evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
CARC 58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.  Usage: 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 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.   Group Code CO (Contractual Obligations).  MSN 16.2  This service cannot be paid when provided in this location/facility.   Spanish Version  Este servicio no se puede pagar cuando es suministrado en esta sitio/facilidad.   In addition to the codes listed above, contractors shall afford appeal rights to all denied parties.   --When denying claims for covered CAR T -cell therapy procedures because the appropriate ICD -10 coding was not used, use the following messages:   CARC 50 -  These are non -covered services  because this is not deemed a "medical necessity" by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(Medicare Claims Processing Manual)
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.   Group Code CO or PR dependent upon liability.  MSN 15.20 -  The following polices were used when we made this decision: NCD 110.24.  Spanish Version  Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 110.24.   --When denying claims for covered CAR T -cell therapy procedures because they are not performed in POS 11 or 49, use the following messages:   CARC 58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(Medicare Claims Processing Manual)
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.   Group Code CO or PR (Patient Responsibility) dependent upon liability. (Use PR when the GA modifier is appended to the line item).                                                      MSN 09.040 -  This item or service was denied because information required to make payment  was incorrect.                                                                 MSN 15.20 -  The following polices were used when we made this decision: NCD 110.24.   Spanish Version  Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 110.24.  --When denying claims for covered CAR T -cell therapy procedures because they do not contain new modifier -LU, use the following messages:   CARC 4 - The procedure code is inconsistent with the modifier used. Usage: 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 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.   Group Code CO   MSN 15.20 - The following polices were used when we made this decision: NCD 110.24.   Spanish Version  Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 110.24.  --When denying claims for covered CAR T -cell therapy procedures because the fractional units exceed 1 unit, use the following messages:   CARC 151 - Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
(Medicare Claims Processing Manual)
Group Code CO   MSN 15.060 - The information provided does not support the need for this many services or items within this period of time.   Spanish Version - (La informacin proporcionada no confirma la necesidad de estos servicios o artculos en este periodo de tiempo.)  -- Contractors shall reject claims for allogeneic CAR T -cell therapy ICD -10-PCS codes XW033G7 and XW043G7 and autologous CAR T -cell therapy ICD -10-PCS codes XW033C7 and XW043C7 when not billed for clinical trials under NCD 310.1 with the NCT number for the specific trial, condition code 30, value code D4, and the Z00.6 clinical trial diagnosis code effective for dates of service on or after October 1, 2021, using the following messages:   CARC 55: Procedure/treatment/drug is deemed experimental/investigational by the payor.  Group Code: CO  MSN 16.77  This service/item was not covered because it was not provided as part of a qualifying trial/study.   Spanish Version  (Este servicio/artculo no fue cubierto porque no estaba incluido como parte de un ensayo clnico/estudio calificado.)   In addition to the codes listed above, contractors shall afford appeal rights to all denied parties.   400.5 - Claims Editing (Rev. 11721; Issued: 11-28-22; Effective: 01 -01-23; Implementation: 01-03-23)  A. Fee- For-Service Medicare   Medicare edits CAR T -cell therapy claims based on requirements found in NCD 110.24.   B. Beneficiaries enrolled in Medicare Advantage (MA) plans
(Medicare Claims Processing Manual)
