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Contractor Information

Contractor Name: Novitas Solutions, Inc. - Full list of policies of this Medicare Contractor Contractor Number: 04111 Contractor Type: MAC A

LCD Information

LCD ID Number: L39068 Status: A-Approved LCD Title: Platelet Rich Plasma Geographic Jurisdiction: Colorado Other Jurisdictions Original Determination Effective Date: 12/12/2021 Original Determination Ending Date: Revision Effective Date: 12/12/2021 Revision End Date: CMS National Coverage Policy: This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for platelet rich plasma. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for platelet rich plasma and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site: IOM Citations: CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 10 General Exclusions from Coverage CMS Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 270.3 Blood-Derived Products for Chronic Non-Healing Wounds1 CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30A Physician’s Services Chapter 30, Section 50.3.1 Mandatory ABN Uses Social Security Act (Title XVIII) Standard References: Title XVIII of the Social Security Act, §1862(a)(1)(A) states that no Medicare payment may be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. Title XVIII of the Social Security Act, §1862(a)(1)(D) addresses services that are determined to be investigational or experimental. Title XVIII of the Social Security Act, §1862(a)(7). This section excludes routine physical examinations. Sorry, you need to login or register to view additional sections of this Medicare policy. *