Page images

C. Evaluation. Usually, when the cancer nsists only of a local lesion with metastasis the regional lymph nodes which apparently us been completely excised, imminent recurnce or metastasis is not anticipated. Excep

are noted in sections 13.03, 13.05B, 1.09D, 13.10A, 13.11A-F, 13.17C, 13.22A-B, id 13.24A. Local or regional recurrence after radical irgery or pathological evidence of incomete excision by radical surgery are to be fuated with unresectable lesions and, for le purpose of our program may be evaluated ; "inoperable." These situations are usually llowed by severe impairment within 6 Lonths to 1 year. A severe impairment may sually be determined to exist, because the urtallment of activities is imminent.

Local or regional recurrence after incomlete excision of a localized, completely reectable tumor is not to be equated with ecurrence after radical surgery.

When a cancer has metastasized beyond he regional lymph nodes the impairment is evere and usually terminates fatally vithin a short time despite palliative therapy. exceptions are partially hormone-dependent umors; isotope-sensitive metastases; or renote metastases which have not been pparent for 5 or more years. 13.01 CATEGORY OF IMPAIRMENTS, NEOPLASTIC

DISEASES-MALIGNANT 13.02 Epidermoid carcinoma (including lympho-epithelioma of base of tongue, pharynx and tonsil). A. Inoperable or recurrent after radical surgery; or

B. Remote metastasis.

13.03 Sarcoma of skin-Angiosarcoma or mycosis fungoides with metastasis to regional lymph nodes or beyond.

13.04 Sarcoma of soft parts. A. Not controlled by prescribed therapy; or

B. Cellular sarcoma with remote metastasis.

13.05 Malignant melanoma. A. Recurrent after excision; or

B. With metastasis to adjacent skin or regional lymph nodes or elsewhere.

13.06 Lymph nodes. A. Hodgkins disease, lymphosarcoma or giant follicular lymphoblastoma—not controlled by prescribed therapy or with evidence of mediastinal, pelvic, abdominal, retroperitoneal or skeletal extension from peripheral lymph nodes; or

B. Metastasis from distant carcinoma; or

C. Lymph nodes site of unresectable carcinoma.

13.07 Salivary glands-carcinoma or sarcoma with metastasis beyond the regional lymph nodes.

13.08 Thyroid gland-carcinoma with metastasis beyond the regional lymph nodes not controlled by prescribed therapy.

13.09 Breast. A. Inoperable carcinoma including acute (inflammatory) carcinoma;

chronous or metachronous, is usually primary in each breast.); or

D. Sarcoma with metastasis anywhere.

13.10 Skeletal system (exclusive of the jaw). A. Osteogenic sarcoma, Ewing's tumor, reticulum cell sarcoma with evidence of metastasis; or

B. Multiple or diffuse myeloma; or

C. Metastatic carcinoma to bone (except those originating in thyroid or prostate, evaluate under the criteria in § 13.08 or $ 13.23).

13.11 Mandible, maxilla, orbit, or temporal fossa. A. Sarcoma of any type with metastasis; or

B. Carcinoma of the antrum with extension into the orbit, or ethmoid or sphenoid sinus, or with regional or remote metastasis; or

C. Orbital tumors with intracranial extension; or

D. Tumors of the temporal fossa with perforation of skull and meningeal involvement; or

E. Adamantinoma with orbital or intracranial infiltration; or

F. Tumors of Rathke's pouch with infiltration of the base of the skull or bilateral metastasis to the cervical lymph nodes or remote metastasis.

13.12 Brain or spinal cord. A. Metastatic carcinoma to brain or spinal cord.

B. Evaluate other tumors under the cri. teria described in § 11.05 and § 11.08.

13.13 Lungs-bronchogenic carcinoma or adenocarcinoma. A. Unresectable; or

B. Recurrent after resection; or
C. Incomplete excision; or

D. Infiltration of the chest wall or preoperative pleural effusion or remote metastasis; or

E. Metastatic carcinoma or sarcoma to the lungs (except metastasis from thyroid, evaluate under the criteria in § 13.08).

13.14 Pleura or mediastinum. A Pleural mesothelioma, with pleural effusion or remote metastasis; or

B. All primary or metastatic tumors of the anterior mediastinum (except thyroid or parathyroid tumors and benign thymoma and primary Hodgkins disease); or

C. Metastatic carcinoma or sarcoma to the pleura or mediastinum (except metastasis from thyroid, evaluate under the criteria in $ 13.08).