A. Fee- For-Service Medicare   Medicare edits CAR T -cell therapy claims based on requirements found in NCD 110.24.   B. Beneficiaries enrolled in Medicare Advantage (MA) plans   Effective for clams with dates of service on and after August 7, 2019, CMS determined that the NCD requiring coverage of CAR T -cell therapy for cancer is a significant cost under section 422.109(a)(2) of title 42 of the Code of Federal Regulations. As a result, for CYs 2019 (beginning August 7, 2019) and 2020 only, original fee- for-service Medicare will pay for CAR T- cell therapy for cancer obtained by beneficiaries enrolled in Medicare Advantage (MA) plans when the coverage criteria outlined in the NCD are met. Plans should account for CAR T- cell therapy for cancer items and services in their contract year 2021 bids.   Consistent with 1862 (t)(2) of the Act, MACs will pay for CAR T- cell therapy for cancer for Medicare beneficiaries enrolled in MA plans in CYs 2019 (beginning August 7, 2019) and 2020.  410  Acupuncture for Chronic Low Back Pain (cLBP)  (Rev.  10337, Issued: 08-027-20, Effective: 01-21-20, Implementation: 06 -24 - 20 - A/B MACs; 10 -05-20- SSM Edits; 01 - 04-21 - BR 13 CWF only)  Acupuncture is the selection and manipulation of specific acupuncture points through the insertion of needles or needling, or other non-needling techniques focused on these points.    410.1 - Coverage Requirements  (Rev.  10337, Issued: 08-027-20, Effective: 01-21-20, Implementation: 06 -24 - 20 - A/B MACs; 10 -05-20- SSM Edits; 01 - 04-21 - BR 13 CWF only)
(Medicare Claims Processing Manual)
Effective for services on or after January 21, 2020, the Centers for Medicare & Medicaid Services ( CMS) will cover acupuncture for chronic low back pain (cLBP) under section 1862(a)(1)(A) of the Social Security Act. Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:   For the purpose of this decision, cLBP is defined as:  o Lasting 12 weeks or longer; o nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);  o not associated with surgery; and o not associated with pregnancy.  An additional 8 sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually. Example: If the 1st service is performed on March 21, 2020, the next service beginning a new year cannot be performed until March 1, 2021. This means 11 full months must pass from the date of the 1st service before eligibility begins again.  All types of acupuncture including dry needling for any condition other than cLBP are non- covered by Medicare.   410.2  Claims Processing General Information  (Rev.  10337, Issued: 08-027-20, Effective: 01-21-20, Implementation: 06 -24 - 20 - A/B MACs; 10 -05-20- SSM Edits; 01 - 04-21 - BR 13 CWF only)  Effective for claims with dates of service (DOS) on or after January 21, 2020, contractors shall recognize acupuncture for cLBP services reported with CPT codes 97810, 97811, 97813, 97814, 20560, and 20561 as covered services under National Coverage Determ ination (NCD) 30.3.3 no more than 20 times per annum.  NOTE: If the 1st service is performed on March 21, 2020, the next service beginning a new year cannot be performed until March 1, 2021, 11 full months following the 1st service.   The attached includes the International Classification of Diseases (ICD) -10 diagnosis codes are applicable and must be reported for acupuncture for cLBP services:
(Medicare Claims Processing Manual)
The attached includes the International Classification of Diseases (ICD) -10 diagnosis codes are applicable and must be reported for acupuncture for cLBP services:   Contractors shall accept and process acupuncture for cLBP claims with the - KX modifier  for the 13th through 20th service per annum.   NOTE: The 1st through 12th service over a 90- day period do not require the KX modifier. There is a 20 service maximum per annum for this benefit.   NOTE: By applying the - KX modifier to the claim, the therapy provider is confirming that the additional services are medically necessary as justified by appropriate documentation in the medical record.    410.3  Institutional Claims Bill Type and Revenue Coding Information  (Rev.  10337, Issued: 08- 027-20, Effective: 01 -21-20, Implementation:  06-24 - 20 - A/B MACs; 10 -05-20-SSM Edits; 01 - 04-21 - BR 13 CWF only)   Effective for claims with DOS on or after January 21, 2020, contractors shall recognize acupuncture for cLBP services reported on institutional claims on types of bill (TOBs) 12X, 13X, 71X, 77X, and 85X (and revenue codes not equal to 096X, 097X, and 098X for CAH Method I).    