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Contractor Information

Contractor Name: Palmetto GBA - Full list of policies of this Medicare Contractor Contractor Number: 11502 Contractor Type: MAC B

LCD Information

LCD ID Number: L39260 Status: A-Approved LCD Title: Hyaluronic Acid Injections for Knee Osteoarthritis Geographic Jurisdiction: North Carolina Other Jurisdictions Original Determination Effective Date: 08/21/2022 Original Determination Ending Date: Revision Effective Date: 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 Title XVIII of the Social Security Act, §1862(a)(7) states Medicare will not cover any services or procedures associated with routine physical checkups CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §50.3 Incident-to Requirements and §50.4.1 Approved Use of Drug CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, §13.5.4 Reasonable and Necessary Provision in an LCD Sorry, you need to login or register to view additional sections of this Medicare policy. *