CodeMap® LCD-L39911

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: L39911 Status: A-Approved
LCD Title: Total Joint Arthroplasty
Geographic Jurisdiction: Missouri - Entire State, Missouri - Northwestern Other Jurisdictions
Original Determination Effective Date: 10/13/2024
Original Determination Ending Date:
Revision Effective Date: 02/28/2025
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.

Internet Only Manual (IOM) Citations:

CMS IOM Publication 100-08, Medicare Program Integrity Manual,

Chapter 6, Section 6.5.2 Conducting Patient Status Reviews of Claims for Medicare Part A Payment for Inpatient Hospital Admissions

Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

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 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Federal Register References:

Code of Federal Regulations (CFR), Title 21, Volume 8, Chapter I, Subchapter H, Part 888 Orthopedic Devices.

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06/25/2025 02:52:54 18.97.14.90

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