evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
If you have questions about this notice, you may call 1- 800-MEDICARE (1 -800-633-4227) for additional information.  If you believe the determination is not correct, you may request a redetermination.  You must file your request within 120 days of the date you receive this notice.  A request for a redetermination must be filed either on Form CMS -20027 or on a written request that includes all of the elements listed below.    Beneficiary name   Medicare beneficiary identifier   Specific service and/or item(s) for which a redetermination is being requested  Specific date(s) of service   Signature of the beneficiary or the beneficiarys authorized or appointed representative.   You may send the request to our address listed above. Please keep a copy of any written correspondence for your files.   Sincerely,   360.3.6 - Denial - Military Personnel/Eligible Dependents  (Rev. 4203, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medica re Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   MODEL DENIAL NOTICE A (MAC'S NAME AND ADDRESS)  Date: ______________   Beneficiary: ____________________  Claim Number ________________  DETERMINATION ON EMERGENCY HOSPITAL SERVICES   We are sorry, but payment cannot be made for your stay from________ through________ at (hospital).  Under the law, medical services that have been furnished by a federal hospital to retired members of the armed services, or their eligible dependents, are not covered under the Medicare program.
(Medicare Claims Processing Manual)
If you have questions about this notice, you may call 1- 800-MEDICARE (1 -800-633-4227) for additional information.  If you believe the determination is not correct, you may request a redetermination.  You must file your request within 120 days from the date  you receive this notice. A request for a redetermination must be filed either on Form CMS -20027 or on a written request that includes all of the elements listed below.    Beneficiary name   Medicare beneficiary identifier   Specific service and/or item(s) for which a redetermination is being requested  Specific date(s) of service   Signature of the beneficiary or the beneficiarys authorized or appointed representative.   You may send the request to our address listed above. Please keep a copy of any written correspondence for your files.   Sincerely,   360.3.7 - Full Denial - Shipboard Claim - Beneficiary Filed  (Rev. 4203, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   MODEL DENIAL NOTICE  (MACS NAME AND ADDRESS)   Date: ____________________  Beneficiary: _________________________  Claim Number: __________________  DETERMINATION ON SHIPBOARD SERVICES   We are sorry, but medical services provided on the (vessel/ship's name) cruise ship are not covered.  The Medicare program can make payment for medically necessary shipboard services only if all of the following requirements are met:
(Medicare Claims Processing Manual)
We are sorry, but medical services provided on the (vessel/ship's name) cruise ship are not covered.  The Medicare program can make payment for medically necessary shipboard services only if all of the following requirements are met:   1. The services are furnished while the ship is within the territorial waters of the United States (in a U.S. port, or within 6 hours of departure or arrival at a U.S. port). 2. The services are furnished to an individual who is entitled to Part B benefits;  3. The services are furnished in connection with covered inpatient hospital services;  4. The services furnished on the ship are for the same condition that required inpatient admission;  5. The physician is legally authorized to practice in the country where he or she furnishes the services.   If you have a supplemental insurance policy, you should check with the company carrying that policy to see if they cover these services and what procedures you should follow in submitting your claim.  If you have questions about this notice, you may call 1- 800-MEDICARE (1 -800-633-4227) for additional information.  If you believe the determination is not correct, you may request a redetermination.  You must file your request within 120 days from the date  you receive this notice.  A request for a redetermination must be filed either on Form CMS -20027 or on a written request that includes all of the elements listed below.    Beneficiary name   Medicare beneficiary identifier   Specific service and/or item(s) for which a redetermination is being requested  Specific date(s) of service   Signature of the beneficiary or the beneficiarys authorized or appointed representative.   You may send the request to our address listed above. Please keep a copy of any written correspondence for your files.  Sincerely,   360.3.8 - Full Denial - Foreign Claim - Beneficiary Filed  (Rev. 4203, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)
(Medicare Claims Processing Manual)
360.3.8 - Full Denial - Foreign Claim - Beneficiary Filed  (Rev. 4203, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medic are card transition period and after for certain business areas that will continue to use the HICN as part of their processes.                                     MODEL DENIAL  NOTICE (MACS NAME AND ADDRESS)   Date:    Beneficiary:     Claim Number:      DETERMINATION ON FOREIGN HOSPITAL SERVICES   We are sorry, but payment cannot be made for your stay  from  through  at (hospital) in (country).  Medicare law prohibits payment for items and services furnished outside the United States except in certain limited circumstances .  The term outside the U.S. means anywhere other than the 50 states of the U.S., the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.  There are three situations when Medicare may pay for certain types of health care services rendered in a foreign hospital (a hospital outside the U.S.):   1. Youre in the U.S. when you have a medical emergency and the foreign hospital is closer than the nearest U.S. hospital that can treat your illness or injury.  2. Youre traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S. hospital that can treat your illness or injury. Medicare determines what qualifies as without unreasonable delay on a case -by-case basis.  3. You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether its an emergency.   In these situations, Medicare will pay only for the Medicare-covered services you get in a foreign hospital.
