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					     Title        Determination Number         Indication
                   98HH-002-L
Home Health - Psychiatric Care           The evaluation, psychotherapy and teaching activities needed by patie
                   98HH-002-L
Home Health - Psychiatric Care           The evaluation, psychotherapy and teaching activities needed by patie
Hospice - ALS      97AH-012-L            Amyotrophic Lateral Sclerosis (ALS) may support a prognosis of six m
Hospice - ALS      97AH-012-L            Amyotrophic Lateral Sclerosis (ALS) may support a prognosis of six m
                   99HH-021-L
Physical Therapy for Home Health         Physical therapy services are part of a constellation of rehabilitative se
                   99HH-021-L
Physical Therapy for Home Health         Physical therapy services are part of a constellation of rehabilitative se
                   97AH-008-M
Hospice - HIV Disease                    Medicare coverage of hospice care depends upon a physician's certific
                   97AH-008-M
Hospice - HIV Disease                    Medicare coverage of hospice care depends upon a physician's certific
                   97AH-013-M
Hospice - Liver Disease                  Medicare coverage of hospice care depends upon a physician?s certif
                   97AH-013-M
Hospice - Liver Disease                  Medicare coverage of hospice care depends upon a physician?s certif
                   97AH-014-L
Hospice - Renal Care                     End stage renal disease (ESRD) may support a prognosis of six month
                   97AH-014-L
Hospice - Renal Care                     End stage renal disease (ESRD) may support a prognosis of six month
                   97AH-010-M
Hospice Stroke and Coma                  Medicare coverage of hospice care depends upon a physician?s certif
                   97AH-010-M
Hospice Stroke and Coma                  Medicare coverage of hospice care depends upon a physician?s certif
                   Pathology
Speech-Language MA 2000-06Home Health    Speech-language pathology services are those services necessary for
                   Pathology
Speech-Language MA 2000-06Home Health    Speech-language pathology services are those services necessary for
Rheumatoid Factor98A-0015-L              Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98A-0015-L              Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98A-0015-L              Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98A-0015-L              Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98A-0015-L              Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98A-0015-L              Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98A-0015-L              Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98A-0015-L              Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98A-0015-L              Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98A-0015-L              Rheumatoid factor (RF) is an examination of the blood to determine th
Serum Magnesium97NC-006-L                Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                Magnesium is a mineral required by the body for the use of adenosine
Syphilis Test      96A-0014-L            The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test      96A-0014-L            The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test      96A-0014-L            The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test      96A-0014-L            The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test      96A-0014-L            The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test      96A-0014-L            The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test      96A-0014-L            The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test      96A-0014-L            The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test      96A-0014-L            The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test      96A-0014-L            The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test      96A-0014-L            The Venereal Disease Research Laboratory (VDRL) Test and its analo
Urinalysis         93A-0010-L            A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis         93A-0010-L            A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis         93A-0010-L            A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis        93A-0010-L                          A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis        93A-0010-L                          A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis        93A-0010-L                          A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis        93A-0010-L                          A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis        93A-0010-L                          A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis        93A-0010-L                          A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis        93A-0010-L                          A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis        93A-0010-L                          A urinalysis is a physical, chemical, and microscopic examination of ur
                  02NC-001-L
Abdominal Echography                                  Abdominal ultrasonography is a noninvasive procedure using high freq
                  02NC-001-L
Abdominal Echography                                  Abdominal ultrasonography is a noninvasive procedure using high freq
                  02NC-001-L
Abdominal Echography                                  Abdominal ultrasonography is a noninvasive procedure using high freq
                  02NC-001-L
Abdominal Echography                                  Abdominal ultrasonography is a noninvasive procedure using high freq
                  02NC-001-L
Abdominal Echography                                  Abdominal ultrasonography is a noninvasive procedure using high freq
                  02NC-001-L
Abdominal Echography                                  Abdominal ultrasonography is a noninvasive procedure using high freq
                  02NC-001-L
Abdominal Echography                                  Abdominal ultrasonography is a noninvasive procedure using high freq
                  02NC-001-L
Abdominal Echography                                  Abdominal ultrasonography is a noninvasive procedure using high freq
                  02NC-001-L
Abdominal Echography                                  Abdominal ultrasonography is a noninvasive procedure using high freq
Ambulance Services99NC-008-L                          Medicare covers ambulance services only if they are furnished to a be
Ambulance Services99NC-008-L                          Medicare covers ambulance services only if they are furnished to a be
Ambulance Services99NC-008-L                          Medicare covers ambulance services only if they are furnished to a be
Ambulance Services99NC-008-L                          Medicare covers ambulance services only if they are furnished to a be
Ambulance Services99NC-008-L                          Medicare covers ambulance services only if they are furnished to a be
B12 Injection     99NC-007-L                          Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     99NC-007-L                          Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     99NC-007-L                          Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     99NC-007-L                          Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     99NC-007-L                          Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     99NC-007-L                          Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     99NC-007-L                          Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     99NC-007-L                          Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     99NC-007-L                          Vitamin B12 (cobalamin) is essential to red blood cell production and n
                  L943                                Hyaluronic acid of Osteoarthrosis of the synovial fluid and cartilage. T
Hyaluronate Polymers (Hyalgan«, Synvisc«, Supartz«) for the Treatment is a natural constituent ofKnee
                  L943                                Hyaluronic acid of Osteoarthrosis of the synovial fluid and cartilage. T
Hyaluronate Polymers (Hyalgan«, Synvisc«, Supartz«) for the Treatment is a natural constituent ofKnee
                  L943                                Hyaluronic acid of Osteoarthrosis of the synovial fluid and cartilage. T
Hyaluronate Polymers (Hyalgan«, Synvisc«, Supartz«) for the Treatment is a natural constituent ofKnee
                  L943                                Hyaluronic acid of Osteoarthrosis of the synovial fluid and cartilage. T
Hyaluronate Polymers (Hyalgan«, Synvisc«, Supartz«) for the Treatment is a natural constituent ofKnee
                  L943                                Hyaluronic acid of Osteoarthrosis of the synovial fluid and cartilage. T
Hyaluronate Polymers (Hyalgan«, Synvisc«, Supartz«) for the Treatment is a natural constituent ofKnee
                  L943                                Hyaluronic acid of Osteoarthrosis of the synovial fluid and cartilage. T
Hyaluronate Polymers (Hyalgan«, Synvisc«, Supartz«) for the Treatment is a natural constituent ofKnee
                  L943                                Hyaluronic acid of Osteoarthrosis of the synovial fluid and cartilage. T
Hyaluronate Polymers (Hyalgan«, Synvisc«, Supartz«) for the Treatment is a natural constituent ofKnee
                  L943                                Hyaluronic acid of Osteoarthrosis of the synovial fluid and cartilage. T
