Download Local Coverage Determination

Local Coverage Determination
CPT Codes
95806
LMRP ID
L13202
LMRP Title
Non-Covered Services
LMRP Description
In general, Medicare pays for items and services that are reasonable and necessary for the
diagnosis or treatment of an illness or injury, or to improve the functioning of a
malformed body part. The statutory provisions for Medicare coverage found in section
1862 (a)(1)(A) of the Social Security Act, exclude from Medicare coverage “items and
services that are not reasonable and necessary for the diagnosis of illness or injury or to
improve the functioning of a malformed body member.”
“Not medically necessary” charges are those charges for services that the Medicare FI or
carrier decides were not necessary or reasonable for the patient’s condition.
“Non-covered services” are services and procedures billed to the patient, not covered by
Medicare, and are always denied either because:
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A national decision to noncover the service/procedure exists, or
The service/procedure is included on the list of services determined by the
contractor to be excluded from coverage
These non-covered services are charges that:
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The beneficiary already knows are non-covered because they are included in the
information given in the Medicare handbook (e.g., oral medications, screening
mammograms in less than the designated waiting period, etc.).
They are considered either experimental or investigational in nature.
They are routine physical examinations, for which Medicare does not pay under
any circumstances because of statutory exclusions.
Medicare law places general and categorical limitations on services furnished by certain
health care practitioners, such as dentists, chiropractors and podiatrists. The law
specifically excludes from coverage such services as:
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Cosmetic surgery
Personal comfort items
Custodial care
Routine physical checkups
Services that are not reasonable and necessary for the diagnosis or treatment of an
illness or injury
Unless written notice of non-coverage is issued to the beneficiary prior to rendering a
specific non-covered service, in some instances the provider may be held financially
liable.
Providers are made aware of these non-covered items and services through updates to the
Medicare Coverage Issues Manual, Medicare Carriers Manual, Medicare Hospital
Manual, and other sources.
It is important to note that the fact that a new service or procedure has been issued a CPT
code or is FDA approved does not, in itself, make the procedure “medically reasonable
and necessary.” It is our policy that new services, procedures, drugs, or technology must
be evaluated and approved either nationally or by our local medical review policy process
before they are considered Medicare covered services. Furthermore, national non-covered
services may not be covered by local contractors.
This policy is initiated to list medical services and procedures that are never covered by
the Medicare program.
Indications and Limitations of Coverage and/or Medical Necessity
A service or procedure on the “national non-coverage list” may be non-covered based on
a specific exclusion contained in the Medicare law; for example, acupuncture; it may be
viewed as not yet proven safe and effective and, therefore, not medically reasonable and
necessary; or it may be a procedure that is always considered cosmetic in nature and is
denied on that basis. The precise basis for a national decision to non-cover a procedure
may be found in references cited in this policy.
A service or procedure on the “local” list is always denied on the basis that Riverbend
GBA does not believe it is ever “medically reasonable and necessary.” Our list of local
medical review policy exclusions contains procedures that, for example, are:
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Experimental
Not yet proven safe and effective
Not yet approved by the FDA
Concurrent hospital care during hospice (condition code 07), will be denied when the
hospice diagnosis is:
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Debility, ICD-9 code 799.3
Adult failure to thrive, ICD-9 code 783.7
Other general symptoms, ICD-9 code 780.
CPT/HCPCS Codes
Local Non-coverage Decisions
(*) The following codes with asterisks are non-covered services because they are
considered investigational and/or experimental. These codes are also found in the
lists of codes following the asterisks codes where they are subdivided to their
respective service category.
