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C. Evaluation. Usually, when the cancer consists only of a local lesion with metastasis to the regional lymph nodes which apparently has been completely excised, imminent recurrence or metastasis is not anticipated. Exceptions are noted in sections 13.03, 13.05B, 13.09D, 13.10A, 13.11A-F, 13.17C, 13.22A-B, and 13.24A.
Local or regional recurrence after radical surgery or pathological evidence of incomplete excision by radical surgery are to be equated with unresectable lesions and, for the purpose of our program may be evaluated as "inoperable." These situations are usually followed by severe impairment within 6 months to 1 year. A severe impairment may usually be determined to exist, because the curtailment of activities is imminent.
Local or regional recurrence after incomplete excision of a localized, completely resectable tumor is not to be equated with recurrence after radical surgery.
When a cancer has metastasized beyond the regional lymph nodes the impairment is severe and usually terminates fatally within a short time despite palliative therapy. Exceptions are partially hormone-dependent tumors; isotope-sensitive metastases; or remote metastases which have not been apparent for 5 or more years.
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 nodès; 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
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
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 tubes—all 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
payee shall, subject to review by the
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 accordance with the rules applicable to investment of trust estates by trustees. For example, surplus funds may be deposited in an interest or dividend bearing account in a bank or trust company or in a savings and loan association if the account is either Federally insured or is otherwise insured in accordance with State law requirements. Surplus funds deposited in an interest or dividend bearing account in a bank or trust company or in a savings and loan association must be in a form of account which clearly shows that the representative payee has only a fiduciary, and not a
(Name of representative payee) trustee. U.S. Savings Bonds purchased with surplus funds by representative payees for minor or incapacitated adult beneficiaries should be registered as follows:
(Name of beneficiary) & minor beneficiary for whom
(Name of representative payee) has been designated representative payee by the Secretary of Health, Education, and Welfare, pursuant to 42 U.S.C., section 405(1); or
(Name of beneficiary) an incapacitated adult beneficiary for whom
(Name of representative payee) has been designated representative payeo by the Secretary of Health, Education, and Welfare, pursuant to 42 U.S.C., section 405(1). A representative payee who is the legally appointed guardian or fiduciary of the beneficiary may also register U.S. Savings Bonds purchased with funds from Title II payments in accordance with applicable regulations of the U.S. Treasury Department (31 CFR 315.5 through 315.8). Any other approved investment of the beneficiary's funds made by the representative payee must clearly show that the payee holds the property in trust for the beneficiary. [28 F.R. 7182, July 12, 1963] § 404.1606 Use of benefits for bene.
ficiary in institution. Where a beneficiary is confined in a Federal, State or private institution because of mental or physical incapacity, the relative or other person to whom payments are certified on behalf of the beneficiary shall give highest priority to expenditure of the payments for the current maintenance needs of the beneficiary, including the customary charges made by the institution (see $ 404.1604) in providing care and maintenance. It is considered in the best interests of the beneficiary for the relative or other person to whom payments are certified on
shown, the default of such relative or other person is excused by the Administration, and the required accounting is thereafter submitted. $ 404.1610 Transfer of accumulated
benefit payments. A representative payee who has conserved or invested funds from Title II payments certified to him on behalf of a beneficiary shall, upon direction of the Administration, transfer any such funds (including interest earned from investment of such funds) to a successor payee appointed by the Administration, or, at the option of the Administration, shall transfer such funds, including interest, to the Administration for recertification to a successor payee or to the beneficiary. (28 F.R. 7183, July 12, 1963)
the beneficiary's behalf to allocate expenditure of the payments so certified in a manner which will facilitate the beneficiary's earliest possible rehabilitation or release from the institution or which otherwise will help him live as normal a life as practicable in the institutional environment. § 404.1607 Support of legally depend.
ent spouse, child, or parent. If current maintenance needs of a beneficiary are being reasonably met, & relative or other person to whom payments are certified as representative payee on behalf of the beneficiary may use part of the payments so certified for the support of the legally dependent spouse, a legally dependent child, or a legally dependent parent of the beneficiary. (31 F.R. 3394, Mar. 4, 1966) § 404.1608 Claims of creditors.