Hyaluronate Polymers (Hyalgan«, Synvisc«, Supartz«) for the Treatment is a natural constituent ofKnee
                  L943                                Hyaluronic acid of Osteoarthrosis of the synovial fluid and cartilage. T
Hyaluronate Polymers (Hyalgan«, Synvisc«, Supartz«) for the Treatment is a natural constituent ofKnee
                  L943                                Hyaluronic acid of Osteoarthrosis of the synovial fluid and cartilage. T
Hyaluronate Polymers (Hyalgan«, Synvisc«, Supartz«) for the Treatment is a natural constituent ofKnee
                  L943                                Hyaluronic acid of Osteoarthrosis of the synovial fluid and cartilage. T
Hyaluronate Polymers (Hyalgan«, Synvisc«, Supartz«) for the Treatment is a natural constituent ofKnee
                  L943                                Hyaluronic acid of Osteoarthrosis of the synovial fluid and cartilage. T
Hyaluronate Polymers (Hyalgan«, Synvisc«, Supartz«) for the Treatment is a natural constituent ofKnee
                   Brow Repair
Blepharoplasty and97NC-009-L Procedures               Cosmetic surgery as defined by the Centers for Medicare and Medicai
                   Brow Repair
Blepharoplasty and97NC-009-L Procedures               Cosmetic surgery as defined by the Centers for Medicare and Medicai
                   Brow Repair
Blepharoplasty and97NC-009-L Procedures               Cosmetic surgery as defined by the Centers for Medicare and Medicai
                  99NC-003-L
Botulinum Toxin (Type A and Type B)                   Botulinum toxin injections are used to treat various focal muscle spast
                  99NC-003-L
Botulinum Toxin (Type A and Type B)                   Botulinum toxin injections are used to treat various focal muscle spast
                  99NC-003-L
Botulinum Toxin (Type A and Type B)                   Botulinum toxin injections are used to treat various focal muscle spast
                  99NC-003-L
Botulinum Toxin (Type A and Type B)                   Botulinum toxin injections are used to treat various focal muscle spast
                  99NC-003-L
Botulinum Toxin (Type A and Type B)                   Botulinum toxin injections are used to treat various focal muscle spast
                  99NC-003-L
Botulinum Toxin (Type A and Type B)                   Botulinum toxin injections are used to treat various focal muscle spast
                    99NC-003-L
Botulinum Toxin (Type A and Type B)                 Botulinum toxin injections are used to treat various focal muscle spast
                    99NC-003-L
Botulinum Toxin (Type A and Type B)                 Botulinum toxin injections are used to treat various focal muscle spast
                    97NC-004-L
Diagnostic Colonoscopy                              Colonoscopy is the visualization and examination of the entire colon an
                    97NC-004-L
Diagnostic Colonoscopy                              Colonoscopy is the visualization and examination of the entire colon an
                    97NC-004-L
Diagnostic Colonoscopy                              Colonoscopy is the visualization and examination of the entire colon an
                    97NC-004-L
Diagnostic Colonoscopy                              Colonoscopy is the visualization and examination of the entire colon an
                    97NC-004-L
Diagnostic Colonoscopy                              Colonoscopy is the visualization and examination of the entire colon an
                    97NC-004-L
Diagnostic Colonoscopy                              Colonoscopy is the visualization and examination of the entire colon an
                    97NC-004-L
Diagnostic Colonoscopy                              Colonoscopy is the visualization and examination of the entire colon an
                    97NC-004-L
Diagnostic Colonoscopy                              Colonoscopy is the visualization and examination of the entire colon an
                    97NC-004-L
Diagnostic Colonoscopy                              Colonoscopy is the visualization and examination of the entire colon an
                    97NC-004-L
Diagnostic Colonoscopy                              Colonoscopy is the visualization and examination of the entire colon an
                    L983
Immune Globulin Intravenous (IVIG)                  Intravenous Immune Globulin (IVIG) is a sterile solution of plasma pro
                    L983
Immune Globulin Intravenous (IVIG)                  Intravenous Immune Globulin (IVIG) is a sterile solution of plasma pro
                    L983
Immune Globulin Intravenous (IVIG)                  Intravenous Immune Globulin (IVIG) is a sterile solution of plasma pro
                    L983
Immune Globulin Intravenous (IVIG)                  Intravenous Immune Globulin (IVIG) is a sterile solution of plasma pro
                    L983
Immune Globulin Intravenous (IVIG)                  Intravenous Immune Globulin (IVIG) is a sterile solution of plasma pro
                    98NC-005-L
Colorectal Cancer Screening                         Cancer is the second most common cause of death in the United State
                    98NC-005-L
Colorectal Cancer Screening                         Cancer is the second most common cause of death in the United State
                    98NC-005-L
Colorectal Cancer Screening                         Cancer is the second most common cause of death in the United State
                    98NC-005-L
Colorectal Cancer Screening                         Cancer is the second most common cause of death in the United State
                    98NC-005-L
Colorectal Cancer Screening                         Cancer is the second most common cause of death in the United State
                    98NC-005-L
Colorectal Cancer Screening                         Cancer is the second most common cause of death in the United State
                    98NC-005-L
Colorectal Cancer Screening                         Cancer is the second most common cause of death in the United State
                    98NC-005-L
Colorectal Cancer Screening                         Cancer is the second most common cause of death in the United State
Infliximab          L994                            Infliximab is a chimeric monoclonal antibody which binds specifically to
Infliximab          L994                            Infliximab is a chimeric monoclonal antibody which binds specifically to
Infliximab          L994                            Infliximab is a chimeric monoclonal antibody which binds specifically to
Infliximab          L994                            Infliximab is a chimeric monoclonal antibody which binds specifically to
Infliximab          L994                            Infliximab is a chimeric monoclonal antibody which binds specifically to
Infliximab          L994                            Infliximab is a chimeric monoclonal antibody which binds specifically to
Infliximab          L994                            Infliximab is a chimeric monoclonal antibody which binds specifically to
Infliximab          L994                            Infliximab is a chimeric monoclonal antibody which binds specifically to
Infliximab          L994                            Infliximab is a chimeric monoclonal antibody which binds specifically to
Infliximab          L994                            Infliximab is a chimeric monoclonal antibody which binds specifically to
                    L1006
Interventional Cardiology                           Percutaneous transluminal coronary interventions have, since Gruentz
                    L1006
Interventional Cardiology                           Percutaneous transluminal coronary interventions have, since Gruentz
                    L1006
Interventional Cardiology                           Percutaneous transluminal coronary interventions have, since Gruentz
                    L1006
Interventional Cardiology                           Percutaneous transluminal coronary interventions have, since Gruentz
                    L1022
Modified Barium Swallow Studies                     Modified barium swallow studies by video fluoroscopy used to more ob
                    L1022
Modified Barium Swallow Studies                     Modified barium swallow studies by video fluoroscopy used to more ob
                    L1022
Modified Barium Swallow Studies                     Modified barium swallow studies by video fluoroscopy used to more ob
                    L1022
Modified Barium Swallow Studies                     Modified barium swallow studies by video fluoroscopy used to more ob
                    L1022
Modified Barium Swallow Studies                     Modified barium swallow studies by video fluoroscopy used to more ob
                    00NC-001-L
Psychiatric Partial Hospitalization Program (PHP)   Psychiatric partial hospitalization is a distinct and organized intensive p
                    00NC-001-L
Psychiatric Partial Hospitalization Program (PHP)   Psychiatric partial hospitalization is a distinct and organized intensive p
                    00NC-001-L
Psychiatric Partial Hospitalization Program (PHP)   Psychiatric partial hospitalization is a distinct and organized intensive p
                    97NC-007-L
Electrocardiographic Services                       The coverage criteria and definition of electrocardiographic services ar
                    97NC-007-L
Electrocardiographic Services                       The coverage criteria and definition of electrocardiographic services ar
                    97NC-007-L
Electrocardiographic Services                       The coverage criteria and definition of electrocardiographic services ar
                    97NC-007-L
Electrocardiographic Services                       The coverage criteria and definition of electrocardiographic services ar
                    97NC-007-L
