Italicized font represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.
Title XVIII of the Social Security Act (SSA):
Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Section 1862(a)(1)(A) excludes 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.
Section 1862 (a)(7) excludes routine physical examinations.
Code of Federal Regulations: 42 CFR Section 410.32 – Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostics tests: Conditions. This 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) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary.
CMS Publications:
CMS Publication 100-03, National Coverage Determination Manual, Chapter 1- Coverage Determinations Part 4, §220.1 Computed Tomography (CT)
CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 13 – Radiology Services and Other Diagnostic Procedures, §20 Payment Conditions for Radiology Services
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