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Contractor Information

Contractor Name: Noridian Healthcare Solutions, LLC - Full list of policies of this Medicare Contractor Contractor Number: 03102 Contractor Type: MAC B

LCD Information

LCD ID Number: L36859 Status: A-Approved LCD Title: Trigger Point Injections (TPI) Geographic Jurisdiction: Arizona Other Jurisdictions Original Determination Effective Date: 05/26/2017 Original Determination Ending Date: Revision Effective Date: 04/01/2024 Revision End Date: CMS National Coverage Policy: Italicized font represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording. 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. Title XVIII of the Social Security Act, §1862(a)(1)(D) Investigational or Experimental IOM Citations: CMS IOM Publication 100-08, Medicare Program Integrity Manual, ~ Chapter 13, 13.5.4 Reasonable and Necessary Provision in an LCD Social Security Act (Title XVIII) Standard References: Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations. Code for Federal Regulations (CFR) References: CFR, Title 42, Ch. IV, §410.74 Physician assistant's services, §410.75 Nurse practitioner's services and §410.76 Clinical nurse specialist's services. NCDs NCD 30.3.3 Acupuncture for Chronic Low Back Pain Sorry, you need to login or register to view additional sections of this Medicare policy. *