Electrocardiographic Services                       The coverage criteria and definition of electrocardiographic services ar
                  97NC-007-L
Electrocardiographic Services       The coverage criteria and definition of electrocardiographic services ar
                  97NC-007-L
Electrocardiographic Services       The coverage criteria and definition of electrocardiographic services ar
                  97NC-007-L
Electrocardiographic Services       The coverage criteria and definition of electrocardiographic services ar
                  97NC-007-L
Electrocardiographic Services       The coverage criteria and definition of electrocardiographic services ar
                  97NC-007-L
Electrocardiographic Services       The coverage criteria and definition of electrocardiographic services ar
                  97NC-007-L
Electrocardiographic Services       The coverage criteria and definition of electrocardiographic services ar
Electrolyte Panel 00NC-004-L        This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 00NC-004-L        This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 00NC-004-L        This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 00NC-004-L        This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 00NC-004-L        This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 00NC-004-L        This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 00NC-004-L        This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 00NC-004-L        This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 00NC-004-L        This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 00NC-004-L        This chemistry panel is a disease oriented panel and used in the diagn
                  99NC-006-L
Intravenous Immunoglobulin (IVIG)   Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                  99NC-006-L
Intravenous Immunoglobulin (IVIG)   Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                  99NC-006-L
Intravenous Immunoglobulin (IVIG)   Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                  99NC-006-L
Intravenous Immunoglobulin (IVIG)   Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                  99NC-006-L
Intravenous Immunoglobulin (IVIG)   Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                  99NC-006-L
Intravenous Immunoglobulin (IVIG)   Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                  99NC-006-L
Intravenous Immunoglobulin (IVIG)   Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                  99NC-006-L
Intravenous Immunoglobulin (IVIG)   Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                  99NC-006-L
Intravenous Immunoglobulin (IVIG)   Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
Ionized Calcium 97NC-005-L          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97NC-005-L          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97NC-005-L          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97NC-005-L          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97NC-005-L          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97NC-005-L          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97NC-005-L          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97NC-005-L          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97NC-005-L          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97NC-005-L          Ionized calcium testing is used to evaluate non-bound calcium, a meas
                  98NC-008-L
Sedimentation Rate, Erythrocyte     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                  98NC-008-L
Sedimentation Rate, Erythrocyte     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                  98NC-008-L
Sedimentation Rate, Erythrocyte     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                  98NC-008-L
Sedimentation Rate, Erythrocyte     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                  98NC-008-L
Sedimentation Rate, Erythrocyte     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                  98NC-008-L
Sedimentation Rate, Erythrocyte     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                  98NC-008-L
Sedimentation Rate, Erythrocyte     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                  98NC-008-L
Sedimentation Rate, Erythrocyte     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                  98NC-008-L
Sedimentation Rate, Erythrocyte     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                  98NC-008-L
Sedimentation Rate, Erythrocyte     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                  98NC-008-L
Sedimentation Rate, Erythrocyte     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
Folic Acid, Serum 97NC-001-L        Folic acid, also known as folate, is a B complex vitamin which serves a
Folic Acid, Serum 97NC-001-L        Folic acid, also known as folate, is a B complex vitamin which serves a
Folic Acid, Serum 97NC-001-L        Folic acid, also known as folate, is a B complex vitamin which serves a
Folic Acid, Serum 97NC-001-L        Folic acid, also known as folate, is a B complex vitamin which serves a
Folic Acid, Serum 97NC-001-L        Folic acid, also known as folate, is a B complex vitamin which serves a
Folic Acid, Serum 97NC-001-L        Folic acid, also known as folate, is a B complex vitamin which serves a
Folic Acid, Serum 97NC-001-L       Folic acid, also known as folate, is a B complex vitamin which serves a
Folic Acid, Serum 97NC-001-L       Folic acid, also known as folate, is a B complex vitamin which serves a
Folic Acid, Serum 97NC-001-L       Folic acid, also known as folate, is a B complex vitamin which serves a
Folic Acid, Serum 97NC-001-L       Folic acid, also known as folate, is a B complex vitamin which serves a
                  99NC-001-L
Left Cardiac Catheterization       Cardiac catheterization is a technique in which a flexible catheter is pa
                  99NC-001-L
Left Cardiac Catheterization       Cardiac catheterization is a technique in which a flexible catheter is pa
                  99NC-001-L
Left Cardiac Catheterization       Cardiac catheterization is a technique in which a flexible catheter is pa
                  00NC-006-L
Hepatic Function Panel             This chemistry panel is an organ specific panel used in the diagnosis a
                  00NC-006-L
Hepatic Function Panel             This chemistry panel is an organ specific panel used in the diagnosis a
                  00NC-006-L
Hepatic Function Panel             This chemistry panel is an organ specific panel used in the diagnosis a
                  00NC-006-L
Hepatic Function Panel             This chemistry panel is an organ specific panel used in the diagnosis a
                  00NC-006-L
Hepatic Function Panel             This chemistry panel is an organ specific panel used in the diagnosis a
                  00NC-006-L
Hepatic Function Panel             This chemistry panel is an organ specific panel used in the diagnosis a
                  00NC-006-L
Hepatic Function Panel             This chemistry panel is an organ specific panel used in the diagnosis a
                  00NC-006-L
Hepatic Function Panel             This chemistry panel is an organ specific panel used in the diagnosis a
                  00NC-006-L
Hepatic Function Panel             This chemistry panel is an organ specific panel used in the diagnosis a
                  00NC-006-L
Hepatic Function Panel             This chemistry panel is an organ specific panel used in the diagnosis a
Leuprolide Acetate99NC-002-L       Leuprolide Acetate injection is a synthetic analog of the naturally occur
Leuprolide Acetate99NC-002-L       Leuprolide Acetate injection is a synthetic analog of the naturally occur
Leuprolide Acetate99NC-002-L       Leuprolide Acetate injection is a synthetic analog of the naturally occur
Leuprolide Acetate99NC-002-L       Leuprolide Acetate injection is a synthetic analog of the naturally occur
Leuprolide Acetate99NC-002-L       Leuprolide Acetate injection is a synthetic analog of the naturally occur
Leuprolide Acetate99NC-002-L       Leuprolide Acetate injection is a synthetic analog of the naturally occur
Leuprolide Acetate99NC-002-L       Leuprolide Acetate injection is a synthetic analog of the naturally occur
Leuprolide Acetate99NC-002-L       Leuprolide Acetate injection is a synthetic analog of the naturally occur
Leuprolide Acetate99NC-002-L       Leuprolide Acetate injection is a synthetic analog of the naturally occur
Leuprolide Acetate99NC-002-L       Leuprolide Acetate injection is a synthetic analog of the naturally occur
                   Therapy (HBO)
Hyperbaric Oxygen98NC-003-L        Hyperbaric Oxygen Therapy is a medical treatment in which the patien
                   Therapy (HBO)
Hyperbaric Oxygen98NC-003-L        Hyperbaric Oxygen Therapy is a medical treatment in which the patien
Infliximab        02NC-008-L       Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab        02NC-008-L       Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab        02NC-008-L       Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab        02NC-008-L       Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab        02NC-008-L       Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab        02NC-008-L       Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab        02NC-008-L       Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab        02NC-008-L       Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab        02NC-008-L       Infliximab is a chimeric monoclonal antibody that binds specifically to tu
                  L1117
Non-Invasive Vascular Studies      The accuracy of diagnostic ultrasound and echocardiography procedu
                  L1117
