evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
ICD-10 Description  C91.00  Acute  lymphoblastic  leukemia  not having  achieved  remission  C91.01  Acute  lymphoblastic  leukemia,  in remission  C91.02  Acute  lymphoblastic  leukemia,  in relapse  C91.10  Chronic  lymphocytic  leukemia  of B-cell type not having  achieved  remission  C91.11  Chronic  lymphocytic  leukemia  of B-cell type in remission  C91.12  Chronic  lymphocytic  leukemia  of B-cell type in relapse    C91.30  Prolymphocytic  leukemia  of B-cell type not having  achieved  remission  C91.31  Prolymphocytic  leukemia  of B-cell type,  in remission  C91.32  Prolymphocytic  leukemia  of B-cell type,  in relapse  C91.50  Adult  T-cell lymphoma/leukemia (HTLV -1-associated)  not having  achieved remission  C91.51  Adult  T-cell lymphoma/leukemia  (HTLV -1-associated),  in remission  C91.52  Adult  T-cell lymphoma/leukemia (HTLV -1-associated),  in relapse  C91.60  Prolymphocytic  leukemia  of T-cell type not having achieved  remission  C91.61  Prolymphocytic  leukemia  of T-cell type,  in remission  C91.62  Prolymphocytic  leukemia  of T-cell type,  in relapse  C91.90  Lymphoid  leukemia,  unspecified  not having  achieved  remission  C91.91  Lymphoid  leukemia,  unspecified,  in remission  C91.92  Lymphoid  leukemia,  unspecified,  in relapse  C91.A0  Mature  B-cell leukemia  Burkitt -type not having  achieved  remission  C91.A1  Mature  B-cell leukemia Burkitt -type,  in remission  C91.A2  Mature  B-cell leukemia Burkitt -type,  in relapse  C91.Z0  Other  lymphoid  leukemia  not having  achieved  remission  C91.Z1  Other  lymphoid  leukemia,  in remission  C91.Z2  Other  lymphoid  leukemia,  in relapse  C92.00  Acute
(Medicare Claims Processing Manual)
Other  lymphoid  leukemia  not having  achieved  remission  C91.Z1  Other  lymphoid  leukemia,  in remission  C91.Z2  Other  lymphoid  leukemia,  in relapse  C92.00  Acute  myeloblastic  leukemia,  not having  achieved remission  C92.01  Acute  myeloblastic  leukemia,  in remission  C92.02  Acute  myeloblastic  leukemia,  in relapse  C92.10  Chronic  myeloid  leukemia,  BCR/ABL -positive,  not having  achieved  remission  C92.11  Chronic  myeloid  leukemia,  BCR/ABL -positive,  in remission  C92.12  Chronic  myeloid  leukemia,  BCR/ABL -positive,  in relapse  C92.20  Atypical  chronic  myeloid  leukemia,  BCR/ABL -negative,  not having  achieved  remission  C92.21  Atypical  chronic  myeloid leukemia,  BCR/ABL -negative,  in remission  C92.22  Atypical  chronic  myeloid  leukemia,  BCR/ABL -negative,  in relapse  C92.30  Myeloid  sarcoma,  not having  achieved  remission  C92.31  Myeloid  sarcoma,  in remission  C92.32  Myeloid  sarcoma,  in relapse  C92.40  Acute  promyelocytic  leukemia,  not having achieved  remission  C92.41  Acute  promyelocytic  leukemia,  in remission  C92.42  Acute  promyelocytic  leukemia,  in relapse  C92.50  Acute  myelomonocytic  leukemia,  not having  achieved  remission  C92.51  Acute  myelomonocytic  leukemia,  in remission  C92.52  Acute  myelomonocytic  leukemia,  in relapse  C92.60  Acute  myeloid  leukemia with  11q23 -abnormality  not having  achieved  remission  C92.61  Acute  myeloid  leukemia with  11q23 -abnormality  in remission  C92.62  Acute  myeloid  leukemia  with 11q23 -abnormality  in relapse  C92.90  Myeloid  leukemia,  unspecified,  not having  achieved  remission  C92.91  Myeloid  leukemia,  unspecified  in remission  C92.92  Myeloid  leukemia,  unspecified  in relapse
(Medicare Claims Processing Manual)
