When Medically not covered for CPT 11981,J9225,J9226, 96372

Documentation Requirements   
Medicare will not cover the excess cost for the more expensive of these medications that have the same overall clinical response as another already in widespread use. The patient will not be responsible for the difference in price between the two drugs without an acceptable advanced beneficiary notification (ABN).

Any administration of these drugs in the absence of an acceptable clinical diagnosis (see above section) will be denied as not reasonable and necessary

The manufacturers strongly recommend that the provider should attempt to adhere closely to the schedule (every four weeks, 12 weeks, etc.), though they note that a delay of a few days is permissible.

Because CPT codes 11981-11983 may be used for implants other than J9219, J9225, and J9226, this A/B MAC will not limit these procedures to just these two HCPCS codes and the diagnoses in this LCD. Similarly, 96372 and 96402 will be allowed for indicated diagnoses beyond those in this LCD.
Chart documentation must support the diagnosis on the claim, and be made available to Medicare upon request.

For one-year implants, the chart must document and justify the clinician?s belief that the patient?s life expectancy is at least one year.

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.

When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.  

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