Non-Invasive Vascular Studies      The accuracy of diagnostic ultrasound and echocardiography procedu
                  L1117
Non-Invasive Vascular Studies      The accuracy of diagnostic ultrasound and echocardiography procedu
                  L1117
Non-Invasive Vascular Studies      The accuracy of diagnostic ultrasound and echocardiography procedu
                  L1117
Non-Invasive Vascular Studies      The accuracy of diagnostic ultrasound and echocardiography procedu
                  L1117
Non-Invasive Vascular Studies      The accuracy of diagnostic ultrasound and echocardiography procedu
                  L1117
Non-Invasive Vascular Studies      The accuracy of diagnostic ultrasound and echocardiography procedu
                  L1117
Non-Invasive Vascular Studies      The accuracy of diagnostic ultrasound and echocardiography procedu
                  L1117
Non-Invasive Vascular Studies      The accuracy of diagnostic ultrasound and echocardiography procedu
                  L1117
Non-Invasive Vascular Studies      The accuracy of diagnostic ultrasound and echocardiography procedu
                  L1117
Non-Invasive Vascular Studies      The accuracy of diagnostic ultrasound and echocardiography procedu
                  98NC-009-L
Magnetic Resonance Angiography     The coverage criteria and definition of magnetic resonance angiograph
                  98NC-009-L
Magnetic Resonance Angiography     The coverage criteria and definition of magnetic resonance angiograph
                  98NC-009-L
Magnetic Resonance Angiography     The coverage criteria and definition of magnetic resonance angiograph
                   97NC-003-L
Chest Radiologic Examination (Chest X-ray)      Radiologic examination of the chest (chest X-ray) facilitates the detect
                   97NC-003-L
Chest Radiologic Examination (Chest X-ray)      Radiologic examination of the chest (chest X-ray) facilitates the detect
                   97NC-003-L
Chest Radiologic Examination (Chest X-ray)      Radiologic examination of the chest (chest X-ray) facilitates the detect
                   97NC-003-L
Chest Radiologic Examination (Chest X-ray)      Radiologic examination of the chest (chest X-ray) facilitates the detect
                   97NC-003-L
Chest Radiologic Examination (Chest X-ray)      Radiologic examination of the chest (chest X-ray) facilitates the detect
                   97NC-003-L
Chest Radiologic Examination (Chest X-ray)      Radiologic examination of the chest (chest X-ray) facilitates the detect
                   97NC-003-L
Chest Radiologic Examination (Chest X-ray)      Radiologic examination of the chest (chest X-ray) facilitates the detect
                   97NC-003-L
Chest Radiologic Examination (Chest X-ray)      Radiologic examination of the chest (chest X-ray) facilitates the detect
                   97NC-003-L
Chest Radiologic Examination (Chest X-ray)      Radiologic examination of the chest (chest X-ray) facilitates the detect
                   00NC-002-L
Magnetic Resonance Imaging (MRI) of the Brain   Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic proce
                   00NC-002-L
Magnetic Resonance Imaging (MRI) of the Brain   Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic proce
                   00NC-002-L
Magnetic Resonance Imaging (MRI) of the Brain   Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic proce
                   00NC-002-L
Magnetic Resonance Imaging (MRI) of the Brain   Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic proce
                   00NC-002-L
Magnetic Resonance Imaging (MRI) of the Brain   Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic proce
                   00NC-005-L
Renal Function Panel                            This chemistry panel is a disease-oriented panel used in the diagnosis
                   00NC-005-L
Renal Function Panel                            This chemistry panel is a disease-oriented panel used in the diagnosis
                   00NC-005-L
Renal Function Panel                            This chemistry panel is a disease-oriented panel used in the diagnosis
                   00NC-005-L
Renal Function Panel                            This chemistry panel is a disease-oriented panel used in the diagnosis
                   00NC-005-L
Renal Function Panel                            This chemistry panel is a disease-oriented panel used in the diagnosis
                   00NC-005-L
Renal Function Panel                            This chemistry panel is a disease-oriented panel used in the diagnosis
                   00NC-005-L
Renal Function Panel                            This chemistry panel is a disease-oriented panel used in the diagnosis
                   00NC-005-L
Renal Function Panel                            This chemistry panel is a disease-oriented panel used in the diagnosis
                   00NC-005-L
Renal Function Panel                            This chemistry panel is a disease-oriented panel used in the diagnosis
                   00NC-005-L
Renal Function Panel                            This chemistry panel is a disease-oriented panel used in the diagnosis
                   99NC-004-L
Metabolic Laboratory Panels                     Two of the panel codes are similar in that they include laboratory studi
                   99NC-004-L
Metabolic Laboratory Panels                     Two of the panel codes are similar in that they include laboratory studi
                   99NC-004-L
Metabolic Laboratory Panels                     Two of the panel codes are similar in that they include laboratory studi
                   99NC-004-L
Metabolic Laboratory Panels                     Two of the panel codes are similar in that they include laboratory studi
                   99NC-004-L
Metabolic Laboratory Panels                     Two of the panel codes are similar in that they include laboratory studi
                   99NC-004-L
Metabolic Laboratory Panels                     Two of the panel codes are similar in that they include laboratory studi
                   99NC-004-L
Metabolic Laboratory Panels                     Two of the panel codes are similar in that they include laboratory studi
                   99NC-004-L
Metabolic Laboratory Panels                     Two of the panel codes are similar in that they include laboratory studi
                   99NC-004-L
Metabolic Laboratory Panels                     Two of the panel codes are similar in that they include laboratory studi
                   99NC-004-L
Metabolic Laboratory Panels                     Two of the panel codes are similar in that they include laboratory studi
                   97NC-002-L
Outpatient Occupational Therapy                 Although rehabilitative services are provided by occupational therapy,
                   97NC-002-L
Outpatient Occupational Therapy                 Although rehabilitative services are provided by occupational therapy,
                   97NC-002-L
Outpatient Occupational Therapy                 Although rehabilitative services are provided by occupational therapy,
                   97NC-002-L
Outpatient Occupational Therapy                 Although rehabilitative services are provided by occupational therapy,
                   97NC-002-L
Outpatient Occupational Therapy                 Although rehabilitative services are provided by occupational therapy,
                   97NC-002-L
Outpatient Occupational Therapy                 Although rehabilitative services are provided by occupational therapy,
                   97NC-002-L
Outpatient Occupational Therapy                 Although rehabilitative services are provided by occupational therapy,
                   97NC-002-L
Outpatient Occupational Therapy                 Although rehabilitative services are provided by occupational therapy,
                   97NC-002-L
Outpatient Occupational Therapy                 Although rehabilitative services are provided by occupational therapy,
                   97NC-002-L
Outpatient Occupational Therapy                 Although rehabilitative services are provided by occupational therapy,
                   97NC-002-L
Outpatient Occupational Therapy                 Although rehabilitative services are provided by occupational therapy,
                    Psychiatric Services
Outpatient HospitalL1154                        Outpatient hospital psychiatric services represent a continuum of ambu
                    Psychiatric Services
Outpatient HospitalL1154                        Outpatient hospital psychiatric services represent a continuum of ambu
                   98NC-010-L
Outpatient Observation Bed/Room Services        Observation services are defined as the use of a bed and periodic mon
                   98NC-010-L
Outpatient Observation Bed/Room Services        Observation services are defined as the use of a bed and periodic mon
                   02NC-003-L
Retroperitoneal Ultrasound                      Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   02NC-003-L
Retroperitoneal Ultrasound                      Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   02NC-003-L
Retroperitoneal Ultrasound                      Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   02NC-003-L
Retroperitoneal Ultrasound                 Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   02NC-003-L
Retroperitoneal Ultrasound                 Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   02NC-003-L
Retroperitoneal Ultrasound                 Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   02NC-003-L
Retroperitoneal Ultrasound                 Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   02NC-003-L
Retroperitoneal Ultrasound                 Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   02NC-003-L
Retroperitoneal Ultrasound                 Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   99NC-005-L
