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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: L39420 Status: A-Approved LCD Title: Thermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain Geographic Jurisdiction: Alabama Other Jurisdictions Original Determination Effective Date: 03/05/2023 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) excludes routine physical examinations. 42 CFR §410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) 42 CFR §416.65 Covered surgical procedures CMS Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §220.2 Magnetic Resonance Imaging (MRI) CMS Internet-Only Manual, Publication 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. *