evekhm/cms_iom_500 huggingface dataset:
Article - Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) - Policy Article (A52480)
Criterion 3 is not met when the chemotherapy drug is an oral drug or when the chemotherapy drug is administered intravenously in the home setting because the type and dosage of chemotherapy drugs administered in these situations do not require intravenous antiemetic drugs. If all of the criteria are not met, the oral antiemetic drug will be denied as non-covered.A 3-drug combination regimen consisting of an NK-1 antagonist, a 5HT3 antagonist and dexamethasone is covered when all of the criteria above (1-4) are met and all 3 drugs are given in combination.If the NK-1 antagonist and/or dexamethasone is given as an oral anti-emetic outside of the 3-drug regimen, claims will be denied as statutorily non-covered, no benefit.There are three NK-1 antagonists approved for this use, Aprepitant (J8501), rolapitant (J8670) and netupitant/palonosetron (J8655). Covered 3-drug regimens are:Aprepitant (J8501) or rolapitant (J8670) are covered when given as part of a 3-drug regimen that includes a 5HT3 antagonist (Q0162, Q0166, or Q0180) and dexamethasone (J8540).Netupitant/palonosetron (J8655) is covered when given in conjunction with dexamethasone (J8540). A separate 5HT3 antagonist is not needed. Netupitant/palonosetron has had multiple HCPCS codes assigned, depending on the date of service. Refer to the Coding Guidelines section (below) for instructions.
Article - Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) - Policy Article (A52480)
If all of the above criteria (1-4) are met, the quantity of oral antiemetic drugs covered for each episode of chemotherapy cannot exceed the initial loading dose plus 48 hours of therapy. However, for the drugs granisetron (Q0166) and dolasetron (Q0180), the quantity of drugs covered for each episode of chemotherapy is limited to the initial loading dose plus 24 hours of therapy. Quantities of drugs in excess of these amounts are non-covered.More than one oral antiemetic drug may be covered for concurrent use if more than one oral drug is needed to fully replace the intravenous drugs that would otherwise have been given.The quantity of oral antiemetic drugs that is dispensed should be limited to a 30-day supply. Orders may be refillable.Supply FeeOne unit of service of supply fee code Q0511 is covered for the first covered oral antiemetic drug that is dispensed in a 30-day period. If covered drugs are dispensed by more than one pharmacy during a 30-day period, one unit of Q0511 is covered for each pharmacy. One unit of service of supply fee code Q0512 is covered for each subsequent covered oral antiemetic drug that is dispensed in that 30-day period. If two dosage strengths of the same drug are dispensed on the same day, one unit of service of the appropriate supply fee is payable for each one. If more than one unit of service of code Q0511 is billed per 30 days by a single pharmacy, the excess units of service will be denied as incorrect coding. If the billed units of service of Q0511 or Q0512 exceed the number of drugs on the claim, the excess units will be denied as not separately payable.Supply fees are eligible for coverage only for drugs that are covered under the related LCD. If the drug on the claim is denied as non-covered, the supply fee will be denied as non-covered.The supply fee code must be billed on the same claim as the drug(s). If it is not, the supply fee will be denied as incorrect billing.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)
Article - Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) - Policy Article (A52480)
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and WOPD list is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.The supplier must enter a diagnosis code corresponding to the beneficiary's cancer diagnosis on each claim.The billing of an oral antiemetic 3-drug combination is accomplished by one of the following methods:
Article - Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) - Policy Article (A52480)
Netupitant with its fixed combination of palonosetron (J8655) and dexamethasone (J8540), must be billed on the same claim.Aprepitant (J8501) or rolapitant (J8670) used with a separate 5HT3 antagonist (Q0162, Q0166 or Q0180) and dexamethasone (J8540) must be billed on the same claim.
Article - Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) - Policy Article (A52480)
In addition to the diagnosis code corresponding to the beneficiarys cancer diagnosis, claims for oral aprepitant (J8501), rolapitant (J8670) or netupitant/palonosetron (J8655) must also be accompanied with a diagnosis code of an encounter for antineoplastic chemotherapy.Claims for code Q0181 must identify the name of the drug, the manufacturer, the dosage strength dispensed, each tablet/suppository/etc and frequency of administration during the covered time period (24-48 hours) as specified on the order. This information must be entered in the narrative field of an electronic claim.KX, GA AND GZ MODIFIERSIf dexamethasone (J8540) and either aprepitant (J8501), rolapitant (J8670) or 300mg netupitant/0.5mg palonosetron (J8655) are used in conjunction with one of the anticancer chemotherapeutic agents listed in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD, a KX modifier must be added to each code.If dexamethasone (J8540) and either aprepitant (J8501), rolapitant (J8670) or 300mg netupitant/.5mg palonosetron (J8655) are not used in conjunction with one of the anticancer chemotherapeutic agents listed in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD the GA or GZ modifier must be added to a claim line for aprepitant, rolapitant, netupitant/palonosetron or dexamethasone. When there is an expectation of a denial as not reasonable and necessary, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.Claim lines billed without a KX, GA, or GZ modifier will be rejected as missing information.CODING GUIDELINES
Article - Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) - Policy Article (A52480)
Claim lines billed without a KX, GA, or GZ modifier will be rejected as missing information.CODING GUIDELINESThe following instructions apply to claims billed using J codes. When claims are billed in NCPDP format using NDC numbers, different instructions may apply. Refer to the NCPDP Companion Document available through the CMS web site.Netupitant/palonosetron has had multiple HCPCS codes assigned.
