evekhm/cms_iom_500 huggingface dataset:
(Medicare National Coverage Determinations Manual)
130.7 - Withdrawal Treatments for Narcotic Addictions  (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  Withdrawal is an accepted treatment for narcotic addiction, and Part B payment can be made for these services if they are provided by the physician directly or under his personal supervision and if they are reasonable and necessary.  In reviewing claims, r easonableness and necessity are determined with the aid of the A/B MAC (B)s medical staff.   Drugs that the physician provides in connection with this treatment are also covered if they cannot be self -administered and meet all other statutory requirements.   Cross -reference:   Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 20.4.1.   130.8 - Hemodialysis for Treatment of Schizophrenia  (Rev. 1, 10- 03-03) CIM 35 -51  Not Covered   Scientific evidence supporting use of hemodialysis as a safe and effective means of treatment for schizophrenia is inconclusive at this time.  Accordingly, Medicare does not cover hemodialysis for treatment of schizophrenia.   140 - Miscellaneous Surgical Procedures  (Rev. 1, 10- 03-03)  140.1 - Abortion  (Rev. 48, Issued:  03- 17-06; Effective/Implementation Dates:  06 -19-06) CIM 35 -99  Abortions are not covered Medicare procedures except:    1. If the pregnancy is the result of an act of rape or incest; or    2. In the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.  140.2 - Breast Reconstruction Following Mastectomy  (Rev. 1, 10-03-03) CIM 35 -47  During recent years, there has been a considerable change in the treatment of diseases of the breast such as fibrocystic disease and cancer.  While extirpation of the disease remains of primary importance, the quality of life following initial treatment is increasingly recognized as of great concern.  The increased use of breast reconstruction procedures is due to several factors:   A change in epidemiology of breast cancer, including an apparent increase in incidence;
(Medicare National Coverage Determinations Manual)
 Improved surgical skills and techniques;   The continuing development of better prostheses; and   Increasing awareness by physicians of the importance of postsurgical psychological adjustment.  Reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is considered a relatively safe and effective noncosmetic procedure.  Accordingly, program payment may be made for breast reconstruction surgery following removal of a breast for any medical reason.   Program payment may not be made for breast reconstruction for cosmetic reasons. (Cosmetic surgery is excluded from coverage under 1862(a)(10) of the Act.)   140.4 - Plastic Surgery to Correct Moon Face  (Rev. 1, 10-03-03) CIM 35 -12  Not Covered  The cosmetic surgery exclusion precludes payment for any surgical procedure directed at improving appearance.  The condition giving rise to the patients preoperative appearance is generally not a consideration.  The only exception to the exclusion is surgery for the prompt repair of an accidental injury or for the improvement of a malformed body member which coincidentally serves some cosmetic purpose.  Since surgery to correct a condition of moon face which developed as a side effect of cortisone therapy does not meet the exception to the exclusion, it is not covered under Medicare ( 1862(a)(10) of the Act).   Cross reference: The Medicare Benefit Policy Manual, Chapter 16, General Exclusions From Coverage, 120.  140.5 - Laser Procedures  (Rev. 173, Issued: 09-04- 14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)
(Medicare National Coverage Determinations Manual)
Medicare recognizes the use of lasers for many medical indications.  Procedures performed with lasers are sometimes used in place of more conventional techniques.  In the absence of a specific non- coverage instruction, and where a laser has been approved for marketing by the Food and Drug Administration, A/B MAC discretion may be used to determine whether a procedure performed with a laser is reasonable and necessary and, therefore, covered.  The determination of coverage for a procedure performed using a laser is made on the basis that the use of lasers to alter, revise, or destroy tissue is a surgical procedure.  Therefore, coverage of laser procedures is restricted to practitioners with training in the surgical management of the disease or condition being treated.  140.6  Wrong Surgical or Other Invasive Procedure Performed on a Patient (Effective January 15, 2009)  (Rev. 102; Issued:  07- 02-09; Effective Date:  01 -15-09; Implementation Date:  JULY 6, 2009 FOR B MACS AND CARRIERS OCTOBER 5, 2009, FOR A MACS, FIs, AND FISS)   A. General   In 2002, the National Quality Forum (NQF) published Serious Reportable Events in Healthcare: A Consensus Report1, which listed 27 adverse events that were serious, largely preventable and of concern to both the public and health care providers.  These events and subsequent revisions to the list became known as never events.  