(Medicare Claims Processing Manual)
In these situations, Medicare will pay only for the Medicare-covered services you get in a foreign hospital.  If you have a supplemental insurance policy, you should check with the company carrying that policy to see if they cover these services and what procedures you should follow in submitting your claim.  If you have questions about this notice, you may call 1-800- MEDICARE (1 -800-633-4227) for additional information. If you believe the determination is not correct, you may request a redetermination. You must file your request within 120 days from the date you receive this notice. A request for a redetermination must be filed either on Form CMS -20027 or on a written request that includes all of the elements listed below.   Beneficiary  name   Medicare beneficiary identifier   Specific service and/or item(s) for which a redetermination is being requested   Specific date(s) of  service  Signature of the beneficiary or the beneficiarys authorized or appointed representative.   You may send the request to our address listed above. Please keep a copy of any written correspondence for your files.  Sincerely,  370  Microvolt T -wave Alternans (MTWA)  (Rev. 3265, Issued: 05- 22-15, Effective: 01 -13-15, Implementation: 06-23-15)  On March 21, 2006, the Centers for Medicare & Medicaid Services (CMS) began national coverage of microvolt T -wave Alternans (MTWA) diagnostic testing when it was performed using only the spectral analysis (SA) method for the evaluation of patients at risk for sudden cardiac death (SCD) from ventricular arrhythmias and patients who may be candidates for Medicare coverage of the placeme nt of an implantable cardiac defibrillator (ICD).   Effective for claims with dates of service on and after January 13, 2015, Medicare Administrative Contractors (MACs) may determine coverage of MTWA diagnostic testing when it is performed using methods of analysis other than SA for the evaluation of patients at risk for SCD from ventricular arrhythmias.  Further information can be found at Publication 100-03, section 20.30, of the National Coverage Determinations Manual.
(Medicare Claims Processing Manual)
370.1 - Coding and Claims Processing for MTWA  (Rev. 12396; Issued: 12- 07-23; Effective: 01 -09-24; Implementation: 01 -09-24)  Effective for claims with dates of service on and after March 21, 2006, MACs shall accept CPT 93025 (MTWA for assessment of ventricular arrhythmias) for MTWA diagnostic testing for the evaluation of patients at risk for SCD with the SA method of analysis only. All other methods of analysis for MTWA are non -covered.   Effective for claims with dates of service on and after January 13, 2015, MACs shall at their discretion determine coverage for CPT 93025 for MTWA diagnostic testing for the evaluation of patients at risk for SCD with methods of analysis other than SA. The  KX modifier shall be used as an attestation by the practitioner and/or provider of the service that documentation is on file verifying the MTWA was performed using a method of analysis other than SA for the evaluation of patients at risk for SCD from ven tricular arrhythmias and that all other NCD criteria was met.   NOTE: The KX modifier is NOT required on MTWA claims for the evaluation of patients at risk for SCD if the SA analysis method is used.  NOTE: This diagnosis code list/translation was approved by CMS/Coverage. It may or may not be a complete list of covered indications/diagnosis codes that are covered but should serve as a finite starting point.  As this policy indicates, individual A/B MACs within their respective jurisdictions have the discretion to make coverage determinations they deem reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act. Therefore, A/B MACs may have additional covered diagnosis codes in their individual policies where contractor discretion is appropriate.      ICD -10-Codes:
(Medicare Claims Processing Manual)