Outpatient Physical Therapy                Although there is an overlap in services provided by physical and occu
                   99NC-005-L
Outpatient Physical Therapy                Although there is an overlap in services provided by physical and occu
                   99NC-005-L
Outpatient Physical Therapy                Although there is an overlap in services provided by physical and occu
                   99NC-005-L
Outpatient Physical Therapy                Although there is an overlap in services provided by physical and occu
                   99NC-005-L
Outpatient Physical Therapy                Although there is an overlap in services provided by physical and occu
                   99NC-005-L
Outpatient Physical Therapy                Although there is an overlap in services provided by physical and occu
                   99NC-005-L
Outpatient Physical Therapy                Although there is an overlap in services provided by physical and occu
                   99NC-005-L
Outpatient Physical Therapy                Although there is an overlap in services provided by physical and occu
                   99NC-005-L
Outpatient Physical Therapy                Although there is an overlap in services provided by physical and occu
                   99NC-005-L
Outpatient Physical Therapy                Although there is an overlap in services provided by physical and occu
                   99NC-005-L
Outpatient Physical Therapy                Although there is an overlap in services provided by physical and occu
                   01A-0012-L
Abdominal Echography                       Abdominal ultrasonography is a noninvasive procedure using high freq
                   01A-0012-L
Abdominal Echography                       Abdominal ultrasonography is a noninvasive procedure using high freq
                   01A-0012-L
Abdominal Echography                       Abdominal ultrasonography is a noninvasive procedure using high freq
                   01A-0012-L
Abdominal Echography                       Abdominal ultrasonography is a noninvasive procedure using high freq
                   01A-0012-L
Abdominal Echography                       Abdominal ultrasonography is a noninvasive procedure using high freq
                   01A-0012-L
Abdominal Echography                       Abdominal ultrasonography is a noninvasive procedure using high freq
                   01A-0012-L
Abdominal Echography                       Abdominal ultrasonography is a noninvasive procedure using high freq
                   01A-0012-L
Abdominal Echography                       Abdominal ultrasonography is a noninvasive procedure using high freq
                   01A-0012-L
Abdominal Echography                       Abdominal ultrasonography is a noninvasive procedure using high freq
Rheumatoid Factor98NC-007-L                Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98NC-007-L                Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98NC-007-L                Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98NC-007-L                Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98NC-007-L                Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98NC-007-L                Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98NC-007-L                Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98NC-007-L                Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98NC-007-L                Rheumatoid factor (RF) is an examination of the blood to determine th
Rheumatoid Factor98NC-007-L                Rheumatoid factor (RF) is an examination of the blood to determine th
                   98NC-011-L
Right Cardiac Catheterization              A cardiac catheterization procedure typically includes insertion of a flex
                   98NC-011-L
Right Cardiac Catheterization              A cardiac catheterization procedure typically includes insertion of a flex
                   98NC-011-L
Right Cardiac Catheterization              A cardiac catheterization procedure typically includes insertion of a flex
Serum Magnesium97NC-006-L                  Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                  Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                  Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                  Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                  Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                  Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                  Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                  Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                  Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                  Magnesium is a mineral required by the body for the use of adenosine
Serum Magnesium97NC-006-L                  Magnesium is a mineral required by the body for the use of adenosine
                   99A-0005-L
Outpatient Observation Bed/Room Services   Observation services are defined as the use of a bed and periodic mon
                   99A-0005-L
Outpatient Observation Bed/Room Services   Observation services are defined as the use of a bed and periodic mon
Serum Phosphorus  02NC-004-L           Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  02NC-004-L           Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  02NC-004-L           Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  02NC-004-L           Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  02NC-004-L           Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  02NC-004-L           Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  02NC-004-L           Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  02NC-004-L           Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  02NC-004-L           Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  02NC-004-L           Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  02NC-004-L           Disorders of phosphorus homeostasis may be related to many patholo
                  Language Pathology
Outpatient Speech 02A-0005-L           Speech-Language Pathology (SLP) services are those services neces
                  Language Pathology
Outpatient Speech 02A-0005-L           Speech-Language Pathology (SLP) services are those services neces
                  Language Pathology
Outpatient Speech 02A-0005-L           Speech-Language Pathology (SLP) services are those services neces
                  Language Pathology
Outpatient Speech 02A-0005-L           Speech-Language Pathology (SLP) services are those services neces
                  Language Pathology
Outpatient Speech 02A-0005-L           Speech-Language Pathology (SLP) services are those services neces
                  Language Pathology
Outpatient Speech 02A-0005-L           Speech-Language Pathology (SLP) services are those services neces
                  Language Pathology
Outpatient Speech 02A-0005-L           Speech-Language Pathology (SLP) services are those services neces
                  Language Pathology
Outpatient Speech 02A-0005-L           Speech-Language Pathology (SLP) services are those services neces
                  Language Pathology
Outpatient Speech 02A-0005-L           Speech-Language Pathology (SLP) services are those services neces
                  Language Pathology
Outpatient Speech 02A-0005-L           Speech-Language Pathology (SLP) services are those services neces
                  Language Pathology
Outpatient Speech 02A-0005-L           Speech-Language Pathology (SLP) services are those services neces
                  Language Pathology
Outpatient Speech 02A-0005-L           Speech-Language Pathology (SLP) services are those services neces
Serum Potassium 98NC-006-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98NC-006-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98NC-006-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98NC-006-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98NC-006-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98NC-006-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98NC-006-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98NC-006-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98NC-006-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98NC-006-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98NC-006-L             Potassium is the major cation in intracellular fluid and is of primary imp
                  98NC-001-L
Outpatient Speech-Language Pathology   Speech-Language Pathology (SLP) services are those services neces
                  98NC-001-L
Outpatient Speech-Language Pathology   Speech-Language Pathology (SLP) services are those services neces
                  98NC-001-L
Outpatient Speech-Language Pathology   Speech-Language Pathology (SLP) services are those services neces
                  98NC-001-L
Outpatient Speech-Language Pathology   Speech-Language Pathology (SLP) services are those services neces
                  98NC-001-L
Outpatient Speech-Language Pathology   Speech-Language Pathology (SLP) services are those services neces
                  98NC-001-L
Outpatient Speech-Language Pathology   Speech-Language Pathology (SLP) services are those services neces
                  98NC-001-L
Outpatient Speech-Language Pathology   Speech-Language Pathology (SLP) services are those services neces
                  98NC-001-L
Outpatient Speech-Language Pathology   Speech-Language Pathology (SLP) services are those services neces
                  98NC-001-L
Outpatient Speech-Language Pathology   Speech-Language Pathology (SLP) services are those services neces
                  98NC-001-L
Outpatient Speech-Language Pathology   Speech-Language Pathology (SLP) services are those services neces