This concept and need for the proposed reporting led to NQFs Consensus Standards Maintenance Committee on Serious Reportable Events, which maintains and updates the list which currently contains 28 items. Among surgical events on the list is Wrong surgical procedure performed on a patient.  Similar to any other patient population, Medicare beneficiaries experience serious injury and/or death if wrong surgeries are performed and may require additional healthcare in order to correct adverse outcomes resulting from such errors.  B. Nationally Covered Indications  N/A  C. Nationally Non- covered Indications   The CMS does not cover a particular surgical or other invasive procedure to treat a particular medical condition when a practitioner erroneously performs a different procedure on a Medicare beneficiary because that particular surgical or other invasive procedure is not a reasonable and necessary treatment for the Medicare beneficiarys particular medical condition.
(Medicare National Coverage Determinations Manual)
A surgical or other invasive procedure is considered to be the wrong procedure if it is not consistent with the correctly documented informed consent for that patient.  Emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining informed consent are not considered erroneous under this decision.  Also, the event is not intended to capture changes in the plan upon surgical entry into the patient due to the discovery of pathology in close proximity to the intended site when the risk of a second surgery outweighs the benefit of patient consultation; or the discovery of an unusual physical configuration (e.g., adhesions, spine level/extra vertebrae).  Surgical and other invasive procedures are defined as operative procedures in which skin or mucous membranes and connective tissue are incised or an instrument is introduced through a natural body orifice.  Invasive procedures include a range of procedures from minimally invasive dermatological procedures (biopsy, excision, and deep cryotherapy for malignant lesions) to extensive multi-organ transplantation.  They include all procedures described by the codes in the surgery section of the Current Procedural Terminology (CPT) and other invasive procedures such as percutaneous transluminal angioplasty and cardiac catheterization.  They include minimally invasive procedures involving biopsies or placement of probes or catheters requiring the entry into a body cavity through a needle or trocar.  They do not include use of instruments such as otoscopes for examinations or very minor procedures such as drawing blood.  D. Other ) (Rev. 102; Issued: 02-07- 09; Effect   1 http://www.qualityforum.org/pdf/reports/sre.pdf    N/A  (NCD last reviewed January 2009.)  140.7  Surgical or Other Invasive Procedure Performed on the Wrong Body Part (Effective January 15, 2009 ive Date:  01-15-09; Implementation Date:  JULY 6, 2009 FOR B MACS AND CARRIERS OCTOBER 5, 2009, FOR A MACS, FIs, AND FISS)   A. General
(Medicare National Coverage Determinations Manual)
A. General   In 2002, the National Quality Forum (NQF) published Serious Reportable Events in Healthcare: A Consensus Report2, which listed 27 adverse events that were serious, largely preventable and of concern to both the public and health care providers.  These events and subsequent revisions to the list became known as never events.  This concept and need for the proposed reporting led to NQFs Consensus Standards Maintenance Committee on Serious Reportable Events, which maintains and updates the list which currently contains 28 items.  Among surgical events on the list is Surgery performed on the wrong body part.  Similar to any other patient population, Medicare beneficiaries experience serious injury and/or death if wrong surgeries are performed and may require additional healthcare in order to correct adverse outcomes resulting from such errors.  B. Nationally Covered Indications  N/A  C. Nationally Non- covered Indications   The CMS does not cover a particular surgical or other invasive procedure to treat a particular medical condition when a practitioner erroneously performs the procedure on the wrong body part because that particular surgical or other invasive procedure is not a reasonable and necessary treatment for the Medicare beneficiarys particular medical condition.  A surgical or other invasive procedure is considered to have been performed on the wrong body part if it is not consistent with the correctly documented informed consent for that patient including surgery on the right body part, but on the wrong location of the body; for example, left versus right (appendages and/or organs), or at the wrong level (spine).  Emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining informed consent are not considered erroneous under this decision.  Also, the event is not intended to capture changes in the plan upon surgical entry into the patient due to the discovery of pathology in close proximity to the intended site when the risk of a second surgery outweighs the benefit of patient consultation; o r the discovery of an unusual physical configuration (e.g., adhesions, spine level/extra vertebrae).