13.15 Abdomen. A. Generalized carcinomatosis; or

B. Retroperitoneal cellular sarcoma; or

C. Unresectable benign fibromyxoma of nerve sheath.

13.16 Esophagus or stomach, A. Carcinoma or sarcoma of the upper two-thirds of the esophagus; or

B. Carcinoma or sarcoma, of the distal onethird of the esophagus with metastasis beyond the regional lymph nodes; or

c. Carcinoma of the stomach with either metastasis beyond the regional lymph nodes


B. Recurrent carcinoma; or

C. Remote metastasis from breast carcinoma (Bilateral breast carcinoma, syn

[ocr errors]

or extension into the colon, pancreas or llver; Subpart Q-Representative Payee or

SOURCE: The provisions of this Subpart Q D. Inoperable carcinoma; or

appear at 26 F.R. 11827, Dec. 9, 1961; 26 PR E. Recurrence or metastasis after resec

11938, Dec. 14, 1961, unless otherwise noted. tion; or F. Multiple sarcomas.

§ 404.1601 Payments on behalf of an 13.17 Small intestine. A. Carcinoma or

individual. carcinoid tumor with metastasis beyond the

When it appears to the Administraregional lymph nodes; or

tion that the interest of a beneficiary B. Multiple sarcomas; or

entitled to a payment under Title II C. Sarcoma with metastasis. 13.18 Large intestine (from ileocecal valve

of the Act would be served thereby, cer. to and including anal canal)-carcinoma or

tification of payment may be made by the sarcoma. A. Unresectable; or

Administration, regardless of the legal B. Metastasis beyond the regional lymph competency or incompetency of the nodes; or

beneficiary entitled thereto, either for C. Recurrence, or remote metastasis, after direct payment to such beneficiary, or resection.

for his use and benefit to a relative or 13.19 Liver or Gallbladder. A. Primary or

some other person as the “representametastatic carcinoma, carcinoid tumor or

tive payee" of the beneficiary. If apsarcoma of the liver; or

pointment of a legal guardian, commitB. Carcinoma of the gallbladder or bile duct when unresectable or there is direct

tee or other legal representative for å extension into the liver.

beneficiary, may otherwise be proper, 13.20 Pancreas. Carcinoma in any loca the Administration may, at any time. tion.

withhold certification of payment to & 13.21 Kidneys, adrenal glands, or ure beneficiary or to a relative or other perters--carcinoma. A. Unresectable or with son on behalf of a beneficiary until & metastasis; or

guardian, committee, or other legal rep. B. Metastatic carcinoma to a kidney,

resentative who is duly authorized to adrenal gland, or ureter.

receive payments on behalf of such 13.22 Urinary bladder-carcinoma. With: A. Infiltration beyond the bladder wall;

beneficiary, has been appointed.

& 404.1602 Submission of evidence by B. Metastasis; or

representative payee. C. Unresectable; or

Before any amount shall be certified D. Recurrence after total cystectomy; or

for payment to any relative or other E. Evaluate urinary diversion after total

person as representative payee for and cystectomy under the criteria in $ 6.04. 13.23 Prostate gland. Carcinoma not con

on behalf of a beneficiary, such relative trolled by prescribed therapy.

or other person shall submit to the Ad13.24 Testicles. A. Choriocarcinoma with ministration such evidence as it may metastasis even to regional lymph nodes; or require of his relationship to, or his re

B. Other malignant tumors with metasta sponsibility for the care of, the benesis beyond the para-aortic lymph nodes or

ficiary on whose behalf payment is to when metastasis to the para-aortic lymph

be made, or of his authority to receive nodes are unresectable or not controlled by prescribed therapy.

such payment. The Administration 13.25 Uterus-carcinoma or sarcoma

may, at any time thereafter, require (fundus or cervix). A. Inoperable and not

evidence of the continued existence of controlled by prescribed therapy; or

such relationship, responsibility or auB. Recurrent, after total hysterectomy; or

thority. If any such relative or other C. Total pelvic exenteration.

person fails to submit the required evi13.26 Ovary or fallopian tubesall malig.

dence within a reasonable period of time nant primary or recurrent tumors. With: after it is requested, no further payA. Ascites; or

ments shall be certified to him on be. B. Unresectable infiltration; or

half of the beneficiary unless for good C. Unresectable metastasis to omentum or cause shown, the default of such relative elsewhere in the peritoneal cavity; or

or other person is excused by the AdD. Remote metastasis; or

ministration, and the required evidence E. All metastatic tumors to ovary or Fal

is thereafter submitted. lopian tubes. 13.27 Leukemia. Evaluate under the cri

8 404.1603 Responsibility of representateria in $ 7.00ff, Hemic and Lymphatic

tive payee. System.

