantation  (Rev. 1, 10- 03-03) CIM 35 -53.1  Liver transplantation is covered for children (under age 18) with extrahepatic biliary atresia or any other form of end stage liver disease, except that coverage is not provided for children with a malignancy extending beyond the margins of the liver or those wi th persistent viremia.   Liver transplantation is covered for Medicare beneficiaries when performed in a pediatric hospital that performs pediatric liver transplants if the hospital submits an application which CMS approves documenting that:   The hospitals pediatric liver transplant program is operated jointly by the hospital and another facility that has been found by CMS to meet the institutional coverage criteria in the Federal Register notice of April 12, 1991;    The unified program shares the same transplant surgeons and quality assurance program (including oversight committee, patient protocol, and patient selection criteria); and    The hospital is able to provide the specialized facilities, services, and personnel that are required by pediatric liver transplant patients.   260.3 - Pancreas Transplants (Effective April 26, 2006)  (Rev. 56, Issued: 05- 19-06, Effective: 04 -26-06, Implementation: 07- 03-06 Carriers/10- 02-06 FIs)  A.  General   Pancreas transplantation is performed to induce an insulin- independent, euglycemic state in diabetic patients.  The procedure is generally limited to those patients with severe secondary complications of diabetes, including kidney failure.  However, pancreas transplantation is sometimes performed on patients with labile diabetes and hypoglycemic unawareness.   B.  Nationally Covered Indications   Effective for services performed on or after July 1, 1999, whole organ pancreas transplantation is nationally covered by Medicare when performed simultaneous with or after a kidney transplant.  If the pancreas transplant occurs after the kidney transplant, immunosuppressive therapy begins with the date of discharge from the inpatient stay for the pancreas transplant.  Effective for services performed on or after April 26, 2006, pancreas transplants alone (PA) are reasonable and necessary for Medicare beneficiaries in the following limited circumstances:
(Medicare National Coverage Determinations Manual)
1. PA will be limited to those facilities that are Medicare -approved for kidney transplantation. (Approved centers can be found at http://www.cms.hhs.gov/ESRDGeneralInformation/02_Data.asp#TopOfPage .)   2. Patients must have a diagnosis of type I diabetes:    Patient with diabetes must be beta cell autoantibody positive; or     o Patient must demonstrate insulinopenia defined as a fasting C -peptide level that is less than or equal to 110% of the lower limit of normal of the laboratory's measurement method.  Fasting C -peptide levels will only be considered valid with a concurrently obtained fasting glucose  <225 mg/dL.   3. Patients must have a history of medically -uncontrollable  labile (brittle) insulin -dependent diabetes mellitus with documented recurrent, severe, acutely life -threatening metabolic complications that require hospitalization.  Aforementioned complications include frequent hypoglycemia unawareness or recurring severe ketoacidosis, or recurring severe hypoglycemic attacks;    4. Patients must have been optimally and intensively managed by an endocrinologist for at least 12 months with the most medically -recognized advanced insulin formulations and delivery systems;    5. Patients must have the emotional and mental capacity to understand the significant risks associated with surgery and to effectively manage the lifelong need for immunosuppression; and,   6. Patients must otherwise be a suitable candidate for transplantation.   C.  Nationally Non -Covered Indications   The following procedure is not considered reasonable and necessary within the meaning of section 1862(a)(1)(A) of the Social Security Act:   1. Transplantation of partial pancreatic tissue or islet cells (except in the context of a clinical trial (see section 260.3.1 of the National Coverage Determinations Manual).   D.  Other   Not applicable.   (This NCD last reviewed April 2006.)   260.3.1 - Islet Cell Transplantation in the Context of A Clinical Trial (Effective October 1, 2004)  (Rev. 18, Issued 07- 30-04, Effective: 10 -01-04, Implementation: 10- 04-04)  A.  General
(Medicare National Coverage Determinations Manual)
A.  General   As a result of section 733 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (P.L. 108- 173), The Secretary of the Department of Health and Human Services, acting through the National Institute of Diabetes and Digestive and Kidney Disorders, shall conduct a clinical investigation of pancreat ic islet cell transplantation that includes Medicare beneficiaries.   The transplant is performed on patients with Type I diabetes.  A typical islet cell transplant requires over 500,000 islet cells, but varies depending on the recipients weight.  One of the desired patient outcomes is insulin independence.  Elimination of clinically significant hypoglycemia episodes and improved glucose control are other important patient outcomes   One or more pancreata are obtained from donor(s).  The islets must be removed within hours after the recovery of the donor pancreas to ensure viability.  The islet cells are transplanted by injection into the portal vein of the recipient either using direc t visualization, guided ultrasound or percutaneously.  The islet cell transplant may be performed alone, in combination with a kidney transplant, or after a kidney transplant.  Islet recipients require immunosuppressant therapy to prevent rejection of the transplanted islet cells.  Routine follow -up care is necessary for each trial participant.   B.  Nationally Covered Indications   Medicare will pay for the routine costs, as well as transplantation and appropriate related items and services, for Medicare beneficiaries participating in a National Institutes of Health (NIH) -sponsored clinical trial(s).  The term `routine costs' means r easonable and necessary routine patient care costs, including immunosuppressive drugs and other follow -up care, as defined in section 310.1 of the NCD Manual.   Specifically, Medicare will cover transplantation of pancreatic islet cells, the insulin producing cells of the pancreas.  Coverage will include the costs of acquisition and delivery of the pancreatic islet cells, as well as clinically necessary inpatient and outpatient medical care and immunosuppressants.  C.  Nationally Noncovered Indications   Partial pancreatic tissue transplantation or islet cell transplantation performed outside the context of a clinical trial continues to be noncovered.   D.  Other   Not applicable.   (This NCD last reviewed July 2004.)   260.4 - Reserved  (Rev. 1, 10- 03-03)