(Medicare National Coverage Determinations Manual)
Surgical and other invasive procedures are defined as operative procedures in which skin or mucous membranes and connective tissue are incised or an instrument is introduced through a natural body orifice.  Invasive procedures include a range of procedures from minimally invasive dermatological procedures (biopsy, excision, and deep cryotherapy for malignant lesions) to extensive multi-organ transplantation.  They include all procedures described by the codes in the surgery section of the Current Procedural Terminology (CPT) and other invasive procedures such as percutaneous transluminal angioplasty and cardiac catheterization.  They include minimally invasive procedures involving biopsies or placement of probes or catheters requiring the entry into a body cavity through a needle or trocar.  They do not include use of instruments such as otoscopes for examinations or very minor procedures such as drawing blood.  D. Other  2 http://www.qualityforum.org/pdf/reports/sre.pdf    N/A  (NCD last reviewed January 2009.)  140.8  Surgical or Other Invasive Procedure Performed on the Wrong Patient (Effective January 15, 2009)  (Rev. 102; Issued: 07-02- 09; Effective Date:  01 -15-09; Implementation Date:  JULY 6, 2009 FOR B MACS AND CARRIERS OCTOBER 5, 2009, FOR A MACS, FIs, AND FISS)   A. General   In 2002, the National Quality Forum (NQF) published Serious Reportable Events in Healthcare: A Consensus Report3, which listed 27 adverse events that were serious, largely preventable and of concern to both the public and health care providers.  These events and subsequent revisions to the list became known as never events.  This concept and need for the proposed reporting led to NQFs Consensus Standards Maintenance Committee on Serious Reportable Events, which maintains and updates the list which currently contains 28 items.  Among surgical events on the list is Surgical procedure performed on the wrong patient.  Similar to any other patient population, Medicare beneficiaries experience serious injury and/or death if wrong surgeries are performed and may require additional healthcare in order to correct adverse outcomes resulting from such errors.  B. Nationally Covered Indications  N/A  C. Nationally Non- covered Indications
(Medicare National Coverage Determinations Manual)
N/A  C. Nationally Non- covered Indications   The CMS does not cover a particular surgical or other invasive procedure to treat a particular medical condition when a practitioner erroneously performs a procedure that was intended for a different patient on a Medicare beneficiary who does not need that procedure because it is not a reasonable and necessary treatment for the Medicare beneficiarys particular medical condition.   A surgical or other invasive procedure is considered to have been performed on the wrong patient if that procedure is not consistent with the correctly documented informed consent for that patient.  Surgical and other invasive procedures are defined as operative procedures in which skin or mucous membranes and connective tissue are incised or an instrument is introduced through a natural body orifice.  Invasive procedures include a range of procedures from minimally invasive dermatological procedures (biopsy, excision, and deep cryotherapy for malignant lesions) to extensive multi-organ transplantation.  They include all procedures described by the codes in the surgery section of the Current Procedural Terminology (CPT) and other invasive procedures such as percutaneous transluminal angioplasty and cardiac catheterization.  They include minimally invasive procedures involving biopsies or placement of probes or catheters requiring the entry into a body cavity through a needle or trocar.  They do not include use of instruments such as otoscopes for examinations or very minor procedures such as drawing blood.  D. Other  N/A  (NCD last reviewed January 2009.)  140.9 - Gender Reassignment Surgery for Gender Dysphoria   3 http://www.qualityforum.org/pdf/reports/sre.pdf   (Rev.  194, Issued: 03- 03-17, Effective: 08 -30-16, Implementation; 04- 04-17)  A. General   Gender reassignment surgery is a general term to describe a surgery or surgeries that affirm a persons gender identity.   B. Nationally Covered Indications   N/A  C. Nationally Non -Covered Indications   N/A  D. Other