77605* Hyperthermia treatment
77620* Hyperthermia treatment
82016* Acylcarnitines, qual
82017* Acylcarnitines, quant
84525* Urea nitrogen semi-quant
85337* Thrombomodulin
86316* Immunoassay, tumor other
86343* Leukocyte histamine release
86378* Migration inhibitory factor
86602* Actinomyces antibody
86628* Antibody; Candida
86723* Listeria monocytogenes ab
86732* Mucormycosis antibody
87272* Cryptosporidum/gardia ag, if
87391* Hiv-2 ag, eia
87470* Bartonella, dna, dir probe
87471* Bartonella, dna, amp probe
87472* Bartonella, dna, quant
87475* Lyme dis, dna, dir probe
87476* Lyme dis, dna, amp probe
87477* Lyme dis, dna, quant
87487* Chylmd pneum, dna, quant
87492* Chylmd trach, dna, quant
87511* Gardner vag, dna, amp probe
87512* Gardner vag, dna, quant
87525* Hepatitis g, dna, dir probe
87526* Hepatitis g, dna, amp probe
87527* Hepatitis G, DNA, quant
87529* Hsv, dna, amp probe
87530* Hsv, dna, quant
87532* Hhv-6, dna, amp probe
87533* Hhv-6, dna, quant
87540* Legion pneumo, dna, dir prob
87541* Legion pneumo, dna, amp prob
87542* Legion pneumo, dna, quant
87552* Mycobacteria, dna, quant
87557* M.tuberculo, dna, quant
87562* M.avium-intra, dna, quant
87580* M.pneumon, dna, dir probe
87581* M.pneumon, dna, amp probe
87582* M.pneumon, dna, quant
87592* N.gonorrhoeae, dna, quant
87620* Hpv, dna, dir probe
87621* Hpv, dna, amp probe
87622* Hpv, dna, quant
87650* Strep a, dna, dir probe
87652* Strep a, dna, quant
88371* Protein, western blot tissue
88372* Protein analysis w/probe
^Note: CPT codes 88371 and 88372 are non-covered only when used with the -26
modifier.
92548* Computerized dynamic posturography
92970* Cardioassist, internal
92971* Cardioassist, external
93720-93722* Plethysmography, total body
95806* Sleep study, unattended
G0167* Hyperbaric oxygen treatment not requiring physician attendance, per
treatment session
G0185* Destruction of localized lesions of choroids (e.g., choroidal
neovascularization), transpupillary thermotherapy
G0187* Destruction of macular drusen
J3520* Edetate disodium, per 150 mg (chemical endarterectomy)
Procedures
01990
PHYSIOLOGICAL SUPPORT FOR HARVESTING OF ORGAN(S) FROM
BRAIN-DEAD PATIENT
01995
REGIONAL INTRAVENOUS ADMINISTRATION OF LOCAL
ANESTHETIC AGENT OR OTHER MEDICATION (UPPER OR LOWER
EXTREMITY)
11975
INSERTION, IMPLANTABLE CONTRACEPTIVE CAPSULES
11977
REMOVAL WITH REINSERTION, IMPLANTABLE CONTRACEPTIVE
CAPSULES
11980
SUBCUTANEOUS HORMONE PELLET IMPLANTATION
(IMPLANTATION OF ESTRADIOL AND/OR TESTOSTERONE PELLETS
BENEATH THE SKIN)
15820 15821
15824 15829
15876 15879
17380
ELECTROLYSIS EPILATION, EACH 1/2 HOUR
58321
ARTIFICIAL INSEMINATION; INTRA-CERVICAL
58322
ARTIFICIAL INSEMINATION; INTRA-UTERINE
58323
SPERM WASHING FOR ARTIFICIAL INSEMINATION
58670
LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS
(WITH OR WITHOUT TRANSECTION)
58671
LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY
DEVICE (EG, BAND, CLIP, OR FALOPE RING)
58970
FOLLICLE PUNCTURE FOR OOCYTE RETRIEVAL, ANY METHOD
58974
EMBRYO TRANSFER, INTRAUTERINE
58976
