SUBJECT: LOCAL COVERAGE DETERMINATIONS

Local Coverage Determinations (LCDs) become effective 30 days from the date of publication.. The following general Medicare guidelines apply to all published LCDs:

• Medically Necessary and Reasonable

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A) states "...no payment may be made under Part A or Part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."

Medicare limits coverage of many procedures to certain ICD-9-CM diagnosis codes. Please be aware that it is not enough to link the procedure code to a payable ICD-9-CM diagnosis code. The diagnosis must be present for the procedure to be paid, but in addition, the procedure must be medically reasonable and necessary and representative of the patient’s condition. Medicare may require documentation of medical necessity on a pre-payment and /or post-payment basis or comprehensive medical review basis.

Please note that the ICD-9-CM codes must be coded to the highest level of specificity, coding to the fourth or fifth digit. This is a requirement for all claims.

• Documentation

Documentation supporting the medical necessity of the service should be legible, maintained in the patient’s medical record, and must be made available to Medicare upon request.

• Reimbursement

All of the coverage criteria listed for an individual LCD must be met.

• National Policy

In the event that a national policy is established for an active LCD, the national policy will take precedence over the LCD.

• Medical Review

Medicare will continue to monitor the utilization of Local Coverage Determinations through the Medical Review process.