                  98NC-001-L
Outpatient Speech-Language Pathology   Speech-Language Pathology (SLP) services are those services neces
                  90A-0034-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  90A-0034-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  90A-0034-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  90A-0034-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  90A-0034-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  90A-0034-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  90A-0034-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  90A-0034-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  90A-0034-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  90A-0034-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  01A-0018-L
Colorectal Cancer Screening            Cancer is the second most common cause of death in the United State
                  01A-0018-L
Colorectal Cancer Screening            Cancer is the second most common cause of death in the United State
                  01A-0018-L
Colorectal Cancer Screening            Cancer is the second most common cause of death in the United State
                  01A-0018-L
Colorectal Cancer Screening            Cancer is the second most common cause of death in the United State
                  01A-0018-L
Colorectal Cancer Screening            Cancer is the second most common cause of death in the United State
                  01A-0018-L
Colorectal Cancer Screening            Cancer is the second most common cause of death in the United State
                  01A-0018-L
Colorectal Cancer Screening            Cancer is the second most common cause of death in the United State
                  01A-0018-L
Colorectal Cancer Screening            Cancer is the second most common cause of death in the United State
CT of the Head    93A-0029-L           Cranial Computerized Tomographic (CT) Scan is a very useful and info
CT of the Head    93A-0029-L           Cranial Computerized Tomographic (CT) Scan is a very useful and info
CT of the Head    93A-0029-L           Cranial Computerized Tomographic (CT) Scan is a very useful and info
CT of the Head    93A-0029-L           Cranial Computerized Tomographic (CT) Scan is a very useful and info
CT of the Head    93A-0029-L           Cranial Computerized Tomographic (CT) Scan is a very useful and info
Syphilis Test     96NC-001-L           The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test     96NC-001-L           The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test     96NC-001-L           The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test     96NC-001-L           The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test     96NC-001-L           The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test     96NC-001-L           The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test     96NC-001-L           The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test     96NC-001-L           The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test     96NC-001-L           The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test     96NC-001-L           The Venereal Disease Research Laboratory (VDRL) Test and its analo
Syphilis Test     96NC-001-L           The Venereal Disease Research Laboratory (VDRL) Test and its analo
                  01A-0015-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                 A diagnostic mammography is a
                  01A-0015-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                 A diagnostic mammography is a
                  01A-0015-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                 A diagnostic mammography is a
                  01A-0015-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                 A diagnostic mammography is a
                  01A-0015-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                 A diagnostic mammography is a
                  01A-0015-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                 A diagnostic mammography is a
                  01A-0015-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                 A diagnostic mammography is a
Serum Potassium 98A-0017-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98A-0017-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98A-0017-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98A-0017-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98A-0017-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98A-0017-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98A-0017-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98A-0017-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98A-0017-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98A-0017-L             Potassium is the major cation in intracellular fluid and is of primary imp
Serum Potassium 98A-0017-L             Potassium is the major cation in intracellular fluid and is of primary imp
                  01A-0014-L
Diagnostic Colonoscopy                 Colonoscopy is the visualization and examination of the entire colon an
                  01A-0014-L
Diagnostic Colonoscopy                 Colonoscopy is the visualization and examination of the entire colon an
                  01A-0014-L
Diagnostic Colonoscopy                 Colonoscopy is the visualization and examination of the entire colon an
                  01A-0014-L
Diagnostic Colonoscopy                 Colonoscopy is the visualization and examination of the entire colon an
                  01A-0014-L
Diagnostic Colonoscopy                 Colonoscopy is the visualization and examination of the entire colon an
                  01A-0014-L
Diagnostic Colonoscopy                 Colonoscopy is the visualization and examination of the entire colon an
                  01A-0014-L
Diagnostic Colonoscopy                 Colonoscopy is the visualization and examination of the entire colon an
                   01A-0014-L
Diagnostic Colonoscopy                         Colonoscopy is the visualization and examination of the entire colon an
                   01A-0014-L
Diagnostic Colonoscopy                         Colonoscopy is the visualization and examination of the entire colon an
                   01A-0014-L
Diagnostic Colonoscopy                         Colonoscopy is the visualization and examination of the entire colon an
                   01A-0011-L
Retroperitoneal Ultrasound                     Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   01A-0011-L
Retroperitoneal Ultrasound                     Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   01A-0011-L
Retroperitoneal Ultrasound                     Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   01A-0011-L
Retroperitoneal Ultrasound                     Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   01A-0011-L
Retroperitoneal Ultrasound                     Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   01A-0011-L
Retroperitoneal Ultrasound                     Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   01A-0011-L
Retroperitoneal Ultrasound                     Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   01A-0011-L
Retroperitoneal Ultrasound                     Retroperitoneal ultrasound studies represent the ultrasonic imaging of
                   01A-0011-L
Retroperitoneal Ultrasound                     Retroperitoneal ultrasound studies represent the ultrasonic imaging of
Urinalysis         97NC-008-L                  A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis         97NC-008-L                  A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis         97NC-008-L                  A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis         97NC-008-L                  A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis         97NC-008-L                  A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis         97NC-008-L                  A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis         97NC-008-L                  A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis         97NC-008-L                  A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis         97NC-008-L                  A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis         97NC-008-L                  A urinalysis is a physical, chemical, and microscopic examination of ur
Urinalysis         97NC-008-L                  A urinalysis is a physical, chemical, and microscopic examination of ur
                   99A-0015-L
Positron Emission Tomography                   The definition for Positron Emission Tomography is found in the CMS
                   99A-0015-L
Positron Emission Tomography                   The definition for Positron Emission Tomography is found in the CMS
                   99A-0015-L
Positron Emission Tomography                   The definition for Positron Emission Tomography is found in the CMS
                   99A-0015-L
Positron Emission Tomography                   The definition for Positron Emission Tomography is found in the CMS
                   99A-0015-L
Positron Emission Tomography                   The definition for Positron Emission Tomography is found in the CMS
                   L1276
Outpatient Pulmonary Rehabilitation Services   General Considerations Patients with diagnosed Chronic Respiratory
                   L1276
Outpatient Pulmonary Rehabilitation Services   General Considerations Patients with diagnosed Chronic Respiratory
                   L1276
Outpatient Pulmonary Rehabilitation Services   General Considerations Patients with diagnosed Chronic Respiratory
                   98NC-002-L
Vitamin B12 (Cyanocobalamin) Chemistry Test    The serum cyanocobalamin is a quantitative analysis of serum Vitamin
