evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
110.8  DMEPOS Benefit Category Determination s 120 -  Prosthetic Devices  130 -  Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes  140 -  Therapeutic Shoes for Individuals with Diabetes  150 -  Dental Services  150.1 -  Treatment of Temporomandibular Joint (TMJ) Syndrome  160 -  Clinical Psychologist Services  170 -  Clinical Social Worker (CSW) Services  180 -  Nurse -Midwife (CNM) Services  190 -  Physician Assistant (PA) Services  200 -  Nurse Practitioner (NP) Services  210 -  Clinical Nurse Specialist (CNS) Services  220 -  Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech -Language Pathology Services) Under Medical Insurance  220.1 -  Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech -Language Pathology Services  220.1.1 -  Care of a Physician/Nonphysician Practitioner (NPP)  220.1.2 -  Plans of Care for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services  220.1.3 -  Certification and Recertification of Need for Treatment and Therapy Plans of Care  220.1.4 -  Requirement That Services Be Furnished on an Outpatient Basis  220.2 -  Reasonable and Necessary Outpatient Rehabilitation Therapy Services  220.3 -  Documentation Requirements for Therapy Services  220.4 -  Functional Reporting 230 -  Practice of Physical Therapy, Occupational Therapy, and Speech -Language Pathology 230.1 -  Practice of Physical Therapy  230.2 -  Practice of Occupational Therapy  230.3 -  Practice of Speech -Language Pathology 230.4 -  Services Furnished by a Therapist in Private Practice (TPP)  230.5 -  Physical Therapy, Occupational Therapy and Speech- Language Pathology Services Provided Incident to the Services of Physicians and Nonphysician Practitioners  (NPP)  230.6 -  Therapy Services Furnished Under Arrangements With Providers and Clinics  231 -  Pulmonary Rehabilitation (PR) Program Services Furnished on or After January 1, 2010  232 -  Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Furnished On or After January 1, 2010  240 -  Chiropractic Services -  General  240.1 -  Coverage of Chiropractic Services  240.1.1 -  Manual Manipulation 240.1.2 -  Subluxation May Be Demonstrated by X -Ray or Physicians Exam  240.1.3 -  Necessity for Treatment  240.1.4  Location of Subluxation 240.1.5 -  Treatment
(Medicare Benefit Policy Manual)
Manual Manipulation 240.1.2 -  Subluxation May Be Demonstrated by X -Ray or Physicians Exam  240.1.3 -  Necessity for Treatment  240.1.4  Location of Subluxation 240.1.5 -  Treatment Parameters  250 -  Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities  260 -  Ambulatory Surgical Center Services  260.1 -  Definition of Ambulatory Surgical Center (ASC)  260.2 -  Ambulatory Surgical Center Services  260.3 -  Services Furnished in ASCs Which are Not ASC Facility Services  260.4 -  Coverage of Services in ASCs, Which are Not ASC Services  260.5 -  List of Covered Ambulatory Surgical Center Procedures  260.5.1 -  Nature and Applicability of ASC List  260.5.2 -  Nomenclature and Organization of the List  260.5.3 -  Rebundling of CPT Codes  270 -  Telehealth Services  280  Preventive and Screening Services  280.1  Glaucoma Screening  280.2 -  Colorectal Cancer Screening  280.2.1 -  Covered Services and HCPCS Codes  280.2.2 -  Coverage Criteria 280.2.3 -  Determining Whether or Not the Beneficiary is at High Risk for Developing Colorectal Cancer  280.2.4 -  Determining Frequency Standards  280.2.5 -  Noncovered Services  280.3 -  Screening Mammography  280.4 -  Screening Pap Smears  280.5 -  Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS)  280.5.1  Advance Care Planning (ACP) Furnished as an Optional Element with an Annual Wellness Visit (AWV) upon Agreement with the Patient 290 -  Foot Care  300 -  Diabetes Self -Management Training Services  300.1 -  Beneficiaries Eligible for Coverage and Definition of Diabetes  300.2 -  Certified Providers  300.3 -  Frequency of Training 300.4 -  Coverage Requirements for Individual Training 300.4.1-  Incident - To Provision 300.5 -  Payment for DSMT  300.5.1 -  Special Claims Processing Instructions  A/B MACs (A)  310  Kidney Disease Patient Education Services  310.1 -  Beneficiaries Eligible for Coverage  310.2 -  Qualified Person  310.3 -  Limitations for Coverage  310.4 -  Standards for Content  310.5 -  Outcomes Assessment  320  Home Infusion Therapy Services  320.1  General Requirements for Payment of
(Medicare Benefit Policy Manual)
-  Beneficiaries Eligible for Coverage  310.2 -  Qualified Person  310.3 -  Limitations for Coverage  310.4 -  Standards for Content  310.5 -  Outcomes Assessment  320  Home Infusion Therapy Services  320.1  General Requirements for Payment of Home Infusion Therapy Services  320.2  Home Infusion Therapy Services Benefit is Separate from DME Benefit  320.3  Qualified Home Infusion Therapy Suppliers   320.4  Patient Eligibility for Home Infusion Therapy
(Medicare Benefit Policy Manual)
320.4.1 -  Home Infusion Therapy Services for Homebound Patients  320.5  Plan of Care Requirements   320.5.1 -  Notification of Available Infusion Therapy Options  320.5.2 -  Plan of Care Periodic Review and Provider Coordination 320.6  Professional Services, Including Nursing Services, for Home Infusion               Therapy  320.6.1 -  Home Infusion Therapy Services Training and Education  320.6.2 -  Remote Monitoring and Monitoring Services  320.7  Home Infusion Therapy Drugs  320.7.1 -  Determining Qualifying Home Infusion Drugs  320.8  Determining Qualifying Home Infusion Drugs   320.8.1 -  Home Infusion Drug Payment Categories  320.8.2 -  Infusion Drug Administration Calendar Day and Unit of Single Payment  320.8.3 -  Initial Visits and Subsequent Visits for Home Infusion Therapy Services  320.9 Medical Review    330- Marriage and Family Therapist (MFT) Services    340-  Mental  Health Counselor (MHC) Services   10 - Supplementary Medical Insurance (SMI) Provisions  (Rev. 11355; Issued:04- 14-22; Effective: 05 -16-22; Implementation: 05 -16-22)  The supplementary medical insurance plan covers expenses incurred for the following medical and other health services under Part B of Medicare:    Physicians services, including surgery, consultation, office and institutional calls, and services and supplies furnished incident to a physicians professional service;    Outpatient hospital services furnished incident to physicians services;    Outpatient diagnostic services furnished by a hospital;    Outpatient physical therapy, outpatient occupational therapy, outpatient speech- language pathology services;    Diagnostic x- ray tests, laboratory tests, and other diagnostic tests;    X-ray, radium, and radioactive isotope therapy;    Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations;    Rental or purchase of durable medical equipment for use in the patients home;    Ambulance service;    Prosthetic devices, other than dental, which replace all or part of an internal body organ;    Leg, arm, back and neck braces and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because of breakage, wear, loss, or change in the patients physical condition;    Certain medical supplies used in connection with home dialysis delivery systems;    Rural health clinic (RHC) services;
(Medicare Benefit Policy Manual)
 Certain medical supplies used in connection with home dialysis delivery systems;    Rural health clinic (RHC) services;    Federally Qualified Health Center (FQHC) services;    Ambulatory surgical center (ASC) services;    Screening mammography services;    Screening pap smears and pelvic exams;    Screening glaucoma services;    Influenza, pneumococcal pneumonia, hepatitis B, and COVID -19 vaccines;    Colorectal screening;    Bone mass measurements;    Diabetes self -management services;    Prostate screening; and    Home health visits after all covered Part A visits have been used.  See 250  for provisions regarding supplementary medical insurance coverage of certain of these services when furnished to hospital and SNF inpatients.  Payment may not be made under Part B for services furnished an individual if the individual is entitled to have payment made for those services under Part A.  An individual is considered entitled to have payment made under Part A if the expenses incurred were used to satisfy a Part A deductible or coinsurance amount, or if payment would be made under Part A except for the lack of a request for payment or lack of a physician certification.   Some medical services may be considered for coverage under more than one of the above- enumerated categories.  For example, electrocardiograms (EKGs) can be covered as physicians services or as other diagnostic tests.  It is sufficient to determine that th e requirements for coverage under one category are met to permit payment.   Membership dues, subscription fees, charges for service policies, insurance premiums, and other payments analogous to premiums which entitle enrollees to services or to repairs or replacement of devices or equipment or parts thereof without charge or at a reduced charge, are not considered expenses incurred for covered items or services furnished under such contracts or undertakings.  Examples of such arrangements are memberships in ambulance companies, insurance for replacement of prosthetic lenses, and se rvice contracts for durable medical equipment.  20 - When Part B Expenses Are Incurred  (Rev. 1, 10-01-03) B3-2005
(Medicare Benefit Policy Manual)
Part B expenses for items and services other than expenses for surgery and childbirth (see 20.1, below), are considered to have been incurred on the date the beneficiary received the item or service, regardless of when it was paid for or ordered.  Therefore, when an individual orders an item prior to his or her entitlement to supplemental medical insurance (SMI) but receives the item after the effective date of SMI enrollment, the expense is considered incurred after entitlement began.  However, if an item not  custom-made for the beneficiary was ordered but not furnished, no reimbursement can be made.  (See 20.3 for rules concerning custom-made items ordered but not furnished and the Medicare Claims Processing Manual, Chapter 20, Durable Medical Equipment, Prosthetics and Orthotics, and Supplies (DMEPOS), for additional rules concerning the date of incurred expenses for durable medical equipment.)  20.1 - Physician Expense for Surgery, Childbirth, and Treatment for Infertility  (Rev. 1, 10-01-03) B3-2005.l  A.  Surgery and Childbirth  Skilled medical management is covered throughout the events of pregnancy, beginning with diagnosis, continuing through delivery and ending after the necessary postnatal care.  Similarly, in the event of termination of pregnancy, regardless of whether terminated spontaneously or for therapeutic reasons (i.e., where the life of the mother would be endangered if the fetus were brought to term), the need for skilled medical management and/or medical services is equally important as in those cases carried to ful l term.  After the infant is delivered and is a separate individual, items and services furnished to the infant are not covered on the basis of the mothers eligibility.  Most surgeons and obstetricians bill patients an all- inclusive package charge intended to cover all services associated with the surgical procedure or delivery of the child.  All expenses for surgical and obstetrical care, including preoperative/prenatal examinations and tests and post- operative/postnatal services, are considered incurred on the date of surgery or delivery, as appropriate.  This policy applies whether the physician bills on a package charge basis, or i temizes the bill separately for these items.
