evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
CMS makes payment for covered dental services furnished by a physician, including a doctor of dental medicine or dental surgery, or a non- physician practitioner in accordance with state law and scope of practice in the state where the service is furnished.      Medicare Part A and Part B payment is made for dental services that are inextricably linked to, and substantially related and integral to the clinical success of, certain covered medical services. Integration between the health care professionals furnishing dental and other covered services is a key component in assessing whether dental services are inextricably linked to, and substantially related and integral to the clinical success of, other covered medical services. This integration could take the form of a referral or other exchange of information between the physicians, non-physician practitioners, or other practitioners involved in the delivery of dental and other covered medical services.   This coordination should occur between the health care professionals furnishing the dental and other covered services regardless of whether both individuals are affiliated with or employed by the same entity. If there is no exchange of information, or integration, between the health care professionals regarding the dental services, then there would not be an inextricable link between the dental and covered medical services within the meaning of our regulation a t  411.15(i)(3). This is because the professio nals would not have the necessary information to decide that the dental service(s) is inextricably linked to a covered medical service, and therefore, not subject to the statutory payment exclusion under section 1862(a)(12) of the Act.   Payment may also be made for covered dental services and supplies furnished incident to the professional services of the billing physician or practitioner by auxiliary personnel. For example, services performed by a dental technician, dental hygienist, dental therapist, or registered nurse who is under the direct supervision of the physician, including a dentist, are covered if the services meet the requirements for incident to services as described in 42 CFR  410.26.  Ancillary services and supplies furnished incident to covered dental services are also not excluded, and Medicare payment may be made under Part A or Part B, as applicable, regardless of whether the service is performed in the inpatient or outpatient setting, including, but not limited to the administration of anesthesia, diagnostic x -rays, use of operating room, and other related, otherwise covered procedures.
(Medicare Benefit Policy Manual)
No payment is made for dental services that may be inextricably linked to, and substantially related and integral to the clinical success of other non -covered services.  Such services remain subject to the statutory exclusion at  1862(a)(12) for items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth. More specifically, dental services inextricably linked to a non- covered medical service(s) are not covered or payable. For example, an alveoplasty (the surgical improvement of the shape and condition of the alveolar process) and frenectomy are excluded from coverage when either of these procedures is performed in connection with an excluded service, e.g., the preparation of the mouth for dentures. Similarly, with rare exception, the removal of a torus palatinus (a bony protuberance of the hard palate) is performed in connection with an excluded service, i.e., the preparation of the mouth for dentures. Under such circumstances, Medicare does not pay for this procedure.   MACs have the flexibility to determine on a claim-by- claim basis whether a patients circumstances do or do not fit within the terms of the statutory preclusion or exceptions specified in section 1862(a)(12) of the Act and our regulation at 42 CFR  411.15(i).  These policies do not prevent a MAC from making a determination that payment can be made for dental services in other circumstances under which the dental services are inextricably linked to, and substantially related and integral to the clinical suc cess of, certain covered medical services, but are not specifically addressed in final rules, manual provisions, and the finalized amendments to 411.15(i).   150.1 - Treatment of Temporomandibular Joint (TMJ) Syndrome  (Rev. 1, 10-01-03) PASS memo Read.014  There are a wide variety of conditions that can be characterized as TMJ, and an equally wide variety of methods for treating these conditions.  Many of the procedures fall within the Medicare programs statutory exclusion that prohibits payment for items and services that have not been demonstrated to be reasonable and necessary for the diagnosis and treatment of illness or injury ( 1862(a)(1)
(Medicare Benefit Policy Manual)