A relative or other person to whom payments under Title II of the Act are certified as representative payee on behalf of a beneficiary may not be required to use such payments to discharge an indebtedness of the beneficiary which was incurred before the first month for which payments are certified to a relative or other person on the beneficiary's behalf. In no case, however, may such payee use such payments to discharge such indebtedness of the beneficiary unless the current and reasonably foreseeable future needs of the beneficiary are otherwise provided for. (28 F.R. 7182, July 12, 1963) $ 404.1609 Accountability.
A relative or other person to whom payments are certified as representative payee on behalf of a beneficiary shall submit a written report in such form and at such times as the Administration may require, accounting for the payments certified to him on behalf of the beneficiary unless such payee is a courtappointed fiduciary and, as such, is required to make an annual accounting to the court, in which case a true copy of each such account filed with the court may be submitted in lieu of the accounting form prescribed by the Administration. If any such relative or other person fails to submit the required accounting within a reasonable period of time after it is requested, no further payments shall be certified to him on behall of the beneficiary unless for good cause
PART 405- FEDERAL HEALTH INSURANCE FOR THE AGED (1965 -----
Subpart A-Hospital Insurance Benefits Sec. 405.101 Hospital insurance benefits; general. 405.102 Conditions for entitlement to hos
pital insurance benefits. 405.103 Duration of entitlement to hospital
insurance benefits. 405.110 Inpatient hospital services; scope of
benefits. 405.111 Inpatient hospital services; benefit
limitation during first spell of illness—inpatient of participating tuberculosis or psychiatric
hospital. 405.112 Inpatient hospital services; services
considered for purposes of benefit
limitations. 405.113 Inpatient hospital services; de
ductible. 405.114 Inpatient hospital services; whole
blood cost deductible. 405.115 Inpatient hospital services; coinsur
ance amount. 405.116 Inpatient hospital services; defined. 405.120 Posthospital extended care services;
scope of benefits. 405.122 Posthospital extended care services;
services considered for purposes of
limitation on days of coverage. 405.123 Posthospital extended care services;
whole blood cost deductible. 405.124 Posthospital extended care services;
coinsurance amount. 405.125 Extended care services; deined. 405.130 Posthospital home health services;
general. 405.131 Posthospital home health services;
benefits provided. 405.141 Outpatient hospital dlagnostic serv
ices; conditions. 405.142 Outpatient hospital diagnostic serv
ices; diagnostic study defined. 405.145 Outpatient hospital diagnostic serv
ices; defined. 405.150 Payment for services furnished;
general. 405.151 Payment for services furnished;
determination of amount payable
based on reasonable cost. 405.152 Payment for services furnished;
nonparticipating hospital fur
nishing emergency services. 405.153 Payment for services; hospital out
side the U.S. furnishing emer
gency services. 405.154 Payment for services furnished;
Federal providers. 405.155 Payment for services furnished;
providers obligated to furnish
services at public expense. 405.156 Payment to entitled individual for
services furnished by a nonparticipating hospital; inpatient ad
mission before January 1, 1968. 405.157 Payment to entitled individual for
emergency services furnished
after 1967. 405.158 Payment to entitled individual;
determination of amount payable for services furnished by a non
participating hospital. 405.160 Payment to participating hospital
for inpatient hospital services;
conditions for payment. 405.161 Payment for inpatient hospital
services; furnished after 90- or 150-day limit or after 190-day
limit. 405.162 Prohibition against payment for
inpatient hospital services furnished after utilization review finding that further services are
not medically necessary. 405.163 Prohibition against payment for in
patient hospital services furnished after 20th consecutive day by a hospital which has failed to make
timely utilization review. 405.165 Payment for posthospital extended
care services; conditions. 405.166 Prohibition against payment for
posthospital extended care services furnished after a utilization review finding that services are
not medically necessary. 405.167 Prohibition against payment for
services furnished by a facility which fails to make timely utili
zation review. 405.170 Payment for posthospital home
health services; conditions. 405.175 Payment to participating hospital
for outpatient hospital diagnostic
services; conditions. 405.180 No payment for services furnished
to an alien before the first full calendar month in the United
States. 405.181 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 Stato
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.