Forepilepsy, the AspireSR, and SenTivaVNStherapy systems are the two most recently developed VNS devices1). vagus nerve) neurostimulator electrode array and pulse generator. In addition, to further enhance the protection of human subjects in studies conducted under CED, the study must provide and obtain meaningful informed consent from patients regarding the risks associated with the study items and/or services, and the use and eventual disposition of the collected data. Conventional VNS Therapy devices include Normal Mode and Magnet Mode. 0000015859 00000 n (TN 1708) (CR9751), 11/2016 - This change request (CR) is the 9th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs). All other information remains the same. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent quarterly releases and individual CRs as appropriate. PubMed PMID: 30071175. This documentation includes, but is not limited to, appropriate use criteria, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. What are the population distributions of the maximum months of remission, both consecutive and overall, separately? All other information remains the same. VNS is non-covered for treatment-resistant depression (TRD) when furnished outside of a CMS-approved Coverage with Evidence Development (CED) study. The research study is in compliance with all applicable Federal regulations concerning the protection of human subjects found in the Code of Federal Regulations (CFR) at 45 CFR Part 46. Epub 2015 Feb 13. 982 0 obj <> endobj endstream endobj startxref This feature was obtained from 15 patients who underwent implantation of the closed-loop AspireSR VNS Therapy System8). CPT Copyright 2022 American Medical Association. Accepted addition of codes 645X1, 645X2, 645X3 to identify hypoglossal versus vagal nerve stimulator services; Revision of codes 64568, 64575, 64580, 64581 to separately identify hypoglossal nerve stimulator service from vagus nerve stimulator services; and Deletion of Category III codes 0466T, 0467T, 0468T. If this is your first visit, be sure to check out the FAQ & read the forum rules. Acta Neurochir (Wien). <> More from December 2020/January 2021 Vol. SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures) Medical Policy Description/Scope This document addresses the implantation of, and procedures related to, occipital, supraorbital and trigeminal nerve stimulation devices. 2018 May;58:120-126. doi: 10.1016/j.seizure.2018.03.022. Additionally, the new code eliminates the issues with 31575 by including sedation, with 31622 by accounting for maneuvers that may alleviate proximal airway obstruction, and with 92502 as an endoscopic service that captures the dynamic patency of the upper airway. hbbbg`b``a endstream endobj 88 0 obj <>/Metadata 9 0 R/Pages 8 0 R/StructTreeRoot 11 0 R/Type/Catalog/ViewerPreferences<>>> endobj 89 0 obj <>/Font<>/ProcSet[/PDF/Text]>>/Rotate 0/StructParents 0/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 90 0 obj <> endobj 91 0 obj <> endobj 92 0 obj <> endobj 93 0 obj <> endobj 94 0 obj <> endobj 95 0 obj <> endobj 96 0 obj <> endobj 97 0 obj <>stream In addition, CMS will review studies to determine if they meet the 13 criteria listed below. VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. Obstructive sleep apnea (OSA) is a common condition in children and one that most otolaryngologists are familiar with. (TN 10145) (CR11461), 06/2020 - Transmittal 10145, dated May 22, 2020, is being rescinded and replaced by Transmittal 10199, dated, June 23, 2020 to update business requirement 11461.1 with clarifying language to the MACs and to extend the implementation date from June 23, 2020 to July 22, 2020. What is the time from treatment until remission scores are first achieved? Code History Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process. Vagus nerve stimulation For CPT, Category refers to the CODING 0000001407 00000 n Please do not use this feature to contact CMS. Ther Adv Chronic Dis. Epilepsy Res. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. Previous NCD coding changes appear in ICD-10 quarterly updates that can be found at: https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html, along with other CRs implementing new policy NCDs. Section Spotlight: Women in Otolaryngology (WIO). 