LCD for Non-Covered Services (L13202)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L13202 

 

LCD Title 

Non-Covered Services 

 

Contractor's Determination Number 

13202 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  

 

CMS National Coverage Policy 

CMS National Coverage Policy

CIM- Coverage Issues Manual

CMS Online Manual

CCI- Correct Coding Initiative

Social Security Act (Title XVIII) Standard References

 

  • 1862 (a)(1)(A) Medically Reasonable & Necessary
  • 1862 (a)(1)(D) Investigational or Experimental
  • 1862 (a)(6) Personal Comfort Items
  • 1862 (a)(7) Screening (Routine Physical Checkups)
  • 1862 (a)(10) Cosmetic Surgery
  • 1862 (a)(12) Dental
  • 1862 (a)(13)(A) Treatment of Flat Foot
  • 1862 (a)(13)(B) Treatment of Subluxation of the Foot
  • 1862 (a)(13)(C) Routine Foot Care

 

 

Primary Geographic Jurisdiction 

New Jersey
Tennessee
 

 

Secondary Geographic Jurisdiction 

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 09/30/2003  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 04/24/2006  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

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.

Concurrent hospital care during hospice (condition code 07), will be denied when the hospice diagnosis is:

·  Debility, ICD-9 code 799.3

·  Adult failure to thrive, ICD-9 code 783.7

·  Other general symptoms, ICD-9code 780.9

"Non-covered services" are services and procedures billed to the patient, not covered by Medicare, and are always denied either because:

 

  • 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:

 

  • The beneficiary already knows are noncovered 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:

 

  • 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

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 noncover 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:

 

  • experimental
  • not yet proven safe and effective
  • not yet approved by the FDA




Reasons for Denial

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:

 

  • Investigational
  • Cosmetic
  • Routine screening
  • Dental
  • Program exclusion
  • Otherwise not covered
  • Never medically necessary


 

 

Coverage Topic 

Diagnostic Tests and X-Rays
Lab Services
Outpatient Hospital Services
Prescription Drugs
Surgical Services
 

 

Coding Information

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

Hospital-inpatient or home health visits (Part B only)

13x

Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)

14x

Non-Patient Laboratory Specimens

18x

Hospital-swing beds

21x

SNF-inpatient, Part A

22x

SNF-inpatient or home health visits (Part B only)

23x

SNF-outpatient (HHA-A also)

28x

SNF-swing beds

71x

Clinic-rural health

72x

Clinic-hospital based or independent renal dialysis facility

73x

Clinic-independent provider based FQHC (eff 10/91)

74x

Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97)

75x

Clinic-CORF

83x

Special facility or ASC surgery-ambulatory surgical center (Discontinued for Hospitals Subject to Outpatient PPS; hospitals must use 13X for ASC claims submitted for OPPS payment -- eff. 7/00)

85x

Special facility or ASC surgery-rural primary care hospital (eff 10/94)

 

 

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.

 

025X

Pharmacy-general classification

026X

IV therapy-general classification

027X

Medical/surgical supplies-general classification (also see 062X)

030X

Laboratory-general classification

031X

Laboratory pathological-general classification

0323

Radiology diagnostic-arteriography

033X

Radiology therapeutic-general classification

034X

Nuclear medicine-general classification

035X

Computed tomographic (CT) scan-general classification

036X

Operating room services-general classification

037X

Anesthesia-general classification

040X

Other imaging services-general classification

041X

Respiratory services-general classification

042X

Physical therapy-general classification

043X

Occupational therapy-general classification

044X

Speech language pathology-general classification

046X

Pulmonary function-general classification

048X

Cardiology-general classification

049X

Ambulatory surgical care-general classification

050X

Outpatient services-general classification (deleted 9/93)

051X

Clinic-general classification

052X

Free-standing clinic-general classification

055X

Skilled nursing-general classification

063X

Drugs requiring specific identification-general classification

073X

EKG/ECG-general classification

074X

EEG-general classification

075X

Gastro-intestinal services-general classification

076X

Treatment or observation room-general classification

092X

Other diagnostic services-general classification

094X

Other therapeutic services-general classification

 

 

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
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)

Laboratory Procedures

80055

OBSTETRIC PANEL

80103

TISSUE PREPARATION FOR DRUG ANALYSIS

82016

ACYLCARNITINES; QUALITATIVE, EACH SPECIMEN

82017

ACYLCARNITINES; QUANTITATIVE, EACH SPECIMEN

82172

APOLIPOPROTEIN, EACH

82286

BRADYKININ

82485

CHONDROITIN B SULFATE, QUANTITATIVE

82489

CHROMATOGRAPHY, QUALITATIVE; THIN LAYER, ANALYTE NOT ELSEWHERE SPECIFIED

82664

ELECTROPHORETIC TECHNIQUE, NOT ELSEWHERE SPECIFIED

83634

LACTOSE, URINE; QUANTITATIVE

83883

NEPHELOMETRY, EACH ANALYTE NOT ELSEWHERE SPECIFIED

84061

PHOSPHATASE, ACID; FORENSIC EXAMINATION

84255

SELENIUM

84525

UREA NITROGEN; SEMIQUANTITATIVE (EG, REAGENT STRIP TEST)

