LCD ID Number: L38792 Status: A-Approved
LCD Title: Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza®)
Geographic Jurisdiction: North Carolina Other Jurisdictions
Original Determination Effective Date:
02/07/2021
Original Determination Ending Date:
Revision Effective Date:
05/26/2022
Revision End Date:
CMS National Coverage Policy:
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) indicates no payment may be made in the case of clinical care where items and services provided are in research and experimentation.
CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 14, §10 Coverage of Medical Devices
CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 23, §30 Services Paid Under the Medicare Physician's Fee Schedule
CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.5.4 Reasonable and Necessary Provisions in LCDs
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