Effective for claims with DOS on or after January 21, 2020, contractors shall recognize acupuncture for cLBP services reported with Revenue Code 0940 on institutional claims.  Effective for claims with DOS on or after January 21, 2020, contractors shall recognize acupuncture for cLBP services reported on institutional claims on TOB 12X, 71X, 77X 85X CAH Method II with revenue codes 096X, 097X, and 098X.  410.4  Messaging (Rev.  10337, Issued: 08- 027-20, Effective: 01 -21-20, Implementation:  06-24 - 20 - A/B MACs; 10 -05-20-SSM Edits; 01 - 04-21 - BR 13 CWF only)   Effective for claims with DOS on or after January 21, 2020, contractors shall reject/deny claims that do not contain the appropriate diagnosis/procedure coding noted in section 410.2 and use these messages:
(Medicare Claims Processing Manual)
Effective for claims with DOS on or after January 21, 2020, contractors shall reject/deny claims that do not contain the appropriate diagnosis/procedure coding noted in section 410.2 and use these messages:   Claim Adjustment Reason Code (CARC) 50 -  These are non -covered services because this is not deemed a 'medical necessity' by the payer.   Remittance Advice Remark Code (RARC) M64   Missing/incomplete/invalid other diagnosis.  Group Code CO (Contractual Obligations) or PR (Patient Responsibility) dependent on liability.  MSN 15.20 -  The following polices were used when we made this decision: NCD 30.3.3.  Spanish Version  Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 30.3.3.  NOTE: Due to system requirement, the Fiscal Intermediary Shared System (FISS) has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.  In addition to the codes noted in section 410.2, contractors shall afford appeal rights to all denied parties.   Contractors shall return to provider/return as unprocessable claims for acupuncture for cLBP for services 13 through 20 per annum without the - KX modifier and use these messages:   CARC 4 -  The procedure code is inconsistent with the modifier used or a required modifier is missing. Usage: Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N657 -  This should be billed with the appropriate code for these services.  Group Code CO    Contractors shall reject/deny more than 20 claims per annum for acupuncture  for cLBP and use the following messages:   CARC 96 -  Non -covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segme nt (loop 2110 Service Payment Information REF), if present.   RARC N640 -  Exceeds number/frequency approved/allowed within time period.  Group Code -  CO (Contractual Obligation)
(Medicare Claims Processing Manual)
RARC N640 -  Exceeds number/frequency approved/allowed within time period.  Group Code -  CO (Contractual Obligation)   MSN 15.20 -  The following polices were used when we made this decision: NCD 30.3.3.   Spanish Version  Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 30.3.3.   MSN 15.19: We used a Local Coverage Determination (LCD) to decide coverage for your claim. To appeal, get a copy of the LCD at www.cms.gov/medicare -coverage -database (use the MSN Billing Code for the CPT/HCPCS Code) and send with information from your doc tor."  Spanish Version -  Usamos una Determinacin de Cobertura Local (LCD) para decidir la cobertura de su reclamo. Para apelar, obtenga una copia del LCD en www.cms.gov/medicare -coverage -database (use el cdigo de facturacin de MSN para el cdigo "CPT/HCPCS") y envela con la informacin de su mdico.   NOTE: Due to system requirements, the Fiscal Intermediary Shared System has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.  410.5  Common Working File (CWF) FISS, and Multi- Carrier System (MCS) Editing (Rev.  10337, Issued: 08- 027-20, Effective: 01 -21-20, Implementation:  06-24 - 20 - A/B MACs; 10 -05-20-SSM Edits; 01 - 04-21 - BR 13 CWF only)   The Common Working File (CWF) shall create a new reject for claims with DOS on and after January 21, 2020, for claims received on or after October 5, 2020, to not allow payment for more than 20 acupuncture for cLBP claims per annum.  For acupuncture for cLBP claims CWF, FISS and the Multi -Carrier System (MCS) shall apply appropriate updates to the Next Eligibility Date file for DOS on or after January 21, 2020.
