Medicare Non-Covered Services CPT code list



Medicare does not cover items and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Section 1862(a)(1) of the Social Security Act is the basis for denying payment for types of care, or specific items, services or procedures that are not excluded by any other statutory clause and meet all technical requirements for coverage but are determined to be any of the following:
  • Not generally accepted in the medical community as safe and effective in the setting and for the condition for which it is used.
  • Not proven to be safe and effective based on peer review or scientific literature.
  • Experimental.
  • Not medically necessary in the particular case.
  • Furnished at a level, duration or frequency that is not medically appropriate.
  • Not furnished in accordance with accepted standards of medical practice.
  • Not furnished in a setting (such as inpatient care at a hospital or SNF, outpatient care through a hospital or physician’s office, or home care) appropriate to the patient’s medical needs and condition.
To be considered medically necessary, items and services must have been established as safe and effective. That is, the items and services must be:
  • Consistent with the symptoms or diagnosis of the illness or injury under treatment.
  • Necessary and consistent with generally accepted professional medical standards (e.g., not experimental or investigational).
  • Not furnished primarily for the convenience of the patient, the attending physician, or other physician or supplier.
  • Furnished at the most appropriate level that can be provided safely and effectively to the patient.
A service or procedure on the “Local Non-Coverage Decisions” list is always denied on the basis that TrailBlazer does not believe it is ever medically reasonable and necessary. The TrailBlazer list of LCD exclusions contains procedures that, for example, are:
  • Experimental.
  • Not proven safe and effective.
  • Not approved by the Food and Drug Administration (FDA).
Medical devices that are not approved for marketing by the FDA are considered investigational by Medicare and are not considered reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve functioning of a malformed body member. Program payment, therefore, may not be made for medical procedures and services performed using devices that have not been approved for marketing by the FDA or for those not included in an FDA-approved Investigational Device Exemption (IDE) trial.
If a test, treatment or procedure is neither specifically covered nor excluded in Medicare law or guidelines, contractors must make a coverage determination that is based upon the general acceptance of the test, treatment or procedure by the professional medical community as an effective and proven treatment for the condition for which it is being used. Medicare will make payment only when a service is accepted as effective and proven. Some tests or services are obsolete and have been replaced by more advanced procedures. The tests or procedures may be paid only if the physician who performs them satisfactorily justifies the medical need for the procedure(s).
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. TrailBlazer evaluates new services, procedures, drugs or technology and considers national and local policies before these new services may be considered Medicare covered services (see the “Documentation Requirements” section).
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • 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.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 14X, 18X, 21X, 22X, 23X, 28X, 71X, 72X, 73X, 74X, 75X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
025X, 026X, 027X, 030X, 031X, 032X, 033X, 034X, 035X, 036X, 037X, 040X, 041X, 042X, 043X, 044X, 045X, 046X, 048X, 049X, 050X, 051X, 052X, 055X, 0621, 0622, 0623, 0624, 0636, 073X, 0740, 0750, 076X, 092X, 094X
CPT/HCPCS Codes
Note:
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.

Local Non-Coverage Decisions

Investigational, Unproven or Experimental
C9727*
Insert palate implants (OPPS)
0019T©*
Extracorp shock wv tx,ms nos
0030T©*
Antiprothrombin antibody
0042T©*++
Ct perfusion w/contrast, cbf
0051T©*
Implant total heart system
Note: Per Change Request (CR) 6185, covered only when implanted in patients enrolled in clinical studies that have been approved by Medicare and meet all of the Coverage with Evidence Development (CED) criteria.
0052T©*
Replace component heart syst
0053T©*
Replace component heart syst
0054T©*++
bone surgery using computer
0055T©*++
bone surgery using computer
0058T©
Pathology lab procedure
Note: Use 0058T to identify cryopreservation ovary tiss.
0059T©
Pathology lab procedure
Note: Use 0059T to identify cryopreservation oocyte.
0071T©*
U/s leiomyomata ablate <200
0072T©*
U/s leiomyomata ablate >200
0079T©*
Endovasc visc extnsn repr
0080T©*
Endovasc aort repr rad s&i
0081T©*
Endovasc visc extnsn s&i
0092T©*
Artific disc addl
0095T©*
Artific diskectomy addl
0098T©*
Rev artific disc addl
0099T©*
Implant corneal ring
0100T©*
Prosth retina receive&gen
0101T©*
Extracorp shockwv tx,hi enrg
0102T©*
Extracorp shockwv tx,anesth
0103T©*
Holotranscobalamin
0106T©*
Touch quant sensory test
0107T©*
Vibrate quant sensory test
0108T©*
Cool quant sensory test
0109T©*
Heat quant sensory test
0110T©*
Nos quant sensory test
0111T©*
Rbc membranes fatty acids
0123T©*
Scleral fistulization
0124T©*
Conjunctival drug placement
0126T©*
Chd risk imt study
0141T©*
Perq islet transplant
0142T©*
Open islet transplant
0143T©*
Laparoscopic islet transplant
0155T©*
Lap redo gastr eltrd for mo
0156T©*
Lap redo gastr eltrd for mo
0157T©*
Opn ins gastr eltrd for mo
0158T©*
Opn redo gastr eltrd for mo
0159T©*++
Computer breast MRI add-on
0163T©*
Lumb artif diskectomy addl
0164T©*
Remove lumb artif disc addl
0165T©*
Revise lumb artif disc addl
0166T©*
Tcath vsd close w/o bypass
0167T©*
Tcath vsd close w bypass
0168T©*
Rhinophototx light app bilat
0169T©*
Place stereo cath brain
0173T©*++
Iop monit io pressure
0174T©*++
Cad cxr with interp
0175T©*++
Cad cxr remote
0178T©*
64 Lead ECG w I & R
0179T©*
64 Lead ECG w tracing
0180T©*
64 Lead ECG w I & R only
0181T©*
Corneal hysteresis
0182T©*
HDR elec brachytherapy
0184T©*
Exc rectal tumor endoscopic
0185T©*++
Comptr probablility analysis
0186T©*
Suprachoroidal drug delivery
0190T©*
Intraocular radiation src applicator placement
0191T©*
Ant segment insertion drainage w/o reservoir int
0195T©*
Arthrod presac interbody
0196T©*
Arthrod presac interbody eac
0198T©*
Ocular blood flow measure
0199T©*
Physiologic tremor record
0200T©*
Perq sacral augmt unilat inj
0201T©*
Perq sacral augmt bilat inj
0202T©*
Post vert arthrplst 1 lumbar
0205T©*++
Inirs each vessel add-on
0206T©*
Remote algorithm analys ecg
0207T©*
Clear eyelid gland w/heat
0208T©*
Automated audiometry air
0209T©*
Auto audiometry air/bone
0210T©*
Auto audiometry sp thresh
0211T©*
Auto audiometry sp thresh
0212T©*
Comprehen auto audiometry
0213T©*
Us facet jt inj cerv/t 1 lev
0214T©*
Us facet jt inj cerv/t 2 lev
0215T©*
Us facet jt inj cerv/t 3 lev
0216T©*
Us facet jt inj ls 1 level
0217T©*
Us facet jt inj ls 2 level
0218T©*
Us facet jt inj ls 3 level
0219T©*
Fuse spine facet jt cerv
0220T©*
Fuse spine facet jt thor
0221T©*
Fuse spine facet jt lumbar
0222T©*
Fuse spine facet jt add seg
0223T©*
Acoustic/electr cardgrphy
0224T©*
Acstic/elec cardgrphy av/vv
0225T©*
Acstic/elec cardgrphy av+vv
0226T©*
Anosc high resol dx +-coll
0227T©*
Anosc high resol dx w/bx
0228T©*
Us tfrml edrl inj crv/t 1lvl
0229T©*
Us tfrml edrl inj crv/t +lvl
0230T©*
Us tfrml edrl inj l/s 1lvl
0231T©*
Us tfrml edrl inj l/s +lvl
0232T©*
Inj plsm img guid hrvstg&prep
0233T©*
Skn age meas spctrscpy
0234T©
Trluml perip athrc renal art
0235T©
Trluml perip athrc visceral
0236T©
Trluml perip athrc abd aorta
0237T©
Trluml perip athrc brchiocph
0238T©
Trluml perip athrc iliac art
0239T©
Bioimpedance spectroscopy
0240T©
Esoph motility 3d topography
0241T©
Esoph motility w/stim/perf
0242T©
Gi tract transit & pres meas
0243T©
Intm msr bronchodil wheeze
0244T©
Cont msr bronchodil wheeze
0245T©
Opn tx rib fx 1-2 ribs
0246T©
Opn tx rib fx 3-4 ribs
0247T©
Opn tx rib fx 5-6 ribs
0248T©
Opn tx rib fx 7+ ribs
0249T©
Ligation hemorrhoid w/us
0250T©
Insert bronchial valve
0251T©
Remov bronchial valve addl
0252T©
Bronchscpc rmvl bronch valve
0253T©
Insert aqueous drain device
0254T©
Evasc rpr iliac art bifur
0255T©
Evasc rpr iliac art bifr s&i
0256T©
Evasc aortic hrt valve
0257T©
Opn tthrc aortic hrt valve
0258T©
Aortic hrt valv w/o card byp
0259T©
Aortic hrt valve w/card byp
0260T©
Hypthrm bdy neonate 28d/<
0261T©
Hypthrm head neonate 28d/<
19499©*+
Breast surgery procedure
Note: Use 19499 to identify: 1) catheter lavage of mammary duct; 2) microwave phased array thermotherapy used for destruction/reduction of malignant breast tumor.
20985©*
Cptr-asst dir ms px
22856©*
Cerv artific diskectomy
22857©*
Lumbar artif diskectomy
22861©*
Revise cerv artific disc
22862©
Remove lumb artif disc
22864©*
Remove cerv artif disc
22865©
Revise lumbar artif disc
22899©*+
Spine surgery procedure
Note: When used to identify Thermal Intradiscal Procedures (TIPs) (NCD 150.11).
41530©*
Tongue base vol reduction
42299©*+
Unlisted procedure, palate, uvula
Note: Use 42299 to identify: Laser-Assisted Uvulopalatoplasty (LAUP) or Insertion of palate implants (Pillar procedure) (non-OPPS).
43257©*
Uppr gi scope w/thrml txmnt
53899©*+
Urology surgery procedure
Note: Use 53899 to identify pulsed magnetic neuromodulation.
58999©*+
Genital surgery procedure
Note: Use 58999 to identify speculoscopy.
61630©*
Intracranial angioplasty
Note: Covered only when furnished in accordance with the FDA-approved protocols governing Category B IDE clinical trials (NCD 20.7).
61635©*
Intracran angioplsty w/stent
Note: Covered only when furnished in accordance with the FDA-approved protocols governing Category B IDE clinical trials (NCD 20.7).
64999©*+
Nervous system surgery
Note: Use 64999 to identify: 1) pulsed dorsal root rhizotomy; 2) endoscopic lysis of epidural adhesions; 3) TIPs (NCD 150.11); 4) STS (Sympathetic Therapy System).
66174©*
Translum dil eye canal
67299©*
Unlisted procedure
Note: Use 67299 to identify: 1) Thermotx anadian vasc lesion; 2) Photocoagulat macular drusen
75571©*
Ct hrt w/o dye w/ca test
76499©*+
Radiographic procedure
Note: Use 76499 to identify: 1) DEXA body composition study; 2) electrical impedence scan of breast.
77605©*
Hyperthermia treatment
77620©*
Hyperthermia treatment
81099©*+
Urinalysis test procedure
Note: Use 81099 to identify urinalysis for semi-quantitative analysis of volatile compounds.
83987©
Exhaled breath condensate ph
84145©*
Procalcitonin (pct)
84999©*+
Clinical chemistry test
Note: Use 84999 to identify: 1) measurement of Intermediate Density Lipoproteins (IDL); 2) carbon monoxide, expired gas analysis.
87470©*
Bartonella, dna, dir probe
87472©*
Bartonella, dna, quant
87475©*
Lyme dis, dna, dir probe
87477©*
Lyme dis, dna, quant
87481©*
Candida, amp probe
87482©*
Candida, quanti
87485©*
Chylmd pneum, dna, dir probe
87487©*
Chylmd pneum, quant
87492©*
Chylmd trach, dna, quant
87495©*
Cytomeg, dna, dir probe
87511©*
Gardner vag, dna, amp probe
87512©*
Gardner vag, dna, quant
87515©*
Hepatitis b, dna, dir probe
87520©*
Hepatitis c, rna, dir probe
87525©*
Hepatitis g, dna, dir probe
87527©*
Hepatitis g, dna, quant
87528©*
Hsv, dna, dir probe
87530©*
Hsv, dna, quant
87531©*
Hhv-6, dna, dir probe
87533©*
Hhv-6, dna, quant
87540©*
Legion pneumo, dna, dir prob
87542©*
Legion pneumo, dna, quant
87550©*
Mycobacteria, dna, dir probe
87552©*
Mycobacteria, dna, quant
87555©*
M.tuberculo, dna, dir probe
87557©*
M.tuberculo, dna, quant
87560©*
M.avium-intra, dna, dir prob
87562©*
M.avium-intra, dna, quant
87580©*
M.pneumon, dna, dir probe
87582©*
M.pneumon, dna, quant
87592©*
N.gonorrhoeae, dna, quant
87620©*
Hpv, dna, dir probe
87622©*
Hpv, dna, quant
87651©*
Strep a, dna, amp probe
87652©*
Strep a, dna, quant
89398©*
Unlisted reprod med lab proc
90867©*
Tcranial magn stim tx plan
90868©*
Tcranial magn stim tx deli
91132©*
Electrogastrography
91133©*
Electrogastrography w/test
91299©*+
Gastroenterology procedure
92227©
Remote dx retinal imaging
92228©
Remote retinal imaging mgmt
92284©*
Dark adaptation eye exam
92499©*+
Unlisted ophthalmological service or procedure
Note: Use 92499 to identify: PreView Preferential Hyperacuity Perimetry (PHP) and electroretinogram.
93799©*
Cardiovascular procedure
Note: Use 93799 to identify: 1) Metaidobenzylquanidine (MIBG) imaging; 2) Pulsemetric Dynapulse System (for use as an electrical thoracic bioimpedance device; 3) Left ventricular filling pressure (indirect measurement); 4) At rest cardio gas rebreathe; 5) Exerc cardio gas rebreathe.
94799©*
Pulmonary service/procedure
Note: Use 94799 to identify: 1) Spectroscopy, expired gas analysis (e.g., nitric oxide/carbon dioxide test).
95800©*
Slp stdy unattended
95801©*
Slp stdy unatnd w/anal
96904©*
Whole body photography
97033©*
Iontophoresis
99199©*
Chron care drug investigatn
22899©+
Spine surgery procedure
Note: Use 22899 to identify: arthroscopic laser arthrodesis/rhizotomy of the facet joint with cancellous bone allograph and autologous platelet gell patch and epiduroscopy/myeloscopy.
27599©+
Leg surgery procedure
Note: Use 27599 to identify: tidal knee irrigation.
28890©*
High energy eswt, plantar f
33999©+
Cardiac surgery procedure
Note: Use 33999 to identify: abdominal aorta transplant from a cadaver.
37799©*+
Vascular surgery procedure
Note: Use 37799 to identify: stenting of the vertebral and cerebral arteries. However, stenting of the cerebral arteries may be covered when furnished in accordance with FDA-approved protocols governing Category B IDE clinical trials. (CR 5432).
43843©*
Gastroplasty w/o v-band
44799©*+
Unlisted procedure intestine
Note: Use 44799 to identify: large and small bowel transplants.
53899©*+
Urology surgery procedure
Note: Use 53899 to identify: neocontrol (magnetic incontinence chair).
64999©*+
Nervous system surgery
Note: Use 64999 to identify: 1) blood brain barrier disruption; 2) bretylium bier block; 3) fetal tissue transplantation; 4) nucleoplasty (CoBlation); 5) balloon lacrimoplasty.
76499©*+
Radiographic procedure
Note: Use 76499 to identify: MRI for use in measuring the blood flow, spectroscopy imaging of cortical bone and calcification, and procedures involving resolution of bone or calcification.
76999©*+
Echo examination procedure
Note: Use 76999 to identify: ultrasound-guided sclerotherapy.
78699©*+
Nervous system nuclear exam
Note: Use 78699 to identify: SPECT with Altropane for early diagnosis of Parkinson’s disease.
80103©*
Drug analysis, tissue prep
82016©*
Acylcarnitines, qual
82017©*
Acylcarnitines, quant
82286©*
Assay of bradykinin
82485©*
Assay, chondroitin sulfate
83634©*
Assay of urine for lactose
84255©*
Assay of selenium
84525©*
Urea nitrogen semi-quant
84999©*+
Clinical chemistry test
Note: Use 84999 to identify: Neuronal Thread Protein (NTP).
85337©*
Thrombomodulin
86243©
Fc receptor
86343©*
Leukocyte histamine release
86378©*
Migration inhibitory factor
86723©*
Listeria monocytogenes ab
88371©*
Protein, western blot tissue
88372©*
Protein analysis w/probe
Note: 88371 and 88372 are non-covered only when used with the 26 modifier.
88384©*
Eval molecular probes, 11-50
88385©*
Evalmolecul probes, 51-250
88386©*
Eval molecul probes, 251-500
92548©*
Posturography
92700©*+
Ent procedure/service
Note: Use 92700 with the GY modifier to identify: Politzer procedure.
92970©*
Cardioassist, internal
92971©*
Cardioassist, external
92997©*
Pul art balloon repr, percut
92998©*
Pul art balloon repr, percut
93720©*
Total body plethysmography
93721©*
Plethysmography tracing
93722©*
Plethysmography report
93740©
Temperature gradient studies
Note: Non-covered in Part A; B status in Part B.
93799©*+
Cardiovascular procedure
Note: Use 93799 to identify: 1) Metaidobenzylquanidine (MIBG) imaging; 2) Pulsemetric Dynapulse System (for use as an electrical thoracic bioimpedance device; 3) Left ventricular filling pressure (indirect measurement).
95199©*+
Unlisted allergy/clinical immunologic service or procedure
Note: Use 95199 to identify: adoptive immunotherapy or to identify: provocative testing (e.g., Rinkel test).
95806©*
Sleep study unatt&resp efft
95999©*+
Neurological procedure
Note: Use 95999 to identify: 1) biothesiometry; 2) surface electromyography.
Note: Use 95999 with modifier GY to identify: Quantitative Sensory Testing (QST).
97026©*
Infrared therapy
97033©
Iontophoresis
97039©*+
Unlisted modality
Note: Use 97039 to identify: 1) Light-reflecting rheography; 2) Low energy laser therapy (Anodyne Therapy); 3) Physiotherapy (Aqua PT, Aqua Massage).
97799©*+
Unlisted, physical medicine/rehab
Note: Use 97799 to identify: 1) Matrix Pro elect/DT; 2) Anodyne Therapy/low energy laser therapy; 3) music therapy; 4) electroceutical nerve block; 5) horizontal therapy.
99199©*+
Special service/proc/report
Note: Use 99199 to identify: 1) gamma knife for lesions outside the head; 2) intravenous lidocaine for chronic pain; 3) vacuum therapy for wound healing, 4) Hyperbaric oz tx; no md reqrd.
J3490*+
Unclassified drugs
Note: Use J3490 to identify: Shark cartilage injections.
Other Reasons (Benefit Category Determinations, Other Reasons)
01990©
Support for organ donor
11975©
Insert contraceptive cap
11977©
Removal/reinsert contra cap
15820©
Revision of lower eyelid
15821©
Revision of lower eyelid
15824©
Removal of forehead wrinkles
15825©
Removal of neck wrinkles
15826©
Removal of brow wrinkles
15828©
Removal of face wrinkles
15829©
Removal of skin wrinkles
15876©
Suction assisted lipectomy
15877©
Suction assisted lipectomy
15878©
Suction assisted lipectomy
15879©
Suction assisted lipectomy
17380©
Hair removal by electrolysis
36468©
Injection(s), spider veins
36469©
Injection(s), spider veins
58321©
Artificial insemination
58322©
Artificial insemination
58323©
Sperm washing
58670©
Laparoscopy, tubal cautery
58671©
Laparoscopy, tubal block
58970©
Retrieval of oocyte
58974©
Transfer of embryo
58976©
Transfer of embryo
59012©
Fetal cord puncture, prenatal
84061©
Phosphatase, forensic exam
84830©
Ovulation tests
86970©
RBC pretreatment
86971©
RBC pretreatment
86972©
RBC pretreatment
86975©
RBC pretreatment, serum
86976©
RBC pretreatment, serum
86977©
RBC pretreatment, serum
86978©
RBC pretreatment, serum
89250©
Culture of oocyte(s)/embryo(s), less than 4 days
89251©
Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos
89253©
Embryo hatching
89254©
Oocyte identification
89255©
Prepare embryo for transfer
89257©
Sperm identification
89258©
Cryopreservation, embryo(s)
89259©
Cryopreservation, sperm
89260©
Sperm isolation, simple
89261©
Sperm isolation, complex
89264©
Identify sperm tissue
94014©
Patient recorded spirometry
94015©
Patient recorded spirometry
94016©
Review patient spirometry
94452©
Hast w/report
94453©
Hast w/oxygen titrate
99360©
Physician standby services
D0416
Viral culture
D0421
Gen tst suscept oral disease
D0475
Decalcification procedure
D0476
Spec stains for microorganis
D0477
Spec stains not for microorg
D0478
Immunohistochemical stains
D0479
Tissue in-situ hybridization
D0481
Electron microscopy diagnost
D0482
Direct immunofluorescence
D0483
Indirect immunofluorescence
D0484
Consult slides prep elsewher
D0485
Consult inc prep of slides
D7283
Place device impacted tooth
D7321
Alveoloplasty not w/extracts
D9248
Non-intravenous conscious sedation
J1056
MA/EC contraceptiveinjection
J3530
Nasal vaccine inhalation
P2028
Cephalin floculation
P2029
Congo red, blood
P2033
Thymol turbidity, blood
P2038
Mucoprotein, blood
Note: These lists of non-covered services are not all-inclusive. Refer to the Policies Web page athttp://www.trailblazerhealth.com/Policies for a list of national non-coverage decisions.
* Services that are not covered due to being investigational/experimental or are not reasonable and necessary. To bill the patient for procedures and services that are not covered for these reasons will generally require an Advance Beneficiary Notice (ABN) to be obtained before the service is rendered.
** May be reviewed for payment under Individual Consideration. Medical records must be submitted when requesting a redetermination that documents the patient’s condition meets individual consideration specifics. The redetermination submission must have “LCD INDIVIDUAL CONSIDERATION REQUEST” indicated on the request form to receive individual consideration.
+ Claims for these services will always be reviewed, as they must currently be billed with an unlisted procedure code.
++ Some codes may be bundled or packaged under OPPS, in which case the non-coverage applies to the professional component only.

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