ICD -10-Codes:       ICD-10 CM  ICD-10 DX Description  I21.01  ST elevation (STEMI) myocardial infarction involving left main coronary artery  I21.02  ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery  I21.09  ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall  I21.11  ST elevation (STEMI) myocardial infarction involving right coronary artery  I21.19  ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall  I21.21  ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery  I21.29  ST elevation (STEMI) myocardial infarction involving other sites  I21.3  ST elevation (STEMI) myocardial infarction of unspecified site  I21.4  Non-ST elevation (NSTEMI) myocardial infarction  I21.A1  Myocardial infarction type 2  I21.B  Myocardial infarction with coronary microvascular dysfunction  I22.0  Subsequent ST elevation (STEMI) myocardial infarction of anterior wall  I22.1  Subsequent ST elevation (STEMI) myocardial infarction of inferior wall  I22.2  Subsequent non -ST elevation (NSTEMI) myocardial infarction  I22.8  Subsequent ST elevation (STEMI) myocardial infarction of other sites  I22.9  Subsequent ST elevation (STEMI) myocardial infarction of unspecified site  I24.81  Acute coronary microvascular dysfunction  I24.89  Other forms of acute ischemic heart disease  I24.9  Acute ischemic heart disease, unspecified  I47.0  Re-entry ventricular arrhythmia  I47.2  Ventricular tachycardia  I49.01  Ventricular fibrillation  I49.02  Ventricular flutter  R55 Syncope and collapse     370.2 - Messaging for MTWA (Rev. 3265, Issued: 05- 22-15, Effective: 01 -13-15, Implementation: 06- 23-15)
(Medicare Claims Processing Manual)
370.2 - Messaging for MTWA (Rev. 3265, Issued: 05- 22-15, Effective: 01 -13-15, Implementation: 06- 23-15)  Effective for claims with dates of service on and after January 13, 2015, MACs shall deny claims for MTWA CPT 93025 with methods of analysis other than SA without modifier - KX using the following messages:   CARC 4:  The procedure code is inconsistent with the modifier used or a required modifier is missing. 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 (Contractual Obligation) assigning financial liability to the provider   MSN 15.20 -  The following policies  [NCD 20.30] were used when we made this decision   Spanish Equivalent -  15.20 -  Las siguientes polticas [NCD 20.30] fueron utilizadas cuando se tom esta decisin.     380 - Leadless Pacemakers  (Rev.  3815, Issued: 07- 28-17, Effective: 01 -18-18, Implementation: 08- 29-17 - for MAC local edits; January 2, 2018 -  for MCS shared edits )  Effective for dates of service on or after January 18, 2017, contractors shall cover leadless pacemakers through Coverage with Evidence Development (CED) when procedures are performed in CMS -approved CED studies.  Please refer to the National Coverage Dete rminations Manual (Publication 100- 03, Section 20.8.4) for more information.  380.1  - Leadless Pacemaker Coding and Billing Requirements for Professional Claims  (Rev. 3815, Issued: 07- 28-17, Effective: 01 -18-18, Implementation: 08- 29-17 - for MAC local edits; January 2, 2018 -  for MCS shared edits)   Effective for dates of service on or after January 18, 2017, contractors shall allow the following procedure codes on claims for leadless pacemakers:    0387T    Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular
(Medicare Claims Processing Manual)
Effective for dates of service on or after January 18, 2017, contractors shall allow the following procedure codes on claims for leadless pacemakers:    0387T    Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular          0389T     Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system.   0390T     Peri -procedural device evaluation (in person) and programming of device system parameters before or after surgery, procedure or test with analysis, review and report, leadless pacemaker system.   0391T     Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system.   Effective for dates of service on or after January 18, 2017, contractors shall allow the following ICD -10 diagnosis codes on claims for leadless pacemakers:   Z00.6  Encounter for examination for normal comparison and control in clinical research program.   380.1.1 - Leadless Pacemaker Place of Service Restrictions  (Rev. 3815, Issued: 07- 28-17, Effective: 01 -18-18, Implementation: 08- 29-17 - for MAC local edits; January 2, 2018 -  for MCS shared edits)   Effective for dates of service on or after January 18, 2017, contractors shall only pay claims for leadless pacemakers when services are provided in one of the following places of service (POS):   POS 06  Indian Health Service Provider Based Facility   POS 21  Inpatient Hospital  POS 22 -  On Campus -Outpatient Hospital  POS 26  Military Treatment Facility   380.1.2 - Leadless Pacemaker Modifier  (Rev. 3815, Issued: 07- 28-17, Effective: 01 -18-18, Implementation: 08- 29-17 - for MAC local edits; January 2, 2018 -  for MCS shared edits)
(Medicare Claims Processing Manual)
