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) Items and services related to research and experimentation.
Title XVIII of the Social Security Act, §1862 (a)(7) states Medicare will not cover any services or procedures associated with routine physical checkups.
Title XVIII of the Social Security Act, §1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
42 CFR §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).
42 CFR §414.92 codifies the Appropriate use Criteria Program policies.
CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §220.
The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries.
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