LCD ID Number: L33622 Status: A-Approved
LCD Title: Pain Management
Geographic Jurisdiction: Illinois Other Jurisdictions
Original Determination Effective Date:
Original Determination Ending Date:
Revision Effective Date:
Revision End Date:
CMS National Coverage Policy:
Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.
Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:
Title XVIII of the Social Security Act (SSA):
Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Code of Federal Regulations:
42 CFR, Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:
50 – 50.6 Drugs and BiologicalsCMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:
80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsCMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1:
30.3 AcupunctureCMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:
150.7 Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents
220.1 Computed Tomography
280.14 Infusion Pumps
40 Surgeons and Global Surgery CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 13:
50 Payment for Anesthesiology Services
70 Payment Conditions for Radiology Services
140.3.2 Anesthesia Time and Calculation of Anesthesia Time Units
10 ICD-9-CM Coding for Diagnostic TestsCMS Publication 100-04, Medicare Claims Processing Manual, Chapter 23:
20 Payment Conditions for Radiology Services
30 Computerized Axial Tomography (CT) Procedures
20.9 Correct Coding Initiative (CCI)CMS Publication 100-08, Program Integrity Manual, Chapter 13:
13.5.1 – Reasonable and Necessary Provisions in LCDs National Correct Coding Initiative Policy Manual for Medicare Services, Chapter II: Anesthesia Services. CPT Codes 00000-09999.
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