CodeMap® LCD-L39128

Contractor Information

Contractor Name: Palmetto GBA - Full list of policies of this Medicare Contractor

Contractor Number: 10111
Contractor Type: MAC A

LCD Information

LCD ID Number: L39128 Status: A-Approved
LCD Title: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
Geographic Jurisdiction: Alabama Other Jurisdictions
Original Determination Effective Date: 04/30/2023
Original Determination Ending Date:
Revision Effective Date: 09/12/2024
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

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §50.4.1 Approved Use of Drug

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §10 General Exclusions from Coverage, §140 Dental Services Exclusion, and §180 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §110.23 Stem Cell Transplantation

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12/10/2024 05:21:55 18.97.14.84

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