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Contractor Information

Contractor Name: Wisconsin Physicians Service Insurance Corporation - Full list of policies of this Medicare Contractor Contractor Number: 05302 Contractor Type: MAC B

LCD Information

LCD ID Number: L35490 Status: A-Approved LCD Title: Category III Codes Geographic Jurisdiction: Missouri - Entire State, Missouri - Northwestern Other Jurisdictions Original Determination Effective Date: 10/01/2015 Original Determination Ending Date: Revision Effective Date: 01/01/2025 Revision End Date: CMS National Coverage Policy: Social Security Acts Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. Title XVIII of the Social Security Act, Section 1833(e) of the Social Security Act prevents Medicare from paying for services unless necessary and sufficient information is submitted that shows that services were provided and to determine the amounts due Title XVIII of the Social Security Act Section 1862(a)(1)(D) refers to limitations on items or devices that are investigational or experimental. CMS IOM Citations CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 14- Medical Devices, § 10, Coverage of Medical Devices. CMS IOM Publication 100-03 Medicare Benefit Policy Manual, Chapter 1, Part 1, § 20.4 Implantable Automatic Defibrillators. CMS IOM Publication 100-03 Medicare Benefit Policy Manual, Chapter 1, Part 2, § 150.13 Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS); and Part 4, § 310 Clinical Trials. CMS IOM Publication 100-04, Medicare Benefit Policy Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, § 30 Services paid under the Medicare Physicians Fee Schedule. CMS IOM Publication 100-04 Claims Processing Manual, Chapter 32, § 68 Investigational Device Exemptions (IDE) Studies, and § 330 Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS). CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, § 13.5.4 Reasonable and necessary provisions in LCDs & § 13.5.3 Evidentiary Content CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, § 13.2.4- Proposed LCD. Sorry, you need to login or register to view additional sections of this Medicare policy. *