84830

OVULATION TESTS, BY VISUAL COLOR COMPARISON METHODS FOR HUMAN LUTEINIZING HORMONE

85337

THROMBOMODULIN

86243

FC RECEPTOR

86316

IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH

86343

LEUKOCYTE HISTAMINE RELEASE TEST (LHR)

86378

MIGRATION INHIBITORY FACTOR TEST (MIF)

86602

ANTIBODY; ACTINOMYCES

86628

ANTIBODY; CANDIDA

86723

ANTIBODY; LISTERIA MONOCYTOGENES

86732

ANTIBODY; MUCORMYCOSIS

86970

PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR COMPATIBILITY TESTING; INCUBATION WITH CHEMICAL AGENTS OR DRUGS, EACH

86971

PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR COMPATIBILITY TESTING; INCUBATION WITH ENZYMES, EACH

86972

PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR COMPATIBILITY TESTING; BY DENSITY GRADIENT SEPARATION

86975

PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY IDENTIFICATION; INCUBATION WITH DRUGS, EACH

86976

PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY IDENTIFICATION; BY DILUTION

86977

PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY IDENTIFICATION; INCUBATION WITH INHIBITORS, EACH

86978

PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY IDENTIFICATION; BY DIFFERENTIAL RED CELL ABSORPTION USING PATIENT RBCS OR RBCS OF KNOWN PHENOTYPE, EACH ABSORPTION

87272

INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; CRYPTOSPORIDIUM

87470

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AND BARTONELLA QUINTANA, DIRECT PROBE TECHNIQUE

87471

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AND BARTONELLA QUINTANA, AMPLIFIED PROBE TECHNIQUE

87472

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AND BARTONELLA QUINTANA, QUANTIFICATION

87475

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI, DIRECT PROBE TECHNIQUE

87476

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI, AMPLIFIED PROBE TECHNIQUE

87477

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI, QUANTIFICATION

87485

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE, DIRECT PROBE TECHNIQUE

87487

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE, QUANTIFICATION

87492

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, QUANTIFICATION

87511

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS, AMPLIFIED PROBE TECHNIQUE

87512

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS, QUANTIFICATION

87525

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, DIRECT PROBE TECHNIQUE

87526

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, AMPLIFIED PROBE TECHNIQUE

87527

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, QUANTIFICATION

87529

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, AMPLIFIED PROBE TECHNIQUE

87530

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, QUANTIFICATION

87531

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, DIRECT PROBE TECHNIQUE

87532

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, AMPLIFIED PROBE TECHNIQUE

87533

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, QUANTIFICATION

87540

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA, DIRECT PROBE TECHNIQUE

87541

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA, AMPLIFIED PROBE TECHNIQUE

87542

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA, QUANTIFICATION

87552

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES, QUANTIFICATION

87557

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA TUBERCULOSIS, QUANTIFICATION

87562

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INTRACELLULARE, QUANTIFICATION

87580

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIAE, DIRECT PROBE TECHNIQUE

87581

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIAE, AMPLIFIED PROBE TECHNIQUE

87582

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIAE, QUANTIFICATION

87592

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, QUANTIFICATION

87620

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); PAPILLOMAVIRUS, HUMAN, DIRECT PROBE TECHNIQUE

87621

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); PAPILLOMAVIRUS, HUMAN, AMPLIFIED PROBE TECHNIQUE

87622

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); PAPILLOMAVIRUS, HUMAN, QUANTIFICATION

87650

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, DIRECT PROBE TECHNIQUE

87652

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, QUANTIFICATION

88000 - 88099

NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; WITHOUT CNS - UNLISTED NECROPSY (AUTOPSY) PROCEDURE

88371

PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH INTERPRETATION AND REPORT;

88372

PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH INTERPRETATION AND REPORT; IMMUNOLOGICAL PROBE FOR BAND IDENTIFICATION, EACH

89250 - 89261

CULTURE OF OOCYTE(S)/EMBRYO(S), LESS THAN 4 DAYS; - SPERM ISOLATION; COMPLEX PREP (EG, PERCOLL GRADIENT, ALBUMIN GRADIENT) FOR INSEMINATION OR DIAGNOSIS WITH SEMEN ANALYSIS

89264