(Medicare Benefit Policy Manual)
Occasionally, a physicians bill may include charges for additional services not directly related to the surgical procedure or the delivery.  Such charges are considered incurred on the date the additional services are furnished.   The above policy applies only where the charges are imposed by one physician or by a clinic on behalf of a group of physicians.  Where more than one physician imposes charges for surgical or obstetrical services, all preoperative/prenatal and post -operativ e/postnatal services performed by the physician who performed the surgery or delivery are considered incurred on the date of the surgery or delivery.  Expenses for services rendered by other physicians are considered incurred on the date they were performed.  B.  Treatment for Infertility   Reasonable and necessary services associated with treatment for infertility are covered under Medicare.  Infertility is a condition sufficiently at variance with the usual state of health to make it appropriate for a person who normally is expected to be f ertile to seek medical consultation and treatment.   20.2 - Physician Expense for Allergy Treatment  (Rev. 1, 10-01-03) B3-2005.2, B3-4145  Allergists commonly bill separately for the initial diagnostic workup and for the treatment (See 60.2).  Where it is necessary to provide treatment over an extended period, the allergist may submit a single bill for all of the treatments, or may bill periodically.  In either case the Form CMS -1500 claim shows the Healthcare Common Procedure Coding System (HCPCS) codes and from and through dates of service, or the Form CMS-1450 outpatient claim shows the HCPCS code and date of service (except for critical access hospital (CAH) claims).   20.3 - Artificial Limbs, Braces, and Other Custom Made Items Ordered But Not Furnished (Rev. 1, 10-01-03) B3-2005.3
(Medicare Benefit Policy Manual)
20.3 - Artificial Limbs, Braces, and Other Custom Made Items Ordered But Not Furnished (Rev. 1, 10-01-03) B3-2005.3  A.  Date of Incurred Expense  If a custom -made item was ordered but not furnished to a beneficiary because the individual died or because the order was canceled by the beneficiary or because the beneficiarys condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made based on the suppliers expenses.  (See subsection B for determination of the allowed amount.)  In such cases, the expense is considered incurred on the date the beneficiary died or the date the supplier learned of the cancellation or that the item was no longer reasonable and necessary or appropriate for the beneficiarys condition.  If the beneficiary died or the beneficiarys condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made on either an assigned or unassigned claim.  If the beneficiary, for any other reason, canceled the order, payment can be made to the supplier only.  B.  Determination of Allowed Amount  The allowed amount is based on the services furnished and materials used, up to the date the supplier learned of the beneficiarys death or of the cancellation of the order or that the item was no longer reasonable and necessary or appropriate.  The A/B MA C (B) or (HHH), or DME MAC as appropriate, determines the services performed and the allowable amount appropriate in the particular situation.  It takes into account any salvage value of the device to the supplier.  Where a supplier breaches an agreement to make a prosthesis, brace, or other custom -made device for a Medicare beneficiary, e.g., an unexcused failure to provide the article within the time specified in the contract, payment may not be made for any work or material expended on the ite m.  Whether a particular supplier has lived up to its agreement, of course, depends on the facts in the individual case.   30 - Physician Services  (Rev. 10639; Issued: 03- 12-2021;  Effective: 01 -01-2021; Implementation: 04- 12-2021)   A.  General
(Medicare Benefit Policy Manual)
30 - Physician Services  (Rev. 10639; Issued: 03- 12-2021;  Effective: 01 -01-2021; Implementation: 04- 12-2021)   A.  General   Physician services are the professional services performed by a physician or physicians for a patient including diagnosis, therapy, surgery, consultation, and care plan oversight.  The physician must render the service for the service to be covered. (See Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, 70, for definition of physician.)  A service may be considered to be a physicians service  where the physician either examines the patient in person or is able to visualize some aspect of the patients condition without the interposition of a third persons judgment.  Direct visualization would be possible by means of x- rays, electrocardiogram and electroencephalogram tapes, tissue samples, etc.   For example, the interpretation by a physician of an actual electrocardiogram or electroencephalogram reading that has been transmitted via telephone (i.e., electronically rather than by means of a verbal description) is a covered service.   Professional services of the physician are covered if provided within the United States, and may be performed in a home, office, institution, or at the scene of an accident.  A patients home, for this purpose, is anywhere the patient makes his or her resi dence, e.g., home for the aged, a nursing home, a relatives home.  B.  Consultations   As of January 1, 2010, CMS no longer recognizes consultation codes for Medicare payment, except for inpatient telehealth consultation HCPCS G -codes.  Instead, physicians and qualified nonphysician practitioners are instructed to bill a new or established patient office/outpatient visit CPT code or appropriate hospital or nursing facility care code.  For further detail regarding reporting services that would otherwise be described by the CPT consulta tion codes (99241- 99245 and 99251- 99255), see Pub. 100- 04, Medicare Claims Processing Manual, chapter 12, section 30.6.  For detailed instructions regarding reporting telehealth consultation services and other telehealth services, see Pub. 100- 04, chapter 12, section 190.3.  C.  Patient -Initiated Second Opinions
