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CodeMap® LCD-L39051


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LCD for Cosmetic and Reconstructive Surgery (L39051)
See related Articles:
A58774-Billing and Coding: Cosmetic and Reconstructive Surgery
A58896-Response to Comments: Cosmetic and Reconstructive Surgery (DL39051)

Contractor Information

Contractor Name: Wisconsin Physicians Service Insurance Corporation - Full list of policies of this Medicare Contractor

Contractor Number: 05302

Contractor Type: MAC B

LCD Information

LCD ID Number: L39051 Status: A-Approved

LCD Title: Cosmetic and Reconstructive Surgery

Geographic Jurisdiction: Missouri - Entire State, Missouri - Northwestern Other Jurisdictions

Original Determination Effective Date: 11/14/2021

Original Determination Ending Date:

Revision Effective Date:

Revision End Date:

CMS National Coverage Policy:

CMS PUB. 100-02 Medicare Benefit Policy Manual
Chapter 1 – Inpatient Hospital Services Covered under Part A
§120 - Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare
Chapter 16-General Exclusions from Coverage:
§120 Cosmetic Surgery
§180 - Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.

CMS PUB. 100-3 Medicare National Coverage Determinations Manual
Chapter 1, Part 2
§140.2 - Breast Reconstruction Following Mastectomy
§140.4 - Plastic Surgery to Correct "Moon Face"
Chapter 1, Part 4
§250.4 – Treatment of Actinic Keratosis
§250.5 - Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS)

CMS PUB 100-04 Medicare Claims Processing Manual
Chapter 32 - Billing Requirements for Special Services
§260 - Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS)

CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD.

National Coverage Determination 250.5 Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome

Title XVIII of the Social Security Act(SSA): 1862 (a)(1)(A) Medically Reasonable & Necessary tests used in the diagnosis and management of illness or injury or to improve the function of a malformed body part.
Title XVIII of the Social Security Act(SSA): 1862 (a)(1)(D) Investigational or Experimental.
Title XVIII of the Social Security Act, Section 1862 (a)(10). This section excludes Cosmetic Surgery.

Change Request 10901, Transmittal 829, Local Coverage Determinations (LCDs) October 3, 2018

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06/03/2023 05:29:39

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