LCD ID Number: L34760 Status: A-Approved
LCD Title: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Geographic Jurisdiction: Michigan Other Jurisdictions
Original Determination Effective Date:
Original Determination Ending Date:
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CMS National Coverage Policy:
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 100-03, Medicare National Coverage Determinations Manual, Chapter 1:
Part 1: Section: 80.6 Intraocular Photography; 80.9, Computer Enhanced Perimetry.
Part 2: Section: 140.5 Laser Procedures
Part 4: Section: 220.1 Computerized Tomography (CT)
Change Request 10901, Local Coverage Determinations (LCDs)
CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 – Reasonable and Necessary Provisions in an LCD.
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