2015;56(10):1639-1647. The research study protocol specifies the method and timing of public release of all prespecified outcomes to be measured including release of outcomes if outcomes are negative or study is terminated early. Diagnosis Code for End of Life DBS Battery All other information remains the same. PubMed PMID: 29702409. Individuals who receive placebo VNS will be offered active VNS at the end of the trial. The contractor information can be found at the top of the document in the Contractor Information section (expand the section to see the details). No Shinkei Geka. The vagus nerve is the longest cranial nerve in the body. It is actually two nerves called the left and right vagus nerve. It is considered a mixed nerve because it contains both motor and sensory fibers. The word vagus means wandering in Latin. Effective for services performed on or after February 15, 2019, the Centers for Medicare & Medicaid Services (CMS) will cover FDA-approved vagus nerve stimulation (VNS) devices for treatment-resistant depression (TRD) through Coverage with Evidence Development (CED) when offered in a CMS-approved, double-blind, randomized, placebo-controlled trial with a follow-up duration of at least one year with the possibility of extending the study to a prospective longitudinal study when the CMS-approved, double-blind, randomized placebo-controlled trial has completed enrollment, and there are positive interim findings. Vagus nerve stimulation (VNS) therapy is an established method for treating patients with refractory seizures. Although the initial cost of the device is about 10,000 US dollars, the battery life of the model 100 implanted in the patients in this analysis can exceed 5 years at standard settings. Bulletin: Vagal Nerve Stimulation (VNS) Replacement Parts [Epub ahead of print] PubMed PMID: 31326720. 0000003337 00000 n Code Final results must be reported in a publicly accessibly manner; either in a peer-reviewed scientific journal (in print or on-line), in an on-line publicly accessible registry dedicated to the dissemination of clinical trial information such as ClinicalTrials.gov, or in journals willing to publish in abbreviated format (e.g., for studies with negative or incomplete results). The second new sleep surgery code created by the CPT Editorial Panel for the 2022 code set describes DISE. Review the article, in particular the Coding Information section. 0000003448 00000 n The Food and Drug Administration (FDA) approved VNS for treatment of refractory epilepsy in 1997 and for resistant depression in 2005. %PDF-1.7 hb```}@(!!YE&,DQV /,w U[scc~$' Procedure Code These results indicate the importance of timely delivery of VNS to reduce seizure severity and thus help achieve better seizure control for patients with epilepsy9). Academy advisors and clinical experts participated in the new virtual format to advance these codes on behalf of the specialty. 171 0 obj <>stream Epub 2018 Dec 14. No policy-related changes are included with the ICD-10 quarterly updates. Vagal Nerve Stimulator Placement and Battery Exchanges If a study is regulated by the Food and Drug Administration (FDA), it is also in compliance with 21 CFR Parts 50 and 56. We bear witness to human suffering. Nerve Stimulation 0000001810 00000 n All other information remains the same. What is the rate of response (defined as person months of response/total months of study participation)? Japanese. (TN 70) (CR 5612), 09/2012 - CMS translated the information for this policy from ICD-9-CM/PCS to ICD-10-CM/PCS according to HIPAA standard medical data code set requirements and updated any necessary and related coding infrastructure. 0000003663 00000 n Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent, quarterly releases as needed. Seizure. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. %PDF-1.6 % Some are the result of revisions required to other NCD-related CRs released separately that included ICD-10 coding. If you would like to extend your session, you may select the Continue Button. The information will be reviewed, and approved studies will be identified on the CMS website. Centers for Medicare & Medicaid This email will be sent from you to the :?z_F|sb7|/_/NOw/_\%Nfs|-j~K_^2_W`~?|QO`%a\fAyH'$D~54vCC4,txN`;2)5:dsW|=$p*&0JY Hb05:19~FYqI_(xsK~6_Q:?W{s\WwF\u'!33g:IKM0d'z3gi}?n{r*3vW~?NCG#7&S\~_IG yId&8Ey. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent quarterly releases and individual CRs as appropriate. (TN 1537) (CR 9252), 12/2015 - This change request (CR) is the 3rd maintenance update of ICD-10 conversions/updates specific to national coverage determinations (NCDs). IEEE Trans Biomed Eng. Gently pat the incisions dry with a towel after showering. Applicable To Presence of brain H\n0y Try using the MCD Search to find what you're looking for. The study design did not allow determination of which factors were responsible for improvements12). The only hypoglossal nerve stimulator with current U.S. Food and Drug Administration (FDA) approval includes a sensor that is implanted into the chest wall intercostal muscles through a separate incision, with a subcutaneous attachment to the pulse generator to pace tongue extrusion with inspiration. Conventional VNS Therapy devices include Normal Mode and Magnet Mode. However, the lack of a dedicated CPT code created reimbursement obstacles at many institutions. AspireSR - Neurosurgery Inspire Medical Systems Sleep Services Billing Guide 2021 We were done with the case, the drapes were off, and I had just removed the anode tube to insert the cuffed tracheostomy tube. While there is currently only one FDA-approved HGN device, new devices are also reportable under the new codes as long as they fit under the code descriptors. Additionally, the AMA does not create CPT codes for specific devices. 2019 Jul 8;71:140-144. doi: 10.1016/j.seizure.2019.07.006. 0000027610 00000 n None of these codes, either alone or in combination, accurately capture the work involved in examining the dynamic nature and site(s) of airway obstruction within the nasal cavity, nasopharynx, oropharynx, hypopharynx, and larynx while under anesthesia in an operative setting, nor are they inclusive of the examination of the effects of positional and head and neck manipulation on the obstruction. You can use your browser's Print function (Ctrl-P on a PC or Command-P on a Mac) to view a print preview and then select PDF as the output. Kulju T, Haapasalo J, Rainesalo S, Lehtimki K, Peltola J. Autostimulation in Vagus Nerve Stimulator Treatment: Modulating Neuromodulation. The study results are not anticipated to unjustifiably duplicate existing knowledge. (TN 11400) (CR12705), 06/2022 - Transmittal 11400, dated May 4, 2022, is being rescinded and replaced by Transmittal 11460, dated, June 17, 2022, to update NCD 90.2, NGS, spreadsheet to conform with changes in CR 12124, and change the implementation date for all business requirements except 12705.6 to 30 days from issuance of this correction. The codes were originally created for other stimulators and are also used to define placement of stimulators on other nerves, most commonly the vagus nerve. 2019 Jul;22(5):630-637. doi: 10.1111/ner.12897. Unsupervised classification was subsequently applied to test the discriminative ability and validity of these features to measure responsiveness to VNS therapy. The TWA level was assessed interictally by the Modified Moving Average (MMA) method. About 500,000 of these procedures are performed annually in the U.S. We had just finished the composite resection, and it was late in the evening as the case had gotten off to a later start. No policy-related changes are included with these updates. If appropriate, the Agency must also change billing and claims processing systems and issue related instructions to allow for payment. Our profession can bring stress. What are the patient variables associated with successful treatment of TRD with VNS? Hartshorn A, Jobst B. x]YH~74p9h4v{kkRtIJ-oFK.K"2"2~]e^?\nXm?;z}6enCo? Vagus Nerve Stimulation (VNS) is a pulse generator, similar to a pacemaker, that is surgically implanted under the skin of the left chest and an electrical lead (wire) is We shared information about Medicare coverage for Vagus Nerve Stimulation (VNS) for your reference, for detailed understanding, you can refer to, Medicare National Coverage Determinations Manual Chapter 1, Part 2, Basics of Provider-Based and Teaching Physician Services, Read our latest medical billing and coding blogs, Ambulance Transportation Billing Services, Skilled Nursing Facilities Billing Services, Solving the Puzzle of Legacy Accounts Receivable, Role of MBC in Improving Your Anesthesia Billing Services, GW Modifier for Hospice and Wound Care Billing, Understanding Basics of Neurology Billing for Improved Payments, Trust MBC for Reliable Provider Credentialing Services. 0000008660 00000 n The price of the device is higher than for all other models. Instructions for enabling "JavaScript" can be found here. Enter the code you're looking for in the "Enter keyword, code, or document ID" box. WebBackground: Vagus nerve stimulation (VNS) is an established surgical treatment for medically intractable epilepsy with more than 75 000 devices implanted worldwide. 