of the Act).  Other services and appliances used to treat TMJ fall within the Medicare programs statutory exclusion at 1862(a)(12), which prohibits payment for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.... For these reasons, a diagnosis of TMJ on a claim is insufficient.  The actual condition or symptom must be determined.  160 - Clinical Psychologist Services (Rev. 51, Issued: 06-23- 06, Effective: 01 -01-05, Implementation: 09-21-06)  A.  Clinical Psychologist (CP) Defined   To qualify as a clinical psychologist (CP), a practitioner must meet the following requirements:   Hold a doctoral degree in psychology;  Be licensed or certified, on the basis of the doctoral degree in psychology, by the State in which he or she practices, at the independent practice level of psychology to furnish diagnostic, assessment, preventive, and therapeutic services directly to individuals.  B.  Qualified Clinical Psychologist Services Defined   Effective July 1, 1990, the diagnostic and therapeutic services of CPs and services and supplies furnished incident to such services are covered as the services furnished by a physician or as incident to physicians services are covered.  However, the CP must be legally authorized to perform the services under applicable licensure laws of the State in which they are furnished.  C.  Types of Clinical Psychologist Services That May Be Covered  Diagnostic and therapeutic services that the CP is legally authorized to perform in accordance with State law and/or regulation.  A/B MACs (B) pay all qualified CPs based on the physician fee schedule for the diagnostic and therapeutic services.  (Psychological tests by practitioners who do not meet the requirements for a CP may be covered under the provisions for diagnostic tests as described in 80.2.  Services and supplies furnished incident to a CPs services are covered if the requirements that apply to services incident to a physicians services, as described in 60 are met.  These services must be:    Mental health services that are commonly furnished in CPs offices;   An integral, although incidental, part of professional services performed by the CP;   Performed under the direct personal supervision of the CP; i.e., the CP must be physically present and immediately available;    Furnished without charge or included in the CPs bill; and
(Medicare Benefit Policy Manual)
 Performed under the direct personal supervision of the CP; i.e., the CP must be physically present and immediately available;    Furnished without charge or included in the CPs bill; and   Performed by an employee of the CP (or an employee of the legal entity that employs the supervising CP) under the common law control test of the Act, as set forth in 20 CFR 404.1007 and RS 2101.020 of the Retirement and Survivors Insurance part of the Social Security Program Operations Manual System.   Diagnostic psychological testing services when furnished under the general supervision of a CP.  A/B MACs (B) are required to familiarize themselves with appropriate State laws and/or regulations governing a CPs scope of practice.  D.  Noncovered Services   The services of CPs are not covered if the service is otherwise excluded from Medicare coverage even though a clinical psychologist is authorized by State law to perform them.  For example, 1862(a)(1)(A)  of the Act excludes from coverage services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.  Therefore, even though the services are authorized by State law, the services of a CP that are determined to be not reasonable and necessary are not covered.  Additionally, any therapeutic services that are billed by CPs under CPT psychotherapy codes that include medical evaluation and management services are not  covered.   E.  Requirement for Consultation
(Medicare Benefit Policy Manual)
E.  Requirement for Consultation   When applying for a Medicare provider number, a CP must submit to the A/B MAC (B) a signed Medicare provider/supplier enrollment form that indicates an agreement to the effect that, contingent upon the patients consent, the CP will attempt to consult with the patients attending or primary care physician in accordance with accepted professional ethical norms, taking into consideration patient confidentiality.  If the patient assents to the consultation, the CP must attempt to consult with the patients physician within a reasonable time after receiving the consent.  If the CPs attempts to consult directly with the physician are not successful, the CP must notify the physician within a reasonable time that he or she is furnishing services to the patient.  Additionally, the CP must document, in the patients medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician.  The only exception to the consultation requirement for CPs is in cases where the patients primary care or attending physician refers the patient to the CP. Also, neither a CP nor a primary care nor attending physician may bill Medicare or the patient for this required consultation.  F.  Outpatient Mental Health Services Limitation   All covered therapeutic services furnished by qualified CPs are subject to the outpatient mental health services limitation in Pub 100 -01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, Deductibles, Coinsurance Amounts, and Payment Limitations, 30, (i.e., only 62 1/2 percent of expenses for these services are considered incurred expenses for Medicare purposes).  The limitation does not apply to diagnostic services.   G.  Assignment Requirement  Assignment is required.  170 - Clinical Social Worker (CSW) Services (Rev. 1, 10-01-03) B3-2152  See the Medicare Claims Processing Manual Chapter 12, Physician/Nonphysician Practitioners, 150, Clinical Social Worker Services, for payment requirements.  A.  Clinical Social Worker Defined   Section 1861(hh) of the Act defines a clinical social worker as an individual who:    Possesses a masters or doctors degree in social work;    Has performed at least two years of supervised clinical social work; and