in relapse  C92.90  Myeloid  leukemia,  unspecified,  not having  achieved  remission  C92.91  Myeloid  leukemia,  unspecified  in remission  C92.92  Myeloid  leukemia,  unspecified  in relapse  C92.A0  Acute  myeloid  leukemia  with multilineage  dysplasia,  not having  achieved  remission  C92.A1  Acute  myeloid  leukemia with  multilineage  dysplasia,  in remission  C92 A2  At  l id lk i  ith ltili  d li  i l
(Medicare Claims Processing Manual)
C92.Z0  Other  myeloid  leukemia  not having  achieved  remission  C92.Z1  Other  myeloid  leukemia,  in remission  C92.Z2  Other  myeloid  leukemia, in  relapse  C93.00  Acute  monoblastic/monocytic  leukemia,  not having  achieved  remission  C93.01  Acute  monoblastic/monocytic  leukemia,  in remission  C93.02  Acute  monoblastic/monocytic  leukemia,  in relapse  C93.10  Chronic  myelomonocytic leukemia  not having  achieved  remission  C93.11  Chronic  myelomonocytic leukemia,  in remission  C93.12  Chronic  myelomonocytic leukemia,  in relapse  C93.30  Juvenile  myelomonocytic leukemia,  not having  achieved  remission  C93.31  Juvenile  myelomonocytic  leukemia,  in remission  C93.32  Juvenile  myelomonocytic leukemia,  in relapse  C93.90  Monocytic  leukemia,  unspecified,  not having  achieved  remission  C93.91  Monocytic  leukemia,  unspecified  in remission  C93.92  Monocytic  leukemia,  unspecified  in relapse  C93.Z0  Other  monocytic  leukemia,  not having achieved  remission  C93.Z1  Other  monocytic  leukemia,  in remission  C93.Z2  Other  monocytic  leukemia,  in relapse  C94.00  Acute  erythroid  leukemia,  not having  achieved  remission  C94.01  Acute  erythroid  leukemia,  in remission  C94.02  Acute  erythroid  leukemia, in  relapse  C94.20  Acute  megakaryoblastic  leukemia  not having  achieved  remission  C94.21  Acute  megakaryoblastic  leukemia,  in remission  C94.22  Acute  megakaryoblastic  leukemia,  in relapse  C94.30  Mast  cell leukemia  not having  achieved  remission  C94.31  Mast  cell leukemia,  in remission  C94.32  Mast  cell leukemia,  in relapse  C94.80  Other  specified  leukemias  not having achieved  remission  C94.81  Other  specified  leukemias,  in remission  C94.82  Other  specified  leukemias,  in relapse  C95.00  Acute  leukemia  of unspecified  cell type not having  achieved  remission  C95.01  Acute  leukemia  of
(Medicare Claims Processing Manual)
Other  specified  leukemias,  in remission  C94.82  Other  specified  leukemias,  in relapse  C95.00  Acute  leukemia  of unspecified  cell type not having  achieved  remission  C95.01  Acute  leukemia  of unspecified  cell type, in  remission  C95.02  Acute  leukemia  of unspecified  cell type,  in relapse  C95.10  Chronic  leukemia  of unspecified  cell type not having  achieved  remission  C95.11  Chronic  leukemia  of unspecified  cell type, in  remission  C95.12  Chronic  leukemia  of unspecified  cell type,  in relapse  C95.90  Leukemia,  unspecified  not having  achieved  remission  C95.91  Leukemia,  unspecified,  in remission  C95.92  Leukemia,  unspecified,  in relapse  D45 Polycythemia  vera
(Medicare Claims Processing Manual)
III. For the treatment  of aplastic  anemia;  see table below  for ICD-10- CM codes)       If ICD- 10-CM is applicable,  the following  ranges  of ICD- 10-CM codes  are also covered  for AuSCT:    Resistant  non-Hodgkins  lymphomas, ICD-10-CM diagnosis codes C82.01- C85.29, C85.81-  C86.6, C96.4, and C96.Z -C96.9.   Tandem  transplantation  (multiple  rounds  of autologous  stem cell transplantation) for patients with multiple  myeloma, ICD -10-CM codes C90.00, C90.01, C90.02 and D47.Z9   NOTE:  The  following conditions are  not covered:   Acute leukemia  not in remission   Chronic  granulocytic  leukemia   Solid  tumors  (other  than neuroblastoma)   Multiple  myeloma   For Medicare beneficiaries  age 64 or  older, all  forms  of amyloidosis, primary  and non-primary   Non-primary  amyloidosis