Article - Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) - Policy Article (A52480)
For claims with dates of service prior to July 1, 2015, use HCPCS code Q0181 (UNSPECIFIED ORAL DOSAGE FORM, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR A IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN)For claims with dates of service on or after July 1, 2015 through December 31, 2015, use HCPCS code Q9978 (NETUPITANT 300 MG AND PALONOSETRON 0.5 MG, ORAL)For claims with dates of service on or after January 1, 2016, use HCPCS code J8655 (NETUPITANT 300 MG AND PALONOSETRON 0.5 MG, ORAL)The individual drugs contained in netupitant/palonosetron must not be unbundled and billed separately.Rolapitant has had multiple HCPCS codes assigned.For claim on or after September 02, 2015 and before July 1, 2016 use HCPCS code Q0181 (UNSPECIFIED ORAL DOSAGE FORM, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR A IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN)For dates of service on or after July 1, 2016 and before January 1, 2017 use HCPCS code Q9981 (ROLAPITANT, ORAL, 1 MG).For dates of service on or after January 1, 2017 use HCPCS code J8670 (ROLAPITANT, ORAL, 1 MG).
Article - Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) - Policy Article (A52480)
Codes J8501, J8540, J8650, J8655 and Q0162,Q0163, Q0164, Q0166, Q0167, Q0169, Q0173, Q0174, Q0175, Q0177, Q0180,Q0181 or J8670 may be billed only when the oral antiemetic drug is used in the situations described in Non-Medical Necessity Coverage and Payment Rules section. The quantity of drugs billed using codes Q0162,Q0163, Q0164, Q0166, Q0167, Q0169, Q0173, Q0174, Q0175, Q0177, Q0180,Q0181 must not exceed the 24 or 48 hours of therapy specified above.Refer to the Oral Anticancer Drugs policy for information on coding antiemetic drugs used in conjunction with oral anticancer drugs.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Orthopedic Footwear - Policy Article (A52481)
CMS National Coverage PolicyN/AArticle Text
Article - Orthopedic Footwear - Policy Article (A52481)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. "reasonable and necessary").Orthopedic footwear is covered under the leg, arm, back, and neck braces, and artificial legs, arms and eyes benefit (Social Security Act 1861(s)(9)). In order for a beneficiary's DME to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.Shoes, inserts, and modifications are covered in limited circumstances. They are covered in selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers. However, different codes are used for footwear provided under this benefit. See the medical policy on Therapeutic Shoes for Persons with Diabetes for details.
Article - Orthopedic Footwear - Policy Article (A52481)
Shoes are also covered if they are an integral part of a covered leg brace described by codes L1900, L1920, L1980,L1990, L2000, L2005, L2010, L2020,L2030, L2050, L2060, L2080, or L2090. Oxford shoes (L3224, L3225) are covered in these situations. Other shoes, e.g. high top, depth inlay or custom for non-diabetics, etc. (L3649), are also covered if they are an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. Heel replacements (L3455, L3460), sole replacements (L3530, L3540), and shoe transfers (L3600, L3610,L3620, L3630 andL3640) involving shoes on a covered brace are also covered. Inserts and other shoe modifications (L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3550, L3560, L3570, L3580, L3590 and L3595) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. Shoes and related modifications, inserts, heel/sole replacements or shoe transfers billed without a KX modifier will be denied as noncovered because coverage is statutorily excluded.
Article - Orthopedic Footwear - Policy Article (A52481)
According to a national policy determination, a shoe and related modifications, inserts, and heel/sole replacements, are covered only when the shoe is an integral part of a brace. A matching shoe which is not attached to a brace and items related to that shoe must not be billed with a KX modifier and will be denied as noncovered because coverage is statutorily excluded.Shoes which are incorporated into a brace must be billed by the same supplier billing for the brace. Shoes which are billed separately (i.e., not as part of a brace) will be denied as noncovered. A KX modifier must not be used in this situation.Shoes are denied as noncovered when they are put on over a partial foot prosthesis or other lower extremity prosthesis (L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5400, L5410, L5420, L5430, L5450, L5460, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595 and L5600) which is attached to the residual limb by other mechanisms because there is no Medicare benefit for these items.A foot pressure off-loading/ supportive device (A9283) is denied as noncovered because there is no Medicare benefit category for these items.