0 Collected information included demographics, use of antiepileptic drugs and seizure type, frequency and duration before and after VNS implantation. If that doesnt work please contact, Technical issues include things such as a link is broken, a report fails to run, a page is not displaying correctly, a search is taking an unexpectedly long time to complete. (TN 1388) (TN 1388) (CR 8691), 08/2015 - This change request (CR) is the 3rd maintenance update of ICD-10 conversions/updates specific to national coverage determinations (NCDs). (TN 11460) (CR12705), 08/2022 - The purpose of this Change Request (CR) is to provide a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. An official website of the United States government. SenTivais an implantable and programmable pulse generator for treatment of refractory epilepsy. These new codes will become part of the CPT code set in 2022. WebThe Rheos Baroreflex Hypertension Therapy System (CVRx, Inc., Minneapolis, MN) is an implantable device for the treatment of patients with drug-resistant hypertension (i.e., the hypertensive state characterized by the inability of multiple anti-hypertensive drug interventions to lower BP to goal levels) who have a systolic BP (SBP) of greater Whether the highly interesting CBSD feature will provide an additional benefit for the patients, and will rectify the additional costs, respectively, cannot be answered in the short-term. What is the rate of remission (defined as person months of response/total months of study participation)? The Vivistim Paired VNS System is a PMA-approved (P210007), FDA Breakthrough Device Cases were divided into two cohorts, those in whom the VNS was a new insertion, and those in whom the VNS battery was changed from a previous model to AspireSR. Inclusion or exclusion of a code does not constitute or Medicare Administrative Contractors (MACs) are required to follow NCDs. 0000023691 00000 n The purpose of this proposed change, which is supported by the AAO-HNS, is to clarify that the code is an add-on code that cannot be separately reported for Medicare patients. If you are having an issue like this please contact, You are leaving the CMS MCD and are being redirected to the CMS MCD Archive that contains outdated (No Longer In Effect) Local Coverage Determinations and Articles, You are leaving the CMS MCD and are being redirected to, NCD - Vagus Nerve Stimulation (VNS) (160.18). WebCPT code 61885 groups to APG 223 (Level III Nerve Procedures) with an APG downstate payment including capital will be $15,390. This involves the implantation of a generator Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent quarterly releases and individual CRs as appropriate. D2e>JG0LMP R`~`$J]Yk $WOA1 ?6 B!^F*z 9i Vagus and External Trigeminal Nerve Stimulation Your MCD session is currently set to expire in 5 minutes due to inactivity. Of this patient population, approximately 13% of men and 6% of women have moderate to severe obstructive sleep apnea (apnea-hypopnea index or AHI 15.). The rule of thirds used in counseling patients may need to be modified accordingly7). VNS provides indirect modulation of brain activity through the stimulation of the vagus nerve. Peak TWA level in all 28 patients improved (group mean, 43%, from 724.3 to 412.3V; p<0.0001). WebCPT codes not covered for indications listed in the CPB: Transcutaneous vagal nerve stimulation - no specific code : Other CPT codes related to the CPB: 61534: Craniotomy The device is surgically implanted under the patients skin. Please contact the Medicare Administrative Contractor (MAC) who owns the document. These signals are in turn sent to the brain. required field. Vagal Nerve Stimulator- replacement of pulse generator 2) Try using the MCD Search and enter your information in the "Enter keyword, code, or document ID" box. The E-37 protocol (NCT01846741) was a prospective, unblinded, U.S. multisite study of the AspireSR() in subjects with drug-resistant partial onset seizures and history of ictal tachycardia. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. WebCPT coding for the post-activation check-in call may include the following codes: CPT Procedure Code Code Description RVU Service 99441- 994432 Phone call check-in between provider and patient1 NF: 1.63-3.77 Fac: 1.04-2.89 Audio-only E/M G20123 Brief check-in via telephone or other device to determine if office visit is needed1 All aspects of the study are conducted according to appropriate standards of scientific integrity. Hamilton P, Soryal I, Dhahri P, Wimalachandra W, Leat A, Hughes D, Toghill N, Hodson J, Sawlani V, Hayton T, Samarasekera S, Bagary M, McCorry D, Chelvarajah R. Clinical outcomes of VNS therapy with AspireSR() (including cardiac-based seizure detection) at a large complex epilepsy and surgery centre. % PubMed PMID: 30549376. It is found in the 2022 version of the ICD-10 Procedure Coding System (PCS) and can be used in all HIPAA-covered transactions from Oct 01, 2021 - Sep 30, 2022 . The mean follow-up was 137.5 months (range 2-29 months). What are the changes in disability, quality of life, general psychiatric status, and suicidality? The page could not be loaded. An NCD becomes effective as of the date of the decision memorandum. The intraoperative handling is equivalent to former models-except for the placement of the generator, which might cause cosmetic issues and has to be discussed with the patient carefully. These new codes will become part of the CPT code set in 2022. Long-term Expectations of Vagus Nerve Stimulation: A 2017 Feb;64(2):419-428. doi: 10.1109/TBME.2016.2554559. Effective for services performed on or after February 15, 2019, the Centers for Medicare & Medicaid Services (CMS) will cover FDA-approved VNS devices for treatment resistant depression (TRD) through Coverage with Evidence Development (CED) when offered in a CMS-approved, double-blind, randomized, placebo-controlled trial with a follow-up duration of at least one year with the possibility of extending the study to a prospective longitudinal study when the CMS-approved, double-blind, randomized placebo-controlled trial has completed enrollment, and there are positive interim findings. Look for a Billing and Coding Article in the results and open it. endstream endobj 983 0 obj <. endobj [(3)New Therapeutic Modalities using Seizure Detection Devices for Medically Refractory Epilepsy:AspireSR and the RNS System]. Twenty implanted subjects (ages 21-69) experienced 89 seizures in the EMU. (TN 11342) (CR12606), 04/2022 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. WebVagus nerve stimulation (VNS) sends regular, mild pulses of electrical energy to the brain via the vagus nerve, through a device that is similar to a pacemaker. Vagus Nerve Stimulation To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom As the new CPT codes cover the procedure in its entirety and are specific to HGN, the Category III add-on codes (0466T, 0467T, 0468T) used to report these codes will be deleted from the code set in 2022. endstream endobj startxref Tailor programming for specific periods of the day, Select which parameters will change, what time the change will occur, and the duration of the change, Program a titration schedule in one office visit, Titration changes will be applied while the patient lives their life, Simply titrate to therapeutic range as fast as is tolerated, Safe and easy pathway towards achieving targeted therapy levels, Follow an FDA-approved protocol or create custom protocols for specific patient profiles, Quickly view long-term data at follow-up visits, Easily assess events of interest such as acute therapy activations, prone position, and low heart rate. 1025 0 obj <>stream For the most part, codes are no longer included in the LCD (policy). Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. Please Note: For Durable Medical Equipment (DME) MACs only, CPT/HCPCS codes remain located in LCDs. At the October 2020 American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel meeting, the AMA accepted new Category I CPT codes for both hypoglossal nerve stimulation (HGN) and drug-induced sleep endoscopy (DISE). Out of Committee: Endocrine Surgery Committee. The possible need for thyroid hormone supplementation or replacement is one of the major concerns for these patients undergoing surgery. Nonetheless they can be troubling in many ways to patients who then seek treatment, which often results in thyroid surgery. The main goal of our organization is to assist physicians looking for billers and coders, at the same time help billing specialists looking for jobs, reach the right place. Effective for services performed on or after February 15, 2019, the Centers for Medicare & Medicaid Services (CMS) will cover FDA-approved vagus nerve stimulation (VNS) devices for