LCD ID Number: L36889 Status: A-Approved
LCD Title: Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography
Geographic Jurisdiction: Washington 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), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services that “are not 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)(7) and 42 Code of Federal Regulations, Section 411.15, exclude routine physical examinations.
Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.
CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §50-50.4, and CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §20.4.4, allows for a separate payment for the supply of a radiopharmaceutical diagnostic imaging agent and/or pharmacologic stressing agent with diagnostic nuclear medicine procedures.
CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §50. This section specifies coverage for drugs and biologicals.
CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, §20.10; Supplies, regarding pharmaceutic stressing agents. (Repealed 02/22/2010,see Pub. 100-04, Ch. 32, §140.)
The Code of Federal Regulations (CFR), 42 CFR 410.32, specifies that all diagnostic tests “must be ordered by the physician who is treating the beneficiary.”
Section 4317(b), of the Balanced Budget Act (BBA) of 1997, specifies that referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered.
CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.6.1; Requirements for Ordering and Following Orders for Diagnostic Tests and Definitions.
CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §30.6.6.B, clarifies coverage for preoperative evaluations.
CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §§20, 20.1, 20.2, 20.2.2, 20.2.3, 20.3.1 and 20.3.2; Payment conditions for Radiology Services.
CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80, Requirements for Diagnostic X-Ray, Diagnostic Laboratory and other Diagnostic Tests sets forth the various levels of physician supervision required for diagnostic tests.
CMS Manual System, Pub.100.04, Medicare Claims Processing Manual, Chapter 32, §§140.1, 140.1.1, 140.2, 126.96.36.199, 188.8.131.52, 184.108.40.206, 220.127.116.11, 18.104.22.168, 140.3, 140.3.1., Cardiac Rehabilitation.
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05/10/2021 11:16:25 22.214.171.124