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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.

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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
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

or

B. Recurrent carcinoma; or

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

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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

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payee shall, subject to review by the
Administration and to such require-
ments as it may from time to time
prescribe, apply the payments certified
to him on behalf of a beneficiary only
for the use and benefit of such bene-
ficiary in the manner and for the pur-
poses determined by him to be in the
beneficiary's best interest.
§ 404.1604 Use of benefits for current

maintenance.
Payments certified to a relative or
other person on behalf of a beneficiary
shall be considered as having been ap-
plied for the use and benefit of the
beneficiary when they are used for the
beneficiary's current maintenance-i.e.,
to replace current income lost because
of the disability, retirement, or death
of the insured individual. Where a
beneficiary is receiving care in an in-
stitution (see $ 404.1606), current main-
tenance shall include the customary
charges made by the institution to in-
dividuals it provides with care and serv-
ices like those it provides the beneficiary
and charges made for current and fore-
seeable 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 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

603

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; deductibles.

Sec.
405.144 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.

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