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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 Sorry, you need to login or register to view additional sections of this Medicare policy. * All information on this web site is compiled directly from information obtained from the Center for Medicare and Medicaid Services (CMS) and from its Contractors. CodeMap® has made every reasonable effort to ensure the accuracy of the information contained on this web site. However, the ultimate responsibility for correct coding and claims submission lies with the provider of services. CodeMap® makes no representation, warranty, or guarantee that this compilation of Medicare information is error-free or that the use of this information will result in Medicare coverage and subsequent payment of claims. Final coverage and payment of claims are subject to many factors exclusively controlled by CMS and its contractors. No part of this web page or data displayed may be redistibuted or used without the express written consent of Wheaton Partners, LLC. 06/03/2023 05:29:39 35.172.111.47