(Medicare Claims Processing Manual)
Also coverage for conditions other than those specifically designated as  covered in 90.2 or specifically designated as non -covered in this section  or in 90.3will  be at the discretion  of the  individual  contractor.  ICD-10 Description  D60.0  Chronic  acquired  pure red cell aplasia  D60.1  Transient  acquired  pure red cell aplasia  D60.8  Other  acquired  pure red cell aplasias  D60.9  Acquired  pure red cell  aplasia,  unspecified  D61.01  Constitutional  (pure)  red blood  cell aplasia  D61.09  Other  constitutional  aplastic  anemia  D61.1  Drug -induced aplastic  anemia  D61.2  Aplastic  anemia  due to other  external agents  D61.3  Idiopathic  aplastic  anemia  D61.810  Antineoplastic  chemotherapy  induced pancytopenia  D61.811  Other  drug-induced  pancytopenia  D61.818  Other  pancytopenia  D61.82  Myelophthisis  D61.89  Other  specified  aplastic anemias  and other  bone  marrow failure  syndromes  D61.9  Aplastic  anemia,  unspecified   90.3 - Non-Covered Conditions (Rev.11035, Issued:10 -13-21, Effective: 11-17-21; Implementation:  11-17-21)  Autologous  stem  cell transplantation  is not covered  for the following conditions:    a) Acute leukemia  not in remission  prior  to October  1, 2000 (if ICD -10-CM is applicable,  ICD -10-CM codes  C91.00, C92.00,  C93.00, C94.00,  and C95.00)   b) Chronic  granulocytic  leukemia  prior  to October  1, 2000 (if ICD-10-CM is applicable,  ICD-10-CM code  C92.10);   c) Solid tumors prior to October 1, 2000 (other than neuroblastoma) (if ICD - 10-CM is applicable,  ICD-10-CM codes  C00.0  C80.2 and D00.0  D09.9);
(Medicare Claims Processing Manual)
d) Multiple  myeloma  prior  to October  1, 2000 (if  ICD -10-CM is applicable,  ICD-10-CM codes C90.00, C90.01, C90.02 and D47.Z9);   e) Tandem transplantation, on or after October 1, 2000 (if ICD -10-CM is applicable,  ICD-10-CM codes  C90.00, C90.01, C90.02, and D47.Z9)  ;  f) Non- primary amyloidosis on or after 10/01/00, for all Medicare  beneficiaries   g) Primary AL amyloidosis effective October 1, 2000, through March 14,  2005 for Medicare beneficiaries  age 64. (if  ICD-10-CM is applicable,  ICD-10- CM codes E85.4, E85.81, E85.9, and E85.89);    NOTE: Coverage for conditions other than those specifically designated as  covered in  90.2 or 90.2.1 or specifically designated as non -covered in this  section will be at the discretion of the individual A/B MAC  (B).  90.4 - Edits  (Rev.11035, Issued:10 -13-21, Effective: 11-17-21; Implementation:  11-17-21)  NOTE: Coverage for conditions other than those specifically designated as  covered  in 80.2 or  specifically  designated as  non- covered  in this section  will be  at the discretion of  the individual A/B  MAC (B).    Appropriate diagnosis to procedure code edits should be  implemented  for the non-covered conditions  and services  in 90.2 90.2.1, and 90.3 as applicable   As the ICD-10-CM codes  E85.4, E85.81, E85.89, and E85.9  amyloidosis  does not differentiate  between  primary  and non-primary,  A/B MACs (B) should perform prepay reviews on all claims with a  diagnosis  of ICD -10-CM codes E85.4, E85.81, E85.89, and E85.9 and a HCPCS procedure code of 38241 to determine whether  payment  is appropriate.