                   98NC-002-L
Vitamin B12 (Cyanocobalamin) Chemistry Test    The serum cyanocobalamin is a quantitative analysis of serum Vitamin
                   98NC-002-L
Vitamin B12 (Cyanocobalamin) Chemistry Test    The serum cyanocobalamin is a quantitative analysis of serum Vitamin
                   98NC-002-L
Vitamin B12 (Cyanocobalamin) Chemistry Test    The serum cyanocobalamin is a quantitative analysis of serum Vitamin
                   98NC-002-L
Vitamin B12 (Cyanocobalamin) Chemistry Test    The serum cyanocobalamin is a quantitative analysis of serum Vitamin
                   98NC-002-L
Vitamin B12 (Cyanocobalamin) Chemistry Test    The serum cyanocobalamin is a quantitative analysis of serum Vitamin
                   98NC-002-L
Vitamin B12 (Cyanocobalamin) Chemistry Test    The serum cyanocobalamin is a quantitative analysis of serum Vitamin
                   98NC-002-L
Vitamin B12 (Cyanocobalamin) Chemistry Test    The serum cyanocobalamin is a quantitative analysis of serum Vitamin
                   98NC-002-L
Vitamin B12 (Cyanocobalamin) Chemistry Test    The serum cyanocobalamin is a quantitative analysis of serum Vitamin
                   98NC-002-L
Vitamin B12 (Cyanocobalamin) Chemistry Test    The serum cyanocobalamin is a quantitative analysis of serum Vitamin
                   94A-0019-L
Electrocardiographic Services                  The coverage criteria and definition of electrocardiographic services ar
                   94A-0019-L
Electrocardiographic Services                  The coverage criteria and definition of electrocardiographic services ar
                   94A-0019-L
Electrocardiographic Services                  The coverage criteria and definition of electrocardiographic services ar
                   94A-0019-L
Electrocardiographic Services                  The coverage criteria and definition of electrocardiographic services ar
                   94A-0019-L
Electrocardiographic Services                  The coverage criteria and definition of electrocardiographic services ar
                   94A-0019-L
Electrocardiographic Services                  The coverage criteria and definition of electrocardiographic services ar
                   94A-0019-L
Electrocardiographic Services                  The coverage criteria and definition of electrocardiographic services ar
                   94A-0019-L
Electrocardiographic Services                  The coverage criteria and definition of electrocardiographic services ar
                   94A-0019-L
Electrocardiographic Services                  The coverage criteria and definition of electrocardiographic services ar
                   94A-0019-L
Electrocardiographic Services                  The coverage criteria and definition of electrocardiographic services ar
                   94A-0019-L
Electrocardiographic Services                  The coverage criteria and definition of electrocardiographic services ar
                    98A-0034-L
Psychiatric Partial Hospitalization Program (PHP)   Psychiatric partial hospitalization is a distinct and organized intensive p
                    98A-0034-L
Psychiatric Partial Hospitalization Program (PHP)   Psychiatric partial hospitalization is a distinct and organized intensive p
                    98A-0034-L
Psychiatric Partial Hospitalization Program (PHP)   Psychiatric partial hospitalization is a distinct and organized intensive p
                    98A-0014-L
Sedimentation Rate, Erythrocyte                     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                    98A-0014-L
Sedimentation Rate, Erythrocyte                     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                    98A-0014-L
Sedimentation Rate, Erythrocyte                     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                    98A-0014-L
Sedimentation Rate, Erythrocyte                     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                    98A-0014-L
Sedimentation Rate, Erythrocyte                     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                    98A-0014-L
Sedimentation Rate, Erythrocyte                     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                    98A-0014-L
Sedimentation Rate, Erythrocyte                     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                    98A-0014-L
Sedimentation Rate, Erythrocyte                     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                    98A-0014-L
Sedimentation Rate, Erythrocyte                     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                    98A-0014-L
Sedimentation Rate, Erythrocyte                     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                    98A-0014-L
Sedimentation Rate, Erythrocyte                     Erythrocyte sedimentation rate (ESR) is the rate at which erythrocytes
                    93A-0002-L
Chest Radiologic Examination (Chest X-Ray)          Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    93A-0002-L
Chest Radiologic Examination (Chest X-Ray)          Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    93A-0002-L
Chest Radiologic Examination (Chest X-Ray)          Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    93A-0002-L
Chest Radiologic Examination (Chest X-Ray)          Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    93A-0002-L
Chest Radiologic Examination (Chest X-Ray)          Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    93A-0002-L
Chest Radiologic Examination (Chest X-Ray)          Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    93A-0002-L
Chest Radiologic Examination (Chest X-Ray)          Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    93A-0002-L
Chest Radiologic Examination (Chest X-Ray)          Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    93A-0002-L
Chest Radiologic Examination (Chest X-Ray)          Radiologic examination of the chest (chest x-ray) facilitates the detecti
                      Therapy (HBO)
Hyperbaric Oxygen98A-0016-L                         Hyperbaric Oxygen Therapy is a medical treatment in which the patien
                      Therapy (HBO)
Hyperbaric Oxygen98A-0016-L                         Hyperbaric Oxygen Therapy is a medical treatment in which the patien
                    01A-0016-L
Hepatic Function Panel                              This chemistry panel is an organ specific panel used in the diagnosis a
                    01A-0016-L
Hepatic Function Panel                              This chemistry panel is an organ specific panel used in the diagnosis a
                    01A-0016-L
Hepatic Function Panel                              This chemistry panel is an organ specific panel used in the diagnosis a
                    01A-0016-L
Hepatic Function Panel                              This chemistry panel is an organ specific panel used in the diagnosis a
                    01A-0016-L
Hepatic Function Panel                              This chemistry panel is an organ specific panel used in the diagnosis a
                    01A-0016-L
Hepatic Function Panel                              This chemistry panel is an organ specific panel used in the diagnosis a
                    01A-0016-L
Hepatic Function Panel                              This chemistry panel is an organ specific panel used in the diagnosis a
                    01A-0016-L
Hepatic Function Panel                              This chemistry panel is an organ specific panel used in the diagnosis a
                    01A-0016-L
Hepatic Function Panel                              This chemistry panel is an organ specific panel used in the diagnosis a
                    01A-0016-L
Hepatic Function Panel                              This chemistry panel is an organ specific panel used in the diagnosis a
Ionized Calcium 97A-0003-L                          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97A-0003-L                          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97A-0003-L                          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97A-0003-L                          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97A-0003-L                          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97A-0003-L                          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97A-0003-L                          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97A-0003-L                          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97A-0003-L                          Ionized calcium testing is used to evaluate non-bound calcium, a meas
Ionized Calcium 97A-0003-L                          Ionized calcium testing is used to evaluate non-bound calcium, a meas
                    01A-0009-L
Magnetic Resonance Imaging (MRI) of the Brain       Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic proce
                    01A-0009-L
Magnetic Resonance Imaging (MRI) of the Brain       Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic proce
                    01A-0009-L
Magnetic Resonance Imaging (MRI) of the Brain       Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic proce
                    01A-0009-L
Magnetic Resonance Imaging (MRI) of the Brain       Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic proce
                    01A-0009-L
Magnetic Resonance Imaging (MRI) of the Brain       Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic proce
                    L1317
Partial Hospitalization Programs                    Partial hospitalization is a distinct and organized intensive psychiatric o
                    L1317
Partial Hospitalization Programs                    Partial hospitalization is a distinct and organized intensive psychiatric o
                    L1317
