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Contractor Information

Contractor Name: Palmetto GBA - Full list of policies of this Medicare Contractor Contractor Number: 11201 Contractor Type: MAC A

LCD Information

LCD ID Number: L39671 Status: A-Approved LCD Title: Trigger Point Injections (TPI) Geographic Jurisdiction: South Carolina Other Jurisdictions Original Determination Effective Date: 03/31/2024 Original Determination Ending Date: Revision Effective Date: Revision End Date: CMS National Coverage Policy: Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those 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, §1862(a)(1)(D) states no payment can be made for services that are for research or experimentation. Title XVIII of the Social Security Act, Section §1862(a)(7) states Medicare will not cover any services or procedures associated with routine physical examinations. Title XVIII of the Social Security Act, Section §1861(s)(2) Medical and Other Health Services 42 CFR §410.74 Physician assistants’ services, §410.75 Nurse practitioners’ services and §410.76 Clinical nurse specialists’ services CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, §13.5.4 Reasonable and Necessary Provision in LCDs CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1 §30.3.3 Acupuncture for Chronic Lower Back Pain (cLBP) Sorry, you need to login or register to view additional sections of this Medicare policy. *