(Medicare Claims Processing Manual)
90.5 - Suggested MSN and RA Messages  (Rev.11035, Issued:10 -13-21, Effective: 11-17-21; Implementation:  11-17-21)   The contractor shall use an appropriate MSN and CARC message  such as the following:   MSN  - 15.4, The  information provided does  not support  the need  for this service  or item;  CARC -  150, Payment adjusted because the payer deems the  information  submitted  does  not support  this level  of service.   90.6 - Clinical Trials for Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndrome (MDS)  (Rev. 11035, Issued:10 -13-21, Effective: 11-17-21; Implementation:  11-21)  Myelodysplastic Syndrome (MDS) refers to a group of diverse blood  disorders  in which  the bone  marrow  does  not produce  enough  healthy, functioning blood cells. These disorders are varied with  regard to clinical characteristics, cytologic and pathologic features, and  cytogenetics.   On August 4, 2010, the Centers for Medicare & Medicaid Services  (CMS)  issued  a national  coverage  determination  (NCD)  stating  that CMS believes that the evidence does not demonstrate that the use of  allogeneic hematopoietic stem cell transplantation (HSCT) improves  health outcomes in Medicare beneficiaries with MDS. Therefore,  allogeneic  HSCT  for MDS  is not  reasonable  and necessary  under  1862(a)(1)(A) of the Social Security Act (the Act). However,  allogeneic  HSCT  for MDS  is reasonable  and necessary  under  1862(a)(1)(E)  of the Act and therefore covered  by Medicare ONLY if provided pursuant to a Medicare -approved clinical study under  Coverage with Evidence Development (CED). Refer to Pub.100- 03, National Coverage Determinations Manual, Chapter 1, section  110.8.1, for more information about this policy, and Pub. 100- 04, Medicare Claims Processing Manual, Chapter 3, section 90.3.1, for  information  on CED.   B Adjudication Requirements
(Medicare Claims Processing Manual)
B Adjudication Requirements   Payable Conditions. For claims with dates of service on and after  August  4, 2010, contractors  shall  pay for claims  for HSCT  for MDS  when the service was provided pursuant to a Medicare -approved  clinical study under CED; these services are paid only in the  inpatient setting (Type of Bill (TOB) 11X), as outpatient Part B  (TOB 13X), and in Method II critical access hospitals (TOB 85X). Contractors shall require the following coding in order to pay for  these  claims:     Existing Medicare -approved clinical trial coding conventions, as required in Pub. 100- 04, Medicare Claims Processing  Manual, Chapter 32, section 69, and inpatient billing requirements regarding acquisition of stem cells in Pub. 100-  04, Medicare Claims Processing Manual, Chapter 3, section 90.3.3.    If ICD -10-CM is applicable, ICD -10-PCS, procedure codes  30230C0, 30230G0, 30230Y0, 30233G0, 30233C0, 30233Y0, 30240C0, 30240G0, 30240Y0, 30243C0, 30243G0, and30243Y0    If Outpatient  Hospital  or Professional  Claims: HCPCS  procedure  code 38240   If ICD -10-CM is applicable, ICD -10-CM diagnosis codes, D46.A, D46.B, D46.C, D46.Z, D46.0, D46.1, D46.20, D46.21, D46.22, D46.4, D46.9, and Z00.6  Professional  claims  only:  place  of service codes  21 or  22.  Denials. Contractors shall deny claims failing to meet any of the above criteria. In addition, contractors shall apply the following  requirements:    Providers  shall  issue  a hospital  issued  notice  of non-coverage (HINN) or advance beneficiary notice (ABN) to the beneficiary if the services performed are not provided in accordance with CED.    Contractors  shall  deny claims  that do not  meet  the criteria  for coverage with the  following messages:   CARC 50 -  These are non -covered services because this is not  deemed  a 'medical necessity'  by the payer.