(Medicare Benefit Policy Manual)
C.  Patient -Initiated Second Opinions   Patient -initiated second opinions that relate to the medical need for surgery or for major nonsurgical diagnostic and therapeutic procedures (e.g., invasive diagnostic techniques such as cardiac catheterization and gastroscopy) are covered under Medicare.  In the event that the recommendation of the first and second physician differs regarding the need for surgery (or other major procedure), a third opinion is also covered.  Second and third opinions are covered even though the surgery or other procedure, i f performed, is determined not covered.  Payment may be made for the history and examination of the patient, and for other covered diagnostic services required to properly evaluate the patients need for a procedure and to render a professional opinion.  I n some cases, the results of tests done by the first physician may be available to the second physician.   D.  Concurrent Care   Concurrent care exists where more than one physician renders services more extensive than consultative services during a period of time.  The reasonable and necessary services of each physician rendering concurrent care could be covered where each is required to play an active role in the patients treatment, for example, because of the existence of more than one medical condition requiring diverse specialized medical services.   In order to determine whether concurrent physicians services are reasonable and necessary, the A/B MAC (B) must decide the following:   1. Whether the patients condition warrants the services of more than one physician on an attending (rather than consultative) basis, and  2. Whether the individual services provided by each physician are reasonable and necessary.   In resolving the first question, the A/B MAC (B) should consider the specialties of the physicians as well as the patients diagnosis, as concurrent care is usually (although not always) initiated because of the existence of more than one medical condition requiring diverse specialized medical or surgical services.  The specialties of the physicians are an indication of the necessity for concurrent services, but the patients condition and the inherent reasonableness and necessity of the services, as determ ined by the A/B MAC (B)s medical staff in accordance with locality norms, must also be considered.  For example, although cardiology is a sub- specialty of internal medicine, the treatment of both diabetes and of a serious heart condition might require the  concurrent services of two physicians, each practicing in internal medicine but specializing in different sub- specialties.
(Medicare Benefit Policy Manual)
While it would not be highly unusual for concurrent care performed by physicians in different specialties (e.g., a surgeon and an internist) or by physicians in different subspecialties of the same specialty (e.g., an allergist and a cardiologist) to be found medically necessary, the need for such care by physicians in the same specialty or subspecialty (e.g., two internists or two cardiologists) would occur infrequently since in most cases both physicians would possess the skills and knowledge necessary to treat the patient.  However, circumstances could arise which would necessitate such care.  For example, a patient may require the services of two physicians in the same specialty or sub- specialty when one physician has further limited his or her practice to some unusual aspect of that specialty, e.g., tropical medicine.  Similarly, concurrent services provided by a family physician and an internist may or may not be found to be reasonable and necessary, depending on the circumstances of the specific case.  If it is determined that the services of one of the physicians are not warranted by the patients condition, payment may be made only for the other physicians (or physicians) services.   Once it is determined that the patient requires the active services of more than one physician, the individual services must be examined for medical necessity, just as where a single physician provides the care.  For example, even if it is determined that the patient requires the concurrent services of both a cardiologist and a surgeon, payment may not be made for any services rendered by either physician which, for that condition, exceed normal frequency or duration unless there are s pecial circumstances requiring the additional care.   The A/B MAC (B) must also assure that the services of one physician do not duplicate those provided by another, e.g., where the family physician visits during the post -operative period primarily as a courtesy to the patient.