Article - Orthopedic Footwear - Policy Article (A52481)
A foot pressure off-loading/ supportive device (A9283) is denied as noncovered because there is no Medicare benefit category for these items.With the exception of the situations described above, orthopedic footwear billed using codes L3000,L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3201, L3202, L3203, L3204, L3206, L3207, L3208, L3209, L3211, L3212, L3213, L3214, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252, L3253, L3254, L3255, L3257, L3260, L3265, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610, L3620, L3630, L3640, and L3649will be denied as noncovered.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)
Article - Orthopedic Footwear - Policy Article (A52481)
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.An order is not required for a heel or sole replacement or transfer of a shoe to a brace.MODIFIERSGY, KX, LT and RT MODIFIERS:When billing for a shoe that is an integral part of a leg brace or for related modifications, inserts, heel/sole replacements or shoe transfer, a KX modifier must be added to the code. If the shoe or related item is not an integral part of a leg brace, the KX modifier must not be used.When billing for a shoe replacement or shoe transfer that is an integral part of a leg brace, a KX modifier must be added to the code.If the shoe and related modifications, inserts, and heel/sole replacements are not an integral part of a brace, the GY modifier must be added to each code.
Article - Orthopedic Footwear - Policy Article (A52481)
If the shoe and related modifications, inserts, and heel/sole replacements are not an integral part of a brace, the GY modifier must be added to each code.If a KX or GY modifier is not included on the claim line, it will be rejected as missing information.When billing for prosthetic shoes (L3250) and related items, diagnosis code(s) to the highest level of specificity describing the condition which necessitates the prosthetic shoes, must be included on each claim for the prosthetic shoes and related items.When code L3649 with a KX modifier is billed, the claim must include a narrative description of the item provided as well as a brief statement of the medical necessity for the item. This must be entered in the narrative field of an electronic claim.The right (RT) and/or left (LT) modifiers must be used with all footwear HCPCS codes in this policy (refer to the CODING GUIDELINES section for additional information).CODING GUIDELINESOxford shoes that are an integral part of a brace are billed using codes L3224 or L3225 with a KX modifier. For these codes, one unit of service is each shoe. Oxford shoes that are not part of a leg brace must be billed with codes L3215 or L3219 without a KX modifier.Other shoes (e.g., high top, depth inlay or custom shoes for non-diabetics, etc.) that are an integral part of a brace are billed using code L3649 with a KX modifier. Other shoes that are not an integral part of a brace must be billed using codes L3216, L3217, L3221, L3222, L3230, L3251, L3252, L3253, or L3649 without a KX modifier.Depth-inlay or custom molded shoes for diabetics and related inserts and modifications are billed using A codes whether or not the shoe is an integral part of a brace. See the medical policy on Therapeutic Shoes for Persons with Diabetes for coverage, documentation, and additional coding guidelines.Code A9283 (FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANY TYPE, EACH) is used for an item that is designed primarily to reduce pressure on the sole or heel of the foot but that does not meet the definition of:
Article - Orthopedic Footwear - Policy Article (A52481)
A therapeutic shoe for diabetics or related insert or modification; orAn orthopedic shoe or modification; orA walking boot
Article - Orthopedic Footwear - Policy Article (A52481)
It may be a shoe-like item, an item that is used inside a shoe and may or may not extend outside the shoe, or an item that is attached to a shoe. It may be prefabricated or custom fabricated.Code L3250 may be used only for a shoe that is custom fabricated from a model of a beneficiary and has a removable custom fabricated insert designed for toe or distal partial foot amputation. The shoe serves to hold the insert on the leg. Code L3250 must not be used for a shoe that is put on other types of leg prostheses (L5010,L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5400, L5410, L5420, L5430, L5450, L5460, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595 and L5600) that are attached to the residual limb by other mechanisms.The right (RT) and/or left (LT) modifiers must be used with all footwear HCPCS codes in this policy. Effective for claims with dates of service (DOS) on or after 3/1/2019, when the same code for bilateral items (left and right) is billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Ostomy Supplies - Policy Article (A52487)
CMS National Coverage PolicyN/AArticle Text
Article - Ostomy Supplies - Policy Article (A52487)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act Section 1862(a)(1)(A) provisions (i.e. "reasonable and necessary").Ostomy supplies are covered under the Prosthetic Device benefit (Social Security Act Section 1861(s)(8)). In order for a beneficiarys equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.Ostomy supplies are covered for use on a beneficiary with a surgically created opening (stoma) to divert urine, or fecal contents outside the body. Ostomy supplies are appropriately used for colostomies, ileostomies or urinary ostomies (see covered diagnosis codes below.) Use for other conditions will be denied as noncovered.A pouch cover should be coded A9270 and will be denied as a noncovered item.Ostomy supplies are not separately payable when a beneficiary is in a covered home health episode. Ostomy supplies must be provided by the home health agency and payment is included in the home health Medicare payment rate. It is not appropriate to bill these to the DME MAC.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.