(Medicare Claims Processing Manual)
 Contractors  shall  deny claims  that do not  meet  the criteria  for coverage with the  following messages:   CARC 50 -  These are non -covered services because this is not  deemed  a 'medical necessity'  by the payer.   NOTE:  Refer to the 835 Healthcare Policy Identification  Segment  (loop 2110 Service Payment  Information  REF),  if present.   RARC N386 -  This decision was based on a National Coverage  Determination  (NCD). An  NCD provides  a coverage determination  as to whether a particular item or service is covered. A copy of this  policy is available a t http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a  copy of the NCD.   Group Code   Patient  Responsibility  (PR) if HINN/ABN issued, otherwise  Contractual  Obligation (CO)   MSN  16.77  This  service/item  was not covered  because  it was  not provided as part of a qualifying trial/study. (Este  servicio/artculo no fue cubierto porque no estaba incluido como  parte de  un ensayo  clnico/estudio calificado.)   100  Billing Requirements for Expanded Coverage of Cochlear Implantation  (Rev. 11875; Issued:02- 23-23; Effective: 09 -26-22; Implementation: 03 -24-23)  Effective for dates of services on and after September 26, 2022, the Centers for Medicare & Medicaid Services (CMS) has expanded the coverage for cochlear implantation to cover bilateral pre-  or post - linguistic, sensorineural, moderate -to-profound hearing loss in individuals with hearing test scores equal to or less than 60% correct in the best aided listening condition on recorded tests of  open -set sentence recognition and who demonstrate limited benefit from amplification.  (See Publication 100 -03, Chapter 1, Section 50.3, for complete coverage criteria).   In addition, CMS is covering cochlear implants for beneficiaries not meeting the coverage criteria listed  under Publication 100- 03, Chapter 1, Section 50.3 when performed in context with:    A Food and Drug Administration (FDA) -approved category B investigational device exemption (IDE) clinical trial as defined at 42 CFR 405.201; or
(Medicare Claims Processing Manual)
 As a routine cost in a clinical trial under the CMS clinical trial policy (see Pub. 100 -03, section 310.1).     100.1  A/B MACs (Part A) Billing Procedures  (Rev. 11875; Issued:02- 23-23; Effective: 09 -26-22; Implementation: 03 -24-23)  There are no special payment methods.  Existing payment methods shall apply.  100.1.1  Applicable Bill Types  (Rev. 601, Issued: 07- 01-05; Effective:  04 -04-05; Implementation: 07 -25-05)  11X, 12X (see note below), 13X, 83X, 85X   NOTE :  Surgical procedures are not acceptable on 12x bill types.   100.1.2  Special Billing Requirements for A/B MACs (A) for Inpatient Billing  (Rev. 11875; Issued:02- 23-23; Effective: 09 -26-22; Implementation: 03 -24-23)   The second or subsequent diagnosis code must be ICD -10-CM Z00.6 (Encounter for exam for normal comparison and control in clinical research program).  These diagnoses alert the claims processing system that this is a clinical trial.    For patients in an FDA -approved category B IDE clinical trial  the - Q0 modifier must be reported with the cochlear implantation device and all other related costs or; (see note below)    For patients in an approved clinical trial under the clinical trial policy the - Q1 modifier must be billed for routine costs and not for the device itself   NOTE:  The - Q0/-Q1 modifiers do not need to be applied to these services (92601- 92604, 92507 & 92521-92524).   100.2  Intermediary Payment Requirements (Rev. 601, Issued: 07- 01-05; Effective:  04 -04-05; Implementation: 07 -25-05)  There are no special payment methods.  Existing payment methods shall apply.  100.3  A/B MACs (Part B) Billing Procedures  (Rev. 11875; Issued:02- 23-23; Effective: 09 -26-22; Implementation: 03 -24-23)  Effective for dates of service performed on and after September 26, 2022, the following applies:
(Medicare Claims Processing Manual)