(Medicare Claims Processing Manual)
NOTE : Appropriate updates include modifications to HUQA, and Extract Records on the Next Generation Desktop (NGD) and the Medicare Beneficiary Database (MBD) for next eligible date and services remaining.   CWF shall count 11 full months starting with the month of a beneficiarys 1st acupuncture for cLBP service. EX: If 1st date of service is October 15, 2020, the next eligible date beginning a new year would be October 1, 2021.  NOTE: A new cLBP auxiliary (AUX) file will be created and HIMR will be updated to post the previous acupuncture for cLBP HCPCS 97810, 97811, 97813, 97814, 20560, or 20561.  For acupuncture for cLPB claims with DOS on and after January 21, 2020, the Multi -Carrier System Desktop Tool shall display the acupuncture for cLBP visits in a format equivalent to the CWF HIMR screen.    Effective for claims with DOS on and after January 21, 2020, received on and after October 5, 2020, CWF shall post acupuncture for cLBP HCPCS codes 97810, 97811, 97813, 97814, 20560, and 20561, reported on institutional claims, TOBs 12X, 13X, 71X, 77X, and 85X (and revenue code not equal to 096X, 097X, 098X), as the technical component on the new cLBP AUX  file.   NOTE: 1 TECH and 1 PROF on same DOS represents 1 service.   NOTE: CWF shall post the Part B Professional claim  line as TECH/PROF for the HCPCS if the modifier is blank.    CWF shall create a new reject for HCPCS 97810, 97811, 97813, 97814, 20560, and 20561 when a beneficiary has reached 20 acupuncture for cLBP sessions and the - KX modifier is not included on the claim line for sessions 13 through 20 (the reject will apply fo r both PROF and TECH sessions).  CWF shall update the determination when any changes occur to the beneficiary master data or claims data that would result in a change to the calculation   CWF shall create a new HICR function for the new cLBP AUX file.
(Medicare Claims Processing Manual)
CWF shall update the determination when any changes occur to the beneficiary master data or claims data that would result in a change to the calculation   CWF shall create a new HICR function for the new cLBP AUX file.   411  Home Infusion Therapy Services  (Rev. 10269, Issued: 08- 07-2020, Effective: 01 -01-2021, Implementation: 01- 04-2021)  411.1  Policy  (Rev. 10269, Issued: 08- 07-2020, Effective: 01 -01-2021, Implementation: 01- 04-2021)  Effective beginning on January 1, 2021, the Medicare home infusion therapy benefit covers the professional services, including nursing services, furnished in accordance with the plan of care, patient training and education (not otherwise covered under the durable medical equipment benefit), remote monitoring, and monitoring services for the provision of home infusion therapy and home infusion drugs furnished by a qualified home infusion therapy supplier. Home infusion therapy means the items and services fu rnished by a qualified home infusion therapy supplier, which are furnished in the individuals home. Payment is for an infusion drug administration calendar day, which means the day on which home infusion therapy services are furnished by skilled profess ionals in the individuals home on the day of infusion drug administration. The skilled services provided on such day must be so inherently complex that they can only be safely and effectively performed by, or under the supervision of, professional or technical personnel.  411.2  Coverage Requirements  (Rev. 10269, Issued: 08- 07-2020, Effective: 01 -01-2021 Implementation: 01- 04-2021)
(Medicare Claims Processing Manual)
Payment for an infusion drug administration calendar day is only made if a beneficiary is furnished certain drugs and biologicals administered through an item of covered DME, and payable only to suppliers enrolled in Medicare as a qualified home infusion therapy supplier. The beneficiary must be under the care of an applicable provider, defined as a physician, nurse practitioner, or physicians assistant, and must be under the care of a physician- established plan of care that prescribes the type, amount , and duration of infusion therapy services. A qualified home infusion therapy supplier is a pharmacy, physician, or other provider of services or supplier licensed by the state in which supplies or services are furnished. Qualified home infusion therapy suppliers must furnish infusion therapy to individuals with acute or chronic conditions requiring administration of home infusion drugs; ensure the safe and effective provision and administration of home infusion therapy on a 7 -day-a-week, 24- hour-a-day basis; and be accredited by an organization designated by the Secretary. The supplier may subcontract with a pharmacy, physician, other qualified supplier or provider of services in order to meet these requirements.    411.3 - Home Infusion Drugs: Healthcare Common Procedural Coding System (HCPCS) Drug Codes (Rev. 11430; Issued: 05- 24-22; Effective: 07 -01-22; Implementation: 07 -05-22) The home infusion therapy services payment is intended to cover the professional services needed for  the administration of certain home infusion drugs covered as supplies necessary for the effective use  of external infusion pumps. This payment separately and explicitly pays for the services related to the  administration of the drugs identified on the DME LCD for External Infusion Pumps, when such services are furnished in the individuals home. Section 1861(iii)(3)(C) of the Act defines home  infusion drug as a parenteral drug or biological administered intravenously, or subcutaneously for an administration p eriod of 15 minutes or more, in the home of an individual through a pump that is an item of durable medical equipment (as defined in section 1861(n) of the Act). Such term does not  include insulin pump systems or self -administered drugs or biologicals on a self -administered drug exclusion list.
