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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: L35761 Status: A-Approved LCD Title: Non-Invasive Peripheral Arterial Vascular Studies Geographic Jurisdiction: Missouri - Entire State, Missouri - Northwestern Other Jurisdictions Original Determination Effective Date: 10/01/2015 Original Determination Ending Date: Revision Effective Date: 10/26/2023 Revision End Date: CMS National Coverage Policy: Italicized font represents CMS national language/wording copied directly from CMS Manuals or CMS transmittals. Contractors are prohibited from changing national NCD language/wording. Title XVIII of the Social Security Act section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Title XVIII of the Social Security Act section 1862 (a) (1) (A) allows coverage and payment of those items or services that are considered to be medically 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 (a) (1) (D) excludes Medicare payment for any expenses incurred for items or services that are investigational or experimental. Title XVIII of the Social Security Act section 1862 (a) (7) excludes routine physical examinations and services from Medicare coverage. 42 CFR, Section 410.32 Diagnosis x-ray tests, diagnostic laboratory tests, and other diagnostic 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 patient are not reasonable and necessary (42 CFR 411.15(k) (1). 42 CFR, Section 410.32 (b) Diagnostic x-ray and other diagnostic tests. (1) Basic rule … all diagnostic x-ray and other diagnostic tests covered under section 1861(s)(3) of the Act and payable under the physician fee schedule must be furnished under the appropriate level of supervision by a physician as defined in section 1861® of the Act. Services furnished without the required level of supervision are not reasonable and necessary. (42 CFR 411.15(k)(1)). CMS Pub 100-02 Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 80 – Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests. CMS Pub 100-03 Medicare National Coverage Determinations (NCD) Manual, - Chapter 1 – Coverage Determinations Part 1, Section 20.14 – Plethysmography; and Part 4 Sections 220.5 - Ultrasound Diagnostic Procedures, 220.11 – Thermography, and 300.1 - Obsolete or Unreliable Diagnostic Tests. CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 7 – SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule), Section 50 – Billing Part B Radiology Services and Other Diagnostic Procedures; and Chapter 13 – Radiology Services and Other Diagnostic Procedures, Sections – 10.1 - Billing Part B Radiology Services and Other Diagnostic Procedures and 20 – Payment Conditions for Radiology Services. CMS Pub 100-08, Medicare Program Integrity Manual, Chapter 13 – Local Coverage Determinations, Section 13.5.1 – Reasonable and Necessary Provisions in LCDs. CMS Publication 100-09, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5 - Correct Coding Initiative. Sorry, you need to login or register to view additional sections of this Medicare policy. *