(Medicare National Coverage Determinations Manual)
A. General   Gender reassignment surgery is a general term to describe a surgery or surgeries that affirm a persons gender identity.   B. Nationally Covered Indications   N/A  C. Nationally Non -Covered Indications   N/A  D. Other  The Centers for Medicare & Medicaid Coverage (CMS) conducted a National Coverage Analysis that focused on the topic of gender reassignment surgery.  Effective August 30, 2016, after examining the medical evidence, CMS determined that no national coverage determination (NCD) is appropriate at this time for gender reassignment surgery for Medicare beneficiaries with gender dysphoria.  In the absence of an NCD, coverage determinations for gender reassignment surgery, under section 1862(a)(1)(A) of the Social Security Act (the Act) and any other relevant statutory requirements, will continue to be made by the local Medicare Administrative Contractors (MACs) on a case- by-case basis.    (This policy last reviewed August 2016.)   150 - Musculoskeletal System  (Rev. 1, 10- 03-03)  150.1 - Manipulation  (Rev. 1, 10- 03-03) CIM 35 -2  A.  Manipulation of the Rib Cage   Manual manipulation of the rib cage contributes to the treatment of respiratory conditions such as bronchitis, emphysema, and asthma as part of a regimen that includes other elements of therapy, and is covered only under such circumstances.  B.  Manipulation of the Head   Manipulation of the occipitocervical  or temporomandibular regions of the head when indicated for conditions affecting those portions of the head and neck is a covered service.   150.2 - Osteogenic Stimulator (Various Effective Dates Below)  (Rev. 41, Issued: 06- 24-05, Effective: 04- 27-05, Implementation: 08- 01-05) CIM -35-48  Electrical Osteogenic Stimulators   A. General
(Medicare National Coverage Determinations Manual)
Electrical Osteogenic Stimulators   A. General   Electrical stimulation to augment bone repair can be attained either invasively or non- invasively.  Invasive devices provide electrical stimulation directly at the fracture site either through percutaneously placed cathodes or by implantation of a coiled cathode wire into the fracture site.  The power pack for the latter device is implanted into soft tissue near the fracture site and subcutaneously connected to the cathode, creating a self -contained system with no external components.  The power supply for the former device is externally placed and the leads connected to the inserted cathodes.  With the non- invasive device, opposing pads, wired to an external power supply, are placed over the cast.  An electromagnetic  field is created between the pads at the fracture site.   B. Nationally Covered Indications   1. Noninvasive Stimulator   The noninvasive stimulator device is covered only for the following indications:    Nonunion of long bone fractures;    Failed fusion, where a minimum of 9 months has elapsed since the last surgery;    Congenital pseudarthroses;    Effective July 1, 1996, as an adjunct to spinal fusion surgery for patients at high risk of pseudarthrosis due to previously failed spinal fusion at the same site or for those undergoing multiple level fusion.  A multiple level fusion involves 3 or more ve rtebrae (e.g., L3- L5, L4 -S1, etc).    Effective September 15, 1980, nonunion of long bone fractures is considered to exist only after 6 or more months have elapsed without healing of the fracture.    Effective April 1, 2000, nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical osteogenic stimulator.  Serial radiographs must include a minimum of 2 sets of radiographs, each including multiple views of the fracture site, separated by a minimum of 90 days.  2. Invasive (Implantable) Stimulator   The invasive stimulator device is covered only for the following indications:    Nonunion of long bone fractures;
(Medicare National Coverage Determinations Manual)
