LCD ID Number: L34645 Status: A-Approved
LCD Title: Drug Testing
Geographic Jurisdiction: Kansas Other Jurisdictions
Original Determination Effective Date:
Original Determination Ending Date:
Revision Effective Date:
Revision End Date:
CMS National Coverage Policy:
Title XVIII of the Social Security Act section 1862 (a) (1) (A). This section excludes coverage and payment of those items or services that are not considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Title XVIII of the Social Security Act section 1862 (a) (1) (D). This section states that no Medicare payment may be made under part A or part B for any expenses incurred for items or services that are investigational or experimental.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations and services.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
Code of Federal Regulations (CFR) Title 42, Part 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 section 411.15 (k) (1) of this chapter).
Medicare regulations at 42 CFR 410.32(a) state in part, that “…diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician 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.” Thus, except where other uses have been authorized by statute, Medicare does not cover diagnostic testing used for routine screening or surveillance.
CMS Pub 100-03 Medicare National Coverage Determination Manual, Chapter 1 – Coverage Determinations, Part 2, Sections 130.5 – Treatment of Alcoholism and Drug Abuse in a Freestanding Clinic and 130.6 – Treatment of Drug Abuse (Chemical Dependency).
CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 - Reasonable and Necessary Provisions in an LCD.
Change Request 10901, Local Coverage Determinations (LCDs)
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