(Medicare Benefit Policy Manual)
Section 1861(hh) of the Act defines a clinical social worker as an individual who:    Possesses a masters or doctors degree in social work;    Has performed at least two years of supervised clinical social work; and    Is licensed or certified as a clinical social worker by the State in which the services are performed; or    In the case of an individual in a State that does not provide for licensure or certification, has completed at least 2 years or 3,000 hours of post masters degree supervised clinical social work practice under the supervision of a masters level social wo rker in an appropriate setting such as a hospital, SNF, or clinic.  B.  Clinical Social Worker Services Defined   Section 1861(hh)(2) of the Act defines clinical social worker services as those services that the CSW is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed for the diagnosis and treatment of mental illnesses.  Services furnished to an inpatient of a hospital or an inpatient of a SNF that the SNF is required to provide as a requirement for participation are not included.  The services that are covered are those that are otherwise covered if furnished by a physician or as incident to a physicians professional service.  C.  Covered Services   Coverage is limited to the services a CSW is legally authorized to perform in accordance with State law (or State regulatory mechanism established by State law).  The services of a CSW may be covered under Part B if they are:    The type of services that are otherwise covered if furnished by a physician, or as incident to a physicians service. (See 30 for a description of physicians services and 70 of Pub 100-1, the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, for the definition of a physician.);   Performed by a person who meets the definition of a CSW (See subsection A.); and   Not otherwise excluded from coverage.  A/B MACs (B) should become familiar with the State law or regulatory mechanism governing a CSWs scope of practice in their service area.   D.  Noncovered Services
(Medicare Benefit Policy Manual)
 Not otherwise excluded from coverage.  A/B MACs (B) should become familiar with the State law or regulatory mechanism governing a CSWs scope of practice in their service area.   D.  Noncovered Services   Services of a CSW are not covered when furnished to inpatients of a hospital or to inpatients of a SNF if the services furnished in the SNF are those that the SNF is required to furnish as a condition of participation in Medicare.  In addition, CSW service s are not covered if they are otherwise excluded from Medicare coverage even though a CSW is authorized by State law to perform them.  For example, the Medicare law excludes from coverage services that are not reasonable and necessary for the diagnosis or  treatment of an illness or injury or to improve the functioning of a malformed body member.   E.  Outpatient Mental Health Services Limitation   All covered therapeutic services furnished by qualified CSWs are subject to the outpatient psychiatric services limitation in Pub 100 -01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, Deductibles, Coinsurance Amounts, and Payment Limitations, 30, (i.e., only 62 1/2 percent of expenses for these services are considered incurred expenses for Medicare purposes).  The limitation does not apply to diagnostic services.   F.  Assignment Requirement   Assignment is required.   180 - Nurse -Midwife (CNM) Services (Rev. 10639; Issued: 03- 12-2021;  Effective: 01 -01-2021; Implementation: 04- 12-2021)   A.  General   Effective on or after July 1, 1988, the services provided by a certified nurse -midwife or incident to the certified nurse -midwifes services are covered.  Payment is made under assignment only.  See the Medicare Claims Processing Manual, Chapter 12, Physician and Nonphysician Practitioners, 130, for payment methodology for nurse midwife services.   B.  Certified Nurse -Midwife Defined
(Medicare Benefit Policy Manual)
B.  Certified Nurse -Midwife Defined   A certified nurse- midwife is a registered nurse who has successfully completed a program of study and clinical experience in nurse -midwifery, meeting guidelines prescribed by the Secretary, or who has been certified by an organization recognized by the Secretary.  The Secretary has recognized certification by the American College of Nurse -Midwives and State qualifying requirements in those States that specify a program of education and clinical experience for nurse -midwives for these purposes.  A nurse-midwife must:   Be currently licensed to practice in the State as a registered professional nurse; and   Meet one of the following requirements:  1. Be legally authorized under State law or regulations to practice as a nurse -midwife and have completed a program of study and clinical experience for nurse -midwives, as specified by the State; or  2. If the State does not specify a program of study and clinical experience that nurse- midwives must complete to practice in that State, the nurse -midwife must:  a. Be currently certified as a nurse- midwife by the American College of Nurse -Midwives;   b. Have satisfactorily completed a formal education program (of at least one academic year) that, upon completion, qualifies the nurse to take the certification examination offered by the American College of Nurse-Midwives; or  c. Have successfully completed a formal education program for preparing registered nurses to furnish gynecological and obstetrical care to women during pregnancy, delivery, and the postpartum period, and care to normal newborns, and have practiced as a nurse-midwife for a total of 12 months during any 18-month period from August 8, 1976, to July 16, 1982.  C.  Covered Services