The invasive stimulator device is covered only for the following indications:    Nonunion of long bone fractures;    Effective July 1, 1996, as an adjunct to spinal fusion surgery for patients at high risk of pseudarthrosis due to previously failed spinal fusion at the same site or for those undergoing multiple level fusion.  A multiple level fusion involves 3 or more vertebrae (e.g., L3- L5, L4 -S1, etc).    Effective September 15, 1980, nonunion of long bone fractures is considered to exist only after 6 or more months have elapsed without healing of the fracture.    Effective April 1, 2000, nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical osteogenic stimulator.  Serial radiographs must include a minimum of 2 sets of radiographs, each including multiple views of the fracture site, separated by a minimum of 90 days.  Ultrasonic Osteogenic Stimulators   A. General   An ultrasonic osteogenic stimulator is a noninvasive device that emits low intensity, pulsed ultrasound.  The device is applied to the surface of the skin at the fracture site and ultrasound waves are emitted via a conductive coupling gel to stimulate fracture healing.  The ultrasonic osteogenic stimulators are not be used concurrently with other non- invasive osteogenic devices.   B. Nationally Covered Indications  Effective January 1, 2001, ultrasonic osteogenic stimulators are covered as medically reasonable and necessary for the treatment of nonunion fractures. In demonstrating non-union fractures, CMS expects:   A minimum of 2 sets of radiographs, obtained prior to starting treatment with the osteogenic stimulator, separated by a minimum of 90 days.  Each radiograph set must include multiple views of the fracture site accompanied with a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the 2 sets of radiographs; and,   Indications that the patient failed at least one surgical intervention for the treatment of the fracture.
(Medicare National Coverage Determinations Manual)
 Effective April 27, 2005, upon reconsideration of ultrasound stimulation for nonunion fracture healing, CMS determines that the evidence is adequate to conclude that noninvasive ultrasound stimulation for the treatment of nonunion bone fractures prior to surgical intervention is reasonable and necessary.  In demonstrating non-union fractures, CMS expects:   A minimum of 2 sets of radiographs, obtained prior to starting treatment with the osteogenic stimulator, separated by a minimum of 90 days.  Each radiograph set must include multiple views of the fracture site accompanied with a written interpretation by a  physician stating that there has been no clinically significant evidence of fracture healing between the 2 sets of radiographs.  C. Nationally Non-Covered Indications  Nonunion fractures of the skull, vertebrae and those that are tumor -related are excluded from coverage.   Ultrasonic osteogenic stimulators may not be used concurrently with other non-invasive osteogenic devices.   Ultrasonic osteogenic stimulators for fresh fractures and delayed unions remains non- covered.   (This NCD last reviewed June 2005.)  150.3 - Bone (Mineral) Density Studies (Effective January 1, 2007)  (Rev. 69, Issued: 05-11- 07, Effective: 01 -01-07, Implementation: 07-02-07)  Conditions for coverage of bone mass measurements are now contained in chapter 15, section 80.5 of Pub. 100-02, Medicare Benefit Policy Manual.  Claims processing instructions can be found in chapter 13, section 140 of Pub. 100- 04, Medicare Claims Processi ng Manual.  150.5 - Diathermy Treatment  (Rev. 173, Issued: 09-04- 14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  High energy pulsed wave diathermy machines have been found to produce some degree of therapeutic benefit for essentially the same conditions and to the same extent as standard diathermy.  Accordingly, where the A/B MACs medical staff has determined that the pulsed wave diathermy apparatus used is one which is considered therapeutically effective, the treatments are considered a covered service, but only for those conditions for which standard diathermy is medically indicated and only when rendered by a physician or incident to a physicians professional services.  Cross -reference: 240.3.  (This NCD last reviewed June 2006.)