treatment-resistant depression (TRD) through Coverage with Evidence Development (CED) when offered in a CMS-approved, double-blind, randomized, placebo-controlled trial with a follow-up duration of at least one year with the possibility of extending the study to a prospective longitudinal study when the. I pulled on the upper stay suture to pull the trachea into view and it immediately came looseobviously the tracheal ring had been broken during its placement. Implementation date: 10/06/2014 Effective date: 10/1/2015. Schneider et al. Verrier RL, Nearing BD, Olin B, Boon P, Schachter SC. WebCoding: The following codes are included below for informational purposes only, and are subject to change without notice. 5. If you need more information on coverage, contact the Medicare Administrative Contractor (MAC) who published the document. If CMS determines that they meet these criteria, the study will be posted on CMS CED website (https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/index.html). |^/a~A~auAPau2P@ @ &C. endobj The new codes create a new code family that is specifically for HGN. WebVagus nerve stimulation (VNS) is a device, similar to a pacemaker, which sends regular, mild pulses of electrical energy to the brain via the vagus nerve to alleviate seizures. While Datta P, Galla KM , Sajja K, et al. 1. For the past 20 years, teams of otolaryngologists have provided continuous cleft care for patients in Kijabe, Kenya, through Samaritans Purse World Medical Mission and partnering with IAC-CURE Childrens Hospital and Smile Train. DISE has been performed by otolaryngologists for almost 30 years. AVNSTherapy generator model, AspireSR, was introduced and approved forCE Markingin February2014. hbbd```b``+f7IM*tL3`r/X&U4YDYIFe Q`"5-WHu )H7f`bd`Ng` G |q Hirsch M, Altenmller DM, Schulze-Bonhage A. Epilepsia. Responsive brain stimulation in epilepsy. Epub 2017 Apr 11. Early experiences with tachycardia-triggered vagus nerve stimulation using the AspireSR stimulator. Some are the result of revisions required to other NCD-related CRs released separately. WebCPT Code: 64590 ICD-10-CM Codes: T85.111A, G40.209 Rationales: CPT: A vagal nerve stimulator stimulator (VNS) used for the treatment of epilepsy is considered a peripheral PubMed PMID: 27450311. All rights reserved. If you need any assistance in medical billing and coding for your practice, you can contact us at info@medicalbillersandcoders.com / 888-357-3226. DISE is currently reported using either CPT codes 31575 (Laryngoscopy, flexible; diagnostic), 31622 (Bronchoscopy, rigid or flexible), or 92502 (Otolaryngologic exam under general anesthesia). No policy-related changes are included with the ICD-10 quarterly updates. The patient is experiencing a major depressive episode (MDE) as measured by a guideline recommended depression scale assessment tool on two visits, within a 45-day span prior to implantation of the VNS device. The records of patients who underwent transplantation during 2015-2017 and are continuously followed in one pediatric-epilepsy clinic were retrospectively analyzed. 2023 American Academy of OtolaryngologyHead and Neck Surgery. Providers are to use CPT Code 64999 for both the trial and permanent insertion of the electrode array when billing for the procedures associated with either NCD - Vagus Nerve Stimulation (VNS) (160.18) - Centers Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service. If your session expires, you will lose all items in your basket and any active searches. Five patients (10.9%) experienced complete seizure-freedom following implantation (4/5 in the new insertion group). The majority of the NCDs included are a result of feedback received from previous ICD-10 NCD CR7818, CR8109, CR8197, CR8691, CR9087, CR9252, CR9540, and CR9631. Applicable CPT code for VNS is CPT code 64568: Incision for implantation of cranial nerve (e.g. 200.2 - ICD-9 Diagnosis Codes for Vagus Nerve Stimulation (Covered since DOS on and after July 1, 1999) 2018 Jul;9(7):135-142. doi: 10.1177/2040622318774173. This guide provides hospital and physician coding and reimbursement information for procedures associated with placement of the Vivistim Paired VNS System (i.e. |_W+ SURG.00112 Implantation of Occipital, Supraorbital or - Anthem Thyroid surgery comes with some generally accepted risks, and quality of life may become significantly altered in several ways. hb```f``z f B,@Q Su%00 T;OphC72^@jNKEL22a2b$s43'|:?20H22*^EL,Pp10@Kin>fb`= 3.0 ~a2M