GAMETE, ZYGOTE, OR EMBRYO INTRAFALLOPIAN TRANSFER, ANY
METHOD
59012
CORDOCENTESIS (INTRAUTERINE), ANY METHOD
77605
HYPERTHERMIA, EXTERNALLY GENERATED; DEEP (IE, HEATING
TO DEPTHS GREATER THAN 4 CM)
77620
HYPERTHERMIA GENERATED BY INTRACAVITARY PROBE(S)
92548
COMPUTERIZED DYNAMIC POSTUROGRAPHY
92582
CONDITIONING PLAY AUDIOMETRY
92583
SELECT PICTURE AUDIOMETRY
92970
CARDIOASSIST-METHOD OF CIRCULATORY ASSIST; INTERNAL
92971
CARDIOASSIST-METHOD OF CIRCULATORY ASSIST; EXTERNAL
92997 92998
93720 93722
93740
TEMPERATURE GRADIENT STUDIES
94014
PATIENT-INITIATED SPIROMETRIC RECORDING PER 30-DAY PERIOD
OF TIME; INCLUDES REINFORCED EDUCATION, TRANSMISSION OF
SPIROMETRIC TRACING, DATA CAPTURE, ANALYSIS OF
TRANSMITTED DATA, PERIODIC RECALIBRATION AND PHYSICIAN
REVIEW AND INTERPRETATION
94015
PATIENT-INITIATED SPIROMETRIC RECORDING PER 30-DAY PERIOD
OF TIME; RECORDING (INCLUDES HOOK-UP, REINFORCED
EDUCATION, DATA TRANSMISSION, DATA CAPTURE, TREND
ANALYSIS, AND PERIODIC RECALIBRATION)
94016
PATIENT-INITIATED SPIROMETRIC RECORDING PER 30-DAY PERIOD
OF TIME; PHYSICIAN REVIEW AND INTERPRETATION ONLY
95078
PROVOCATIVE TESTING (EG, RINKEL TEST)
95806
SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION,
RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN
SATURATION, UNATTENDED BY A TECHNOLOGIST
95831
MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH
REPORT; EXTREMITY (EXCLUDING HAND) OR TRUNK
95832
MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH
REPORT; HAND, WITH OR WITHOUT COMPARISON WITH NORMAL
SIDE
95833
MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH
REPORT; TOTAL EVALUATION OF BODY, EXCLUDING HANDS
95851
RANGE OF MOTION MEASUREMENTS AND REPORT (SEPARATE
PROCEDURE); EACH EXTREMITY (EXCLUDING HAND) OR EACH
TRUNK SECTION (SPINE)
95852
RANGE OF MOTION MEASUREMENTS AND REPORT (SEPARATE
PROCEDURE); HAND, WITH OR WITHOUT COMPARISON WITH
NORMAL SIDE
97020
APPLICATION OF A MODALITY TO ONE OR MORE AREAS;
MICROWAVE
97545
WORK HARDENING/CONDITIONING; INITIAL 2 HOURS
97546
WORK HARDENING/CONDITIONING; EACH ADDITIONAL HOUR
(LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY
PROCEDURE)
99185
HYPOTHERMIA; REGIONAL
99186
HYPOTHERMIA; TOTAL BODY
99360
PHYSICIAN STANDBY SERVICE, REQUIRING PROLONGED
PHYSICIAN ATTENDANCE, EACH 30 MINUTES (EG, OPERATIVE
STANDBY, STANDBY FOR FROZEN SECTION, FOR CESAREAN/HIGH
RISK DELIVERY, FOR MONITORING EEG)
D9248
NON-INTRAVENOUS CONSCIOUS SEDATION
Reasons for Denials
An advance notice of Medicare’s denial of payment must be provided to the patient when
the provider does not want to accept financial responsibility for a service that is
considered investigational/experimental, or is not approved by the FDA, or because there
is a lack of scientific and clinical evidence to support the procedure’s safety and efficacy.
The service does not follow the guidelines of this policy.
The service is considered:
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Investigational
Cosmetic
Routine screening
Dental
Program exclusion
Otherwise not covered
Never medically necessary