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Contractor Information

Contractor Name: Wisconsin Physicians Service Insurance Corporation - Full list of policies of this Medicare Contractor Contractor Number: 05401 Contractor Type: MAC A

LCD Information

LCD ID Number: L39051 Status: A-Approved LCD Title: Cosmetic and Reconstructive Surgery Geographic Jurisdiction: Nebraska Other Jurisdictions Original Determination Effective Date: 11/14/2021 Original Determination Ending Date: Revision Effective Date: 10/13/2024 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 language/wording. CMS PUB. 100-02 Medicare Benefit Policy Manual Chapter 1 – Inpatient Hospital Services Covered under Part A §120 - Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare Chapter 16-General Exclusions from Coverage: §120 Cosmetic Surgery §180 - Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare. CMS PUB. 100-3 Medicare National Coverage Determinations Manual Chapter 1, Part 2 §140.2 - Breast Reconstruction Following Mastectomy §140.4 - Plastic Surgery to Correct "Moon Face" Chapter 1, Part 4 §250.4 – Treatment of Actinic Keratosis §250.5 - Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS) CMS PUB 100-04 Medicare Claims Processing Manual Chapter 32 - Billing Requirements for Special Services §260 - Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS) CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD. National Coverage Determination 250.5 Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome Title XVIII of the Social Security Act (SSA): 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 (SSA): 1862 (a)(1)(D) Investigational or Experimental. Title XVIII of the Social Security Act, Section 1862 (a)(10). This section excludes Cosmetic Surgery. 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. Change Request 10901, Transmittal 829, Local Coverage Determinations (LCDs) October 3, 2018 Sorry, you need to login or register to view additional sections of this Medicare policy. *