LCD ID Number: L35751 Status: A-Approved
LCD Title: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies
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 section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Title XVIII of the Social Security Act section 1862 (a) (1) (A) allows coverage and payment of those items or services that are 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) excludes Medicare payment for any expenses incurred for items or services that are investigational or experimental.
Title XVIII of the Social Security Act section 1862 (a) (7) excludes routine physical examinations and services from Medicare coverage.
42 CFR, Section 410.32 Diagnosis x-ray tests, diagnostic laboratory tests, and other diagnostic 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 patient are not reasonable and necessary (see 42 CFR 411.15(k) (1).
42 CFR, Section 410.32 (b) Diagnostic x-ray and other diagnostic tests. (1) Basic rule. .. all diagnostic x-ray and other diagnostic tests covered under section 1861(s)(3) of the Act and payable under the physician fee schedule must be furnished under the appropriate level of supervision by a physician as defined in section 1861® of the Act. Services furnished without the required level of supervision are not reasonable and necessary. (see 42 CFR 411.15(k)(1)).
CMS Pub. 100-02 Medicare Benefit Policy Manual, Chapter 11 – End Stage Renal Disease, Section 40 – Other Services.
Chapter 15 – Covered Medical and Other Health Services, Section
80 – Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.
CMS Pub 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1 – Coverage Determinations Part 1, Section
20.14 – Plethysmography and
Part 4, Sections 220.5 - Ultrasound Diagnostic Procedures,
CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 7 – SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule), Section
50 – Billing Part B Radiology Services and Other Diagnostic Procedures;
Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/ Supplier Claims, Sections 140 – Monthly Capitation Payment Methods for Physicians’ Services Furnished to Patients on Maintenance Dialysis. A. – Services Included in Monthly Capitation Payment and
180 - Noninvasive Studies for ESRD Patients - Facility and Physician Services;
Chapter 13 – Radiology Services and Other Diagnostic Procedures, Sections –
10.1 Billing Part B Radiology Services and Other Diagnostic Procedures and
20 – Payment Conditions for Radiology Services; and
Chapter 16 – Laboratory Services, Section
40.2 – Payment Limit for Purchased Services, and
Chapter 23 – Fee Schedule Administration and Coding Requirements, Addendum – MPFSDB Record Layouts.
CMS Pub 100-08, Medicare Program Integrity Manual, Chapter 13 – Local Coverage Determinations, Section 13.5.1 – Reasonable and Necessary Provisions in LCDs.
CMS Publication 100-09, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5 - Correct Coding Initiative.
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