(Medicare Benefit Policy Manual)
C.  Covered Services   1.  General  - Effective January 1, 1988, through December 31, 1993, the coverage of nurse- midwife services was restricted to the maternity cycle.  The maternity cycle is a period that includes pregnancy, labor, and the immediate postpartum period.  Beginning with services furnished on or after January 1, 1994, coverage is no longer limited to the maternity cycle.  Coverage is available for services furnished by a nurse-midwife that he or she is legally authorized to perform in the State in which the services are furnished and that would otherwise be covered if furnished by a physician, including obstetrical and gynecological services.  2.  Incident To  - Services and supplies furnished incident to a nurse midwifes service are covered if they would have been covered when furnished incident to the services of a doctor of medicine or osteopathy, as described in 60.  3. Medical Record Documentation for Part B Services  This medical record documentation requirement applies to Part B professional services that are paid under the Medicare physician fee schedule.   Accordingly, for Part B certified nurse-midwives covered services, the certified nurse-midwife may review and verify (sign and date), rather than re-document notes in a patients medical record made by physicians, residents, nurses, medical; physician assistant; nurse practitioner; clinical nurse specialist; certified nurse-midwife; and certified registered nurse anesthetist students or other member s of the medical team, including as applicable, notes documenting the certified nurse-midwives presence and participation in the service.     For documentation requirements specific to E/M services furnished by physicians and certain nonphysician practitioners, see Chapter 12, section 30.6 of the Medicare Claims Processing Manual, publication 100-04.   D.  Noncovered Services   The services of nurse-midwives are not covered if they are otherwise excluded from Medicare coverage even though a nurse-midwife is authorized by State law to perform them.  For example, the Medicare program excludes from coverage routine physical checkups and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.   Coverage of service to the newborn continues only to the point that the newborn is or would normally be treated medically as a separate individual.  Items and services furnished the newborn from that point are not covered on the basis of the mothers eligibility.
(Medicare Benefit Policy Manual)
Coverage of service to the newborn continues only to the point that the newborn is or would normally be treated medically as a separate individual.  Items and services furnished the newborn from that point are not covered on the basis of the mothers eligibility.   E.  Relationship With Physician  Most States have licensure and other requirements applicable to nurse-midwives.  For example, some require that the nurse- midwife have an arrangement with a physician for the referral of the patient in the event a problem develops that requires medical att ention.  Others may require that the nurse-midwife function under the general supervision of a physician.  Although these and similar State requirements must be met in order for the nurse-midwife to provide Medicare covered care, they have no effect on the nurse-midwifes right to personally bill for and receive direct Medicare payment.  That is, billing does not have to flow through a physician or facility.  See 60.2 for coverage of services performed by nurse-midwives incident to the service of physicians.  F.  Place of Service   There is no restriction on place of service.  Therefore, nurse -midwife services are covered if provided in the nurse -midwifes office, in the patients home, or in a hospital or other facility, such as a clinic or birthing center owned or operated by a nur se-midwife.   G.  Assignment Requirement   Assignment is required.   190 - Physician Assistant (PA) Services (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  Effective for services rendered on or after January 1, 1998, any individual who is participating under the Medicare program as a physician assistant for the first time may have his or her professional services covered if he or she meets the qualifications listed below and he or she is legally authorized to furnish PA services in the State where the services are performed.  PAs who were issued billing provider numbers prior to January  1, 1998 may continue to furnish services under the PA benefit.  See the Medicare Claims Processing Manual, Chapter 12, Physician and Nonphysician Practitioners, 110, for payment methodology for PA services.  Payment is made under assignment only.  A.  Qualifications for PAs   To furnish covered PA services, the PA must meet the conditions as follows: