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©*
|
|
87512©*
|
|
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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