Effective for dates of service performed on and after September 26, 2022, the following applies:   A/B MACs (Part B) shall accept claims for cochlear implantation devices and services for beneficiaries meeting the coverage criteria listed under Publication 100- 03, Chapter 1, section 50.3.  A/B MACs (Part B) shall accept claims for cochlear implantation devices and all related costs for beneficiaries not meeting the coverage criteria listed  under Publication 100- 03, Chapter 1, Section 50.3 provided in an FDA -approved category B IDE clinical trial or a trial under the CMS Clinical Trial policy, that is billed with the - Q0 modifier.  The definition of the - Q0 modifier is, Item or service provided in a Medicare specified study.   A/B MACs (Part B)  shall accept claims for routine costs pertaining to beneficiaries not meeting the coverage criteria listed  under Publication 100- 03, Chapter 1, Section 50.3 who are in a clinical trial under the clinical trial policy that is billed with the - Q1 modifier.  The definition of the - Q1 modifier is, Routine clinical service provided in a clinical research study that is in an approved clinical research study   A/B MACs (Part B) shall accept claims for evaluation and therapeutic services related to cochlear implantation.   NOTE:  The - Q0/-Q1 modifier does not need to be applied to these services (92601- 92604, 92507 & 92521-92524).  These services should be billed on an approved electronic claim form or a paper CMS Form 1500.   100.4  Healthcare Common Procedural Coding System (HCPCS)  (Rev. 11875; Issued:02- 23-23; Effective: 09 -26-22; Implementation: 03 -24-23)  The following HCPCS codes are some of those available for use when billing for cochlear implantation services and devices provided by audiologists or physicians, and for the service of 92507, by speech language pathologists.   69930  Cochlear device implantation, with or without mastoidectomy  L8614  Cochlear Device includes all internal and external components   L8619  Cochlear implant external speech processor and controller, integrated system, replacement
(Medicare Claims Processing Manual)
L8619  Cochlear implant external speech processor and controller, integrated system, replacement   L7510  Repair of prosthetic device, repair or replace minor parts   92507  Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); individual  92521  Evaluation of speech fluency (e.g. stuttering, cluttering)   92522  Evaluation of speech sound production (e.g. articulation, phonological process, apraxia, dysarthria)   92523  Evaluation of speech sound production (e.g. articulation, phonological process, apraxia, dysarthria) with evaluation of language comprehension and expression (e.g. receptive and expressive language).   92524  Behavioral and qualitive analysis of voice and resonance   92601  Diagnostic analysis of cochlear implant, patient under 7 years of age; with programming  (Codes 92601 and 92603 describe post -operative analysis and fitting of previously placed external devices, connection to the cochlear implant, and programming of the stimulator.  Codes 92602 and 92604 describe subsequent sessions for measurements and adjus tment of the external transmitter and re -programming of the internal stimulator.)   92602  Diagnostic analysis of cochlear implant, patient under 7 years of age; subsequent programming.  (Do not report 92602 in addition to 92601.)   92603  Diagnostic analysis of cochlear implant, age 7 years or older; with programming  92604  Diagnostic analysis of cochlear implant, age 7 years or older; subsequent reprogramming   A complete list of audiology codes can be found in Pub 100-4, chapter12, section 30.3.  100.5 - Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages (Rev. 11875; Issued:02-23- 23; Effective: 09 -26-22; Implementation: 03-24-23)
(Medicare Claims Processing Manual)
Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for cochlear implantation devices and services for beneficiaries with moderate -to-profound hearing loss in patients with hearing test scores  40% through 9/25/22;  60% effective 9/26/22.   Use the following messages when denying services on claims:   submitted on a TOB other than 11X, 12X (except surgical procedures), 13X or 85X (For Part A only); or  submitted without the Q0/Q1; or   submitted without diagnostic code Z000.6 or  submitted without one of the CPT/HCPCs listed (92521-92524, 92507, 92601- 92604, L7510, L8614, L8619, 69930)  CARC 50 - These are non -covered services because this is not deemed a medical necessity by the payer  RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp . If you do not have web access, you may contact the contractor to request a copy of the NCD.  MSN 15.20 = The following policies were used when we made this decision:  NCD 50. 3 Spanish translation: Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 50.3)  Contractors processing institutional claims shall use the following MSN message in addition to MSN 15.20:  MSN 15.19 - Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICAR E (1-800-633-4227) for a copy of the LCD.