This Local Coverage Determination (LCD) supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for additional hemodialysis sessions. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for additional hemodialysis sessions and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant Centers for Medicare and Medicaid Services (CMS) manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:
Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
CMS Internet-Only Manual, Pub 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 1, §10 General Program Benefits
CMS Internet-Only Manual, Pub 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 2, §10 Hospital Insurance Entitlement
CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 11, §90 Medicare as a Secondary Payer (MSP), §140 Transplantation
CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §110.10 Intravenous Iron Therapy and §110.15 Ultrafiltration, Hemoperfusion and Hemofiltration
CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §260.6 Dental Examination Prior to Kidney Transplantation
CMS Internet-Only Manual, Pub 100-05, Medicare Secondary Payer (MSP) Manual, Chapter 2, §20 MSP Provisions for End-Stage Renal Disease (ESRD) Beneficiaries
CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.5.1 General Requirements
42 CFR §494.80 Condition: Patient assessment
42 CFR §494.90 Condition: Patient plan of care
CMS Final Rule CMS-1651-F published November 4, 2016
CMS Ruling 95-1 (V) Acceptable Standards of Practice—Application
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