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Contractor Information

Contractor Name: Noridian Healthcare Solutions, LLC - Full list of policies of this Medicare Contractor Contractor Number: 01211 Contractor Type: MAC A

LCD Information

LCD ID Number: L39881 Status: A-Approved LCD Title: Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT )/Coronary Plaque Analysis (AI-CPA) Geographic Jurisdiction: American Samoa, Guam, Hawaii, Northern Mariana Islands Other Jurisdictions Original Determination Effective Date: 12/08/2024 Original Determination Ending Date: Revision Effective Date: 02/14/2025 Revision End Date: CMS National Coverage Policy: CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 220. The 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. 42 CFR §414.92 codifies the Appropriate use Criteria Program policies. CMS Publications 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 section 1862 (1) (5) (D). 21st Century Cures Act of 2016 (Public Law 114-255)- The 21st Century Cures Act of 2016 added language to section 1862(l)(5)(D) of the Social Security Act (the Act) directing the Secretary of the Department of Health and Human Services (DHHS) to improve the transparency of the LCD process. 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, §1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. 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 Publication 100-3, National Coverage Determination Manual, Chapter 1 220.1 Computerized Tomography CMS Publication 100-4, Medicare Claims Processing Manual, Chapter 13 20 Payment Conditions for Radiology Services CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 - Reasonable and Necessary Provisions in an LCD. CMS Publication 100-9, Contractor Beneficiary and Provider Communication Manual, Chapter 5 20 Correct Coding Initiative Sorry, you need to login or register to view additional sections of this Medicare policy. *