(Medicare National Coverage Determinations Manual)
D.  Other   Not applicable.   (This NCD last reviewed July 2004.)   260.4 - Reserved  (Rev. 1, 10- 03-03)  260.5 - Intestinal and Multi- Visceral Transplantation (Effective May 11, 2006)  (Rev. 58, Issued:  05- 26-06; Effective:  05 -11-06; Implementation:  06- 26-06)  A.  General   Medicare covers intestinal and multi- visceral transplantation for the purpose of restoring intestinal function in patients with irreversible intestinal failure.  Intestinal failure is defined as the loss of absorptive capacity of the small bowel secondary to severe primary gastrointestinal disease or surgically induced short bowel syndrome.  It may be associated with both mortality and profound morbidity.  Multi- visceral transplantation includes organs in the digestive system (stomach, duodenum, pancreas, l iver and intestine).  The evidence supports the fact that aged patients generally do not survive as well as younger patients receiving intestinal transplantation.  Nonetheless, some older patients who are free from other contraindications have received the procedure and are progressing well, as evidenced by the United Network for Organ Sharing (UNOS) data.  Thus, it is not appropriate to include specific exclusions from coverage, such as an age limitation, in the national coverage policy.   B.  Nationally Covered Indications   Effective for services performed on or after April 1, 2001, this procedure is covered only when performed for patients who have failed total parenteral nutrition (TPN) and only when performed in centers that meet approval criteria.   1.  Failed TPN   The TPN delivers nutrients intravenously, avoiding the need for absorption through the small bowel.  TPN failure includes the following:    Impending or overt liver failure due to TPN induced liver injury.  The clinical manifestations include elevated serum bilirubin and/or liver enzymes, splenomegaly, thrombocytopenia, gastroesophageal varices, coagulopathy, stomal bleeding or hepatic fibrosis/cirrhosis.
(Medicare National Coverage Determinations Manual)
 Thrombosis of the major central venous channels; jugular, subclavian, and femoral veins.  Thrombosis of two or more of these vessels is considered a life threatening complication and failure of TPN therapy.  The sequelae of central venous thrombosis are lack of access for TPN infusion, fatal sepsis due to infected thrombi, pulmonary embolism, Superior Vena Cava syndrome, or chronic venous insufficiency.    Frequent line infection and sepsis.  The development of two or more episodes of systemic sepsis secondary to line infection per year that requires hospitalization indicates failure of TPN therapy.  A single episode of line related fungemia, septic shock and/or Acute Respiratory Distress Syndrome are considered indicators of TPN failure.    Frequent episodes of severe dehydration despite intravenous fluid supplement in addition to TPN.  Under certain medical conditions such as secretory diarrhea and non-constructable gastrointestinal tract, the loss of the gastrointestinal and pancreatobiliary secretions exceeds the maximum intravenous infusion rates that can be tolerated by the cardiopul monary system.  Frequent episodes of dehydration are deleterious to all body organs particularly kidneys and the central nervous system with the development of multiple kidney stones, renal failure, and permanent brain damage.   2.  Approved Transplant Facilities   Intestinal transplantation is covered by Medicare if performed in an approved facility.  The criteria for approval of centers will be based on a volume of 10 intestinal transplants per year with a 1 -year actuarial survival of 65 percent using the Kaplan -Meier technique.   C.  Nationally Non -covered Indications   All other indications remain non- covered.   D.  Other   NA.  (This NCD last reviewed May 2006.)   260.6 - Dental Examination Prior to Kidney Transplantation  (Rev. 1, 10- 03-03) CIM 50 -26
(Medicare National Coverage Determinations Manual)
All other indications remain non- covered.   D.  Other   NA.  (This NCD last reviewed May 2006.)   260.6 - Dental Examination Prior to Kidney Transplantation  (Rev. 1, 10- 03-03) CIM 50 -26  Despite the dental services exclusion in 1862(a)(12)  of the Act (see the Medicare Benefit Policy Manual, Chapter 16, General Exclusions From Coverage, 140;), an oral or dental examination performed on an inpatient basis as part of a comprehensive workup prior to renal transplant surgery is a covered service.  This is because the purpose of the examination is not for the care of the teeth or structures directly supporting the teeth.  Rather, the examination is for the identification, prior to a complex surgical procedure, of existing medical problems where  the increased possibility of infection would not only reduce the chances for successful surgery but would also expose the patient to additional risks in undergoing such surgery.  Such a dental or oral examination would be covered under Part A of the program if performed by a dentist on the hospitals staff, or under Part B if performed by a physician.  (When performing a dental or oral examination, a dentist is not recognized as a physician under 1861(r)  of the Act.)  (See the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, Definitions, 70.2, and the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 150.)   260.7 - Lymphocyte Immune Globulin, Anti -Thymocyte Globulin (Equine)  (Rev. 1, 10- 03-03) CIM 45 -22