A relative or other person to whom [33 F.R. 11749, Aug. 20, 1968; 33 F.R. 12546, certification of payment is made on be. Sept. 5, 1968]

half of a beneficiary as representative

[blocks in formation]

ayee shall, subject to review by the dministration and to such requireients as it may from time to time rescribe, apply the payments certified ) him on behalf of a beneficiary only or the use and benefit of such beneciary in the manner and for the puroses determined by him to be in the eneficiary's best interest. 404.1604 Use of benefits for current

maintenance. Payments certified to a relative or ither person on behalf of a beneficiary hall be considered as having been applied for the use and benefit of the beneficiary when they are used for the seneficiary's current maintenance-i.e., o replace current income lost because of the disability, retirement, or death of the insured individual. Where a beneficiary is receiving care in an intitution (see $ 404.1606), current maintenance shall include the customary charges made by the institution to individuals it provides with care and services like those it provides the beneficiary and charges made for current and foreseeable needs of the beneficiary which are not met by the institution. § 404.1605 Conservation and invest

ment of payments. Payments certified to a relative or other person on behalf of a beneficiary which are not needed for the current maintenance of the beneficiary except as they may be used pursuant to $ 404.1607, shall be conserved or invested on the beneficiary's behalf. Preferred investments are U.S. Savings Bonds, but such funds may also be invested in arcordance with the rules applicable to investment of trust estates by trustees. For example, surplus funds may be is posited in an interest or dividend beazite account in a bank or trust company a savings and loan association if the 2count is either Federally insuret r I otherwise insured in accordance C State law requirements. Surprime fams deposited in an interest or TIC bearing account in a bank or pany or in a savings and log 2 tion must be in a form of clearly shows that the rest payee has only a fiduciary, ar

[merged small][graphic][merged small][merged small][merged small][merged small][merged small][merged small]

the beneficiary's behalf to allocate ex. shown, the default of such relative a penditure of the payments so certified other person is excused by the times in a manner which will facilitate the tration, and the required accounting beneficiary's earliest possible rehabilita thereafter submitted. tion or release from the institution or

8 404.1610 Transfer of accumulated which otherwise will help him live as

benefit payments. normal a life as practicable in the institutional environment.

A representative payee bo has con

served or invested funds from tle il & 404.1607 Support of legally depend.

payments certified to him on behalf ent spouse, child, or parent.

a beneficiary shall, upon direction of the I current maintenance needs of a Administration, transfer any such funes beneficiary are being reasonably met, & (including interest earned from intesrelative or other person to whom pay- ment of such funds) to a successor page: ments are certified as representative appointed by the Administration, oz, payee on behalf of the beneficiary may the option of the Administration, sha" use part of the payments so certified for transfer such funds, including interest the support of the legally dependent to the Administration for recertification spouse, a legally dependent child, or a to a successor payee or to the beneficiars legally dependent parent of the bene [28 FR. 7183, July 12, 1963) ficiary. (31 FR. 3394, Mar. 4, 1966)

PART 405—FEDERAL HEALTH INSUR& 404.1608 Claims of creditors.

ANCE FOR THE AGED (1965 ---A relative or other person to whom

Subpart A-Hospital Insurance Benefits payments under Title II of the Act are Sec. certified as representative payee on be 405.101 Hospital insurance benefits, genera half of a beneficiary may not be required

405.102 Conditions for entitlement to bos to use such payments to discharge an

pital insurance benefits.

405.103 Duration of entitlement to hospita indebtedness of the beneficiary which

insurance benefits. was incurred before the first month for

405.110 Inpatient hospital services; scope of which payments are certified to a relative

benefits. or other person on the beneficiary's be- 405.111 Inpatient hospital services; bene half. In no case, however, may such

limitation during first spell of payee use such payments to discharge

illness—inpatient of participatsuch indebtedness of the beneficiary un

ing tuberculosis or psychiatric less the current and reasonably foresee


405.112 Inpatient hospital services; services able future needs of the beneficiary are

considered for purposes of benefit otherwise provided for.

limitations. [28 F.R. 7182, July 12, 1963)

405.113 Inpatient hospital services; de.

ductible. & 404.1609 Accountability.

405.114 Inpatient hospital services; whole

blood cost deductible. A relative or other person to whom

405.115 Inpatient hospital services; coinsurpayments are certified as representative

ance amount. payee on behalf of a beneficiary shall

405.116 Inpatient hospital services; defined. submit a written report in such form

405.120 Posthospital extended care services; and at such times as the Administration

scope of benefits. may require, accounting for the pay 405.122 Postbospital extended care services; ments certified to him on behalf of the

services considered for purposes of beneficiary unless such payee is a court

limitation on days of coverage. appointed fiduciary and, as such, is re

405.123 Posthospital extended care services; quired to make an annual accounting

whole blood cost deductible. to the court, in which case a true copy

405.124 Posthospital extended care services; of each such account filed with the court

coinsurance amount.