(Medicare Claims Processing Manual)
Home infusion drugs are assigned to three payment categories, as determined by the HCPCS J -code.  Payment category 1 includes certain intravenous antifungals and antivirals, uninterrupted long- term infusions, pain management, inotropic, chelation drugs. Payment category 2 includes subcutaneous  immunotherapy and other certain subcutaneous infusion drugs. Payment category 3 includes certain chemotherapy drugs. CMS will continue to use the G -codes, established for the temporary  transitional payments in CYs 2019 and 2020, for the professional services furnished on an infusion drug administration calendar day for each payment category. CMS has established a single payment  amount for each of the three categories for professional services furnished for each infusion drug administration calendar day. Each payment category will be paid at amounts in accordance with  infusion codes and units for such codes under the physician fee schedule for each infusion drug administration calendar day in the individuals home for drugs assigned to such category. The  payment amounts are equal to 5 hours of infusion therapy in a physicians office. Further policy information  can be found  in Publication 100- 02, Chapter  15, Section 320.
(Medicare Claims Processing Manual)
Category  1 J-Code  Description  J0133  Injection,  acyclovir,  5 mg J0285  Injection,  amphotericin  b, 50 mg J0287  Injection,  amphotericin  b lipid complex,  10 mg J0288  Injection,  amphotericin  b cholesteryl  sulfate  complex,  10 mg J0289  Injection,  amphotericin  b liposome,  10 mg J0895  Injection,  deferoxamine  mesylate,  500 mg J1170  Injection,  hydromorphone,  up to 4 mg J1250  Injection,  dobutamine  hydrochloride,  per 250 mg J1265  Injection,  dopamine  hcl, 40 mg J1325  Injection,  epoprostenol,  0.5 mg J1455  Injection,  foscarnet  sodium,  per 1000  mg J1457  Injection,  gallium  nitrate,  1 mg J1570  Injection,  ganciclovir  sodium,  500 mg J2175  Injection,  meperidine  hydrochloride,  per 100 mg J2260  Injection,  milrinone  lactate,  5 mg J2270  Injection,  morphine  sulfate,  up to 10 mg  J3010  Injection,  fentanyl citrate,  0.1 mg J3285  Injection,  treprostinil,  1 mg Category  2 J-Code  Description  J1551 JB  Injection, immune globulin (cutaquig), 100mg  J1555  JB Injection,  immune  globulin  (cuvitru),  100 mg J1558  JB Injection,  immune  globulin  (xembify),  100mg  J1559  JB Injection,  immune  globulin  (hizentra),  100mg  J1561  JB Injection,  immune  globulin,  (gamunex -c/gammaked),  non-lyophilized  (e.g. liquid),  500 mg J1562  JB Injection,  immune  globulin  (vivaglobin),  100 mg J1569  JB Injection,  immune  globulin,  (gammagard  liquid), non -lyophilized,  (e.g.,  liquid),  500 mg J1575  JB Injection,  immune  globulin/hyaluronidase,  (hyqvia),  100 mg immune  globulin