- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
Radiation therapy management
Other malignant neoplasm of skin
Note: Use codes 173.0–173.9 for basal cell carcinomas.
Neoplasm of unspecified nature of bone soft tissue and skin
Note: Use code 239.2 for Bowen’s disease.
Other specified disorders of metabolism
Note: Use code 277.89 for Langerhans’ cell histiocytosis.
Other atopic dermatitis and related conditions
Contact dermatitis and other eczema
Due to other specific agents
Contact dermatitis and other eczema due to other specified agents
Contact dermatitis and other eczema unspecified cause
Psoriasis and similar disorders
Pityriasis rubra pilaris
Pruritus and related conditions
Lichenification and lichen simplex chronicus
Other specified congenital anomalies of skin
Note: Use code 757.39 for Darier’s disease and benign chronic familial pemphigus.
Per CR 7121 (annual HCPCS update), description changed for the GA modifier. Effective date: 01/01/2011.
Use of LCD and related article made applicable to providers transitioning from WPS to TrailBlazer with addition of contractor number 04901. Effective date: dates of service on or after 10/18/2010.
LCD effective in TX Part A and Part B and Part A CO and NM 06/13/2008
LCD effective in CO Part B 03/21/2008
LCD effective in NM Part B and OK Part A and Part B 03/01/2008
Consolidated LCD posted for notice effective: 12/20/2007