405.125 Extended care services; defined. may be submitted in lieu of the account

405.130 Posthospital home health services; ing form prescribed by the Administra

general. tion. If any such relative or other per

405.131 Posthospital home health services; son fails to submit the required account

benefits provided. ing within a reasonable period of time 405.141 Outpatient hospital diagnostic serv. after it is requested, no further pay

ices; conditions. ments shall be certified to him on behall 405.142 Outpatient hospital diagnostic serp. of the beneficiary unless for good cause

ices; deductibles.

5.144 Outpatient hospital diagnostic serv

ices; diagnostic study defined. 5.145 Outpatient hospital diagnostic serv

ices; defined. 5.150 Payment for services furnished;

general. 5.151 Payment for services furnished;

determination of amount payable

based on reasonable cost. 5.152 Payment for services furnished;

nonparticipating hospital fur

nishing emergency services. 5.153 Payment for services; hospital out

side the U.S. furnishing emer

gency services. 5.154 Payment for services furnished;

Federal providers. 5.155 Payment for services furnished;

providers obligated to furnish

services at public expense. 5.156 Payment to entitled individual for

services furnished by a nonparticipating hospital; inpatient ad

mission before January 1, 1968. 5.157 Payment to entitled individual for

emergency services furnished

after 1967. -5.158 Payment to entitled individual;

determination of amount payable for services furnished by a non

participating hospital. 5.160 Payment to participating hospital

for inpatient hospital services;

conditions for payment. 5.161 Payment for inpatient hospital

services; furnished after 90- or 150-day limit or after 190-day

limit. )5.162 Prohibition against payment for

inpatient hospital services furnished after utilization review finding that further services are

not medically necessary. 25.163 Prohibition against payment for in

patient hospital services furnished after 20th consecutive day by a hospital which has failed to make

timely utilization review. 05.165 Payment for posthospital extended

care services; conditions. 05.166 Prohibition against payment for

posthospital extended care services furnished after & utilization review finding that services are

not medically necessary. 05.167 Prohibition against payment for

services furnished by a facility which fails to make timely utili

zation review. 05.170 Payment for posthospital home

health services; conditions. 05.175 Payment to participating hospital

for outpatient hospital diagnostic

services; conditions. 05.180 No payment for services furnished

to an allen before the first full calendar month in the United

States. 05.181 Individual convicted of subversive

activities; effect on entitlement.

Sec. 405.191 Emergency services; finding that

an emergency existed and/or

has ceased. 405.192 Emergency services; finding of ac

cessibility. Subpart B Supplementary Medical Insurance

Benefits 405.201 Supplementary medical insurance

benefits; general. 405.202 Enrollment; general. 405.205 Supplementary medical insurance

benefits; conditions for enroll

ment. 405.206 Supplementary medical insurance

benefits; persons ineligible to

enroll. 405.210 Enrollment procedures. 405.211 Enrollment periods; general. 405.212 Initial enrollment period. 405.213 General enrollment periods. 405.214 Limitation on enrollment and re

enrollment. 405.217 Enrollment by a State of individuals

receiving money payments under

public assistance program. 405.220 Coverage period; general. 405.221 Coverage period; beginning date. 405.222 Coverage period beginning date; in.

dividuals enrolled under State

agreements. 405.223 Coverage period; manner and time

of termination. 405.224

Good cause for failure to enroll dur.

ing the initial enrollment period

ending May 31, 1966. 405.230 Supplementary medical Insurance

benefits. 405.231 Medical and other health services;

included items and services. 405.232 Medical and other health services;

exclusions. 405.233 Home Health services; general. 405.234 Home Health services; conditions. 405.235 Home Health services; place where

items and services must be fur

nished. 405.236 Home health services; items and

services included. 405.237 Home Health services; items and

services not included. 405.238 Home Health services; “visits"

defined. 405.240 Payment of supplementary medical

insurance benefits; amounts pay

able. 406.241 Payment of supplementary medical

Insurance benefits; election by group-practice prepayment plan as to method of determining

amount of payment. 405.243 Psychiatric services limitation; ex

penses incurred for physician

services. 405.244 Total amount of expenses; expenses

excluded. 405.245 The supplementary medical insur

ance benefits deductible.

« PreviousContinue »