Effective for claims with dates of service on or after January 18, 2017, modifier Q0   Investigational clinical service provided in a clinical research study that is an approved clinical research study, must also be included.  380.1.3 - Leadless Pacemaker Additional Claim Billing Information  (Rev. 3815, Issued: 07- 28-17, Effective: 01 -18-18, Implementation: 08- 29-17 - for MAC local edits; January 2, 2018 -  for MCS shared edits)   The professional claim must also contain the 8 -digit clinical trial identifier in item 23 of the CMS -1500 form or the electronic equivalent.    380.2 - Leadless Pacemaker Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Medicare Summary Notice (MSN) Messages Applicable for Professional Claims Only  (Rev. 3815, Issued: 07- 28-17, Effective: 01 -18-18, Implementation: 08- 29-17 - for MAC local edits; January 2, 2018 -  for MCS shared edits)   Effective for claims with dates of service on or after January 18, 2017, contractors shall deny professional claim lines for leadless pacemakers that do not contain an appropriate POS code and use the following messages:   CARC 58: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. 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 at  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.   MSN 21.25: This service was denied because Medicare only covers this service in certain settings.   Spanish Version: El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones."   Group Code Contractual Obligation (CO).
(Medicare Claims Processing Manual)
Spanish Version: El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones."   Group Code Contractual Obligation (CO).   - Effective for dates of service on or after January 18, 2017, contractors shall return claims with the procedure codes listed in 380.2 billed without modifier Q0  and use the following messages:   CARC 4: The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.         RARC N572:  This procedure not payable unless appropriate non- payable reporting.   Group Code  Contractual Obligation (CO).    - Effective for dates of service on or after January 18, 2017, contractors shall return claims as unprocessable with the procedure codes listed in 10117- 04.2 billed without ICD -10 Z00.6 and use the following messages:     CARC 16 -  Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the N CPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC M76 -  Missing/incomplete/invalid diagnosis or condition.  - Effective for claims with dates of service on or after January 18, 2017, contractors shall return claims as unprocessable  that are billed with the Q0 modifier and do not contain the 8- digit clinical trial identifier in item 23 of the CMS -1500 form or the electronic equivalent.  Use the following messages:    CARC 16: Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)   RARC MA50: Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.   Group Code  Contractual Obligation (CO).
(Medicare Claims Processing Manual)
RARC MA50: Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.   Group Code  Contractual Obligation (CO).   390 - Supervised exercise therapy (SET) Symptomatic Peripheral Artery Disease  (Rev. 4049, Issued: 05-  11-18, Effective: 05 -25-17, Implementation: 07- 02-18)  Effective for claims with dates of service on or after May 25, 2017, the Centers for Medicare and Medicaid Services (CMS) will cover supervised exercise therapy (SET) for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease ( PAD).  Up to 36 sessions over a 12 week period are covered if all of the following components of a SET program are met:     The SET program must:   consist of sessions lasting 30- 60 minutes comprising a therapeutic exercise -training program for PAD in patients with claudication;  be conducted in a physicians office;   be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and    be under the direct supervision of a physician (as defined in 1861(r)(1)) of the Social Security Act (the Act)), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in 1861(aa)(5)) of (the Act) who must be trained in both ba sic and advanced life support techniques.   Beneficiaries must have a face- to-face visit with the physician responsible for PAD treatment to obtain the referral for SET.   At this visit, the beneficiary must receive information regarding cardiovascular disease and PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome assessments.  SET is non -covered for beneficiaries with absolute contraindications to exercise as determined by their primary attending physician. .       Please refer to the National Coverage Determinations Manual (Publication 100 -03, Section 20.35) for more information.   390.1  General Billing Requirements