Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are 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)(1)(D) Items and services related to research and experimentation.
Title XVIII of the Social Security Act, §1862(a)(7) states Medicare will not cover any services or procedures associated with routine physical checkups.
Title XVIII of the Social Security Act, §1862(I)(5)(D) The 21st Century Cures Act of 2016 (Public Law 114-255) added language directing the Secretary of the Department of Health and Human Services (DHHS) to improve the transparency of the LCD process.
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).
CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §220 Radiology and §220.1 Computed Tomography (CT).
CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, §13.5.4 Reasonable and Necessary Provisions in LCDs.
Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries.
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