Partial Hospitalization Programs                     Partial hospitalization is a distinct and organized intensive psychiatric o
                    L1384                            Federal legislation
Medicare Part B Coverage of Services and Procedures in Nursing Facilities has set forth requirements for skilled nursing facilitie
                    L1384                            Federal legislation
Medicare Part B Coverage of Services and Procedures in Nursing Facilities has set forth requirements for skilled nursing facilitie
Rheumatoid FactorL1407Test                           Rheumatoid factor (RF) testing is the examination of the blood to dete
Rheumatoid FactorL1407Test                           Rheumatoid factor (RF) testing is the examination of the blood to dete
Rheumatoid FactorL1407Test                           Rheumatoid factor (RF) testing is the examination of the blood to dete
Rheumatoid FactorL1407Test                           Rheumatoid factor (RF) testing is the examination of the blood to dete
Rheumatoid FactorL1407Test                           Rheumatoid factor (RF) testing is the examination of the blood to dete
Rheumatoid FactorL1407Test                           Rheumatoid factor (RF) testing is the examination of the blood to dete
Rheumatoid FactorL1407Test                           Rheumatoid factor (RF) testing is the examination of the blood to dete
Rheumatoid FactorL1407Test                           Rheumatoid factor (RF) testing is the examination of the blood to dete
Rheumatoid FactorL1407Test                           Rheumatoid factor (RF) testing is the examination of the blood to dete
Rheumatoid FactorL1407Test                           Rheumatoid factor (RF) testing is the examination of the blood to dete
                    L1415
Sentinel Lymph Node Biopsy                            Breast Carcinoma Sentinel lymph node biopsy in breast carcinoma is
                    L1415
Sentinel Lymph Node Biopsy                            Breast Carcinoma Sentinel lymph node biopsy in breast carcinoma is
                    L1415
Sentinel Lymph Node Biopsy                            Breast Carcinoma Sentinel lymph node biopsy in breast carcinoma is
                    L1501
Radiological Examination of the Chest                Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    L1501
Radiological Examination of the Chest                Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    L1501
Radiological Examination of the Chest                Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    L1501
Radiological Examination of the Chest                Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    L1501
Radiological Examination of the Chest                Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    L1501
Radiological Examination of the Chest                Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    L1501
Radiological Examination of the Chest                Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    L1501
Radiological Examination of the Chest                Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    L1501
Radiological Examination of the Chest                Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    L1501
Radiological Examination of the Chest                Radiologic examination of the chest (chest x-ray) facilitates the detecti
                    L1523                            This LCD applies only to off-label use of FDA approved stents. Stent d
Outpatient Transcatheter Placement of Non-Coronary Artery Stents
                    L1523                            This LCD applies only to off-label use of FDA approved stents. Stent d
Outpatient Transcatheter Placement of Non-Coronary Artery Stents
                    L1523                            This LCD applies only to off-label use of FDA approved stents. Stent d
Outpatient Transcatheter Placement of Non-Coronary Artery Stents
                    L1530
UroLume? Endoprosthesis                              The UroLumeTM is a tubular braided mesh cylinder made of high stren
                    L1530
UroLume? Endoprosthesis                              The UroLumeTM is a tubular braided mesh cylinder made of high stren
                    L1530
UroLume? Endoprosthesis                              The UroLumeTM is a tubular braided mesh cylinder made of high stren
                    L1530
UroLume? Endoprosthesis                              The UroLumeTM is a tubular braided mesh cylinder made of high stren
                    L1538
Vagal Nerve Stimulation (VNS) for Epilepsy           Epilepsy is a common condition affecting 0.5 to 1.5 percent of US popu
Troponin            L1544                            Troponin is useful in the diagnosis of myocardial damage and in estim
Troponin            L1544                            Troponin is useful in the diagnosis of myocardial damage and in estim
Troponin            L1544                            Troponin is useful in the diagnosis of myocardial damage and in estim
Troponin            L1544                            Troponin is useful in the diagnosis of myocardial damage and in estim
Troponin            L1544                            Troponin is useful in the diagnosis of myocardial damage and in estim
Troponin            L1544                            Troponin is useful in the diagnosis of myocardial damage and in estim
Troponin            L1544                            Troponin is useful in the diagnosis of myocardial damage and in estim
Troponin            L1544                            Troponin is useful in the diagnosis of myocardial damage and in estim
Troponin            L1544                            Troponin is useful in the diagnosis of myocardial damage and in estim
Troponin            L1544                            Troponin is useful in the diagnosis of myocardial damage and in estim
Urinalysis          L1547                            A urinalysis is a physical, chemical, and microscopic examination of th
Urinalysis          L1547                            A urinalysis is a physical, chemical, and microscopic examination of th
Urinalysis          L1547                            A urinalysis is a physical, chemical, and microscopic examination of th
Urinalysis          L1547                            A urinalysis is a physical, chemical, and microscopic examination of th
Urinalysis          L1547                            A urinalysis is a physical, chemical, and microscopic examination of th
Urinalysis          L1547                            A urinalysis is a physical, chemical, and microscopic examination of th
Urinalysis          L1547                            A urinalysis is a physical, chemical, and microscopic examination of th
Urinalysis          L1547                            A urinalysis is a physical, chemical, and microscopic examination of th
Urinalysis          L1547                           A urinalysis is a physical, chemical, and microscopic examination of th
Urinalysis          L1547                           A urinalysis is a physical, chemical, and microscopic examination of th
Blepharoplasty      L1603                           The goal of functional or reconstructive surgery is to restore normalcy
                    L1609
Botulinum Toxin, Type A                             Botulinum Toxin, Type A injections are used to treat various focal mus
                    L1609
Botulinum Toxin, Type A                             Botulinum Toxin, Type A injections are used to treat various focal mus
                    L1609
Botulinum Toxin, Type A                             Botulinum Toxin, Type A injections are used to treat various focal mus
                    L1609
Botulinum Toxin, Type A                             Botulinum Toxin, Type A injections are used to treat various focal mus
                    L1609
Botulinum Toxin, Type A                             Botulinum Toxin, Type A injections are used to treat various focal mus
                    L1609
Botulinum Toxin, Type A                             Botulinum Toxin, Type A injections are used to treat various focal mus
                    L1609
Botulinum Toxin, Type A                             Botulinum Toxin, Type A injections are used to treat various focal mus
                    L1609
Botulinum Toxin, Type A                             Botulinum Toxin, Type A injections are used to treat various focal mus
                    L1609
Botulinum Toxin, Type A                             Botulinum Toxin, Type A injections are used to treat various focal mus
                    L1609
Botulinum Toxin, Type A                             Botulinum Toxin, Type A injections are used to treat various focal mus
                    L1609
Botulinum Toxin, Type A                             Botulinum Toxin, Type A injections are used to treat various focal mus
                    L1609
Botulinum Toxin, Type A                             Botulinum Toxin, Type A injections are used to treat various focal mus
                    L1645
Cardiac Catheterization and Coronary Angiography    Cardiac catheterization and coronary angiography are the key means f
                    L1645
Cardiac Catheterization and Coronary Angiography    Cardiac catheterization and coronary angiography are the key means f
                    L1645
Cardiac Catheterization and Coronary Angiography    Cardiac catheterization and coronary angiography are the key means f
Pamidronate         02NC-002-L                      Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate         02NC-002-L                      Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate         02NC-002-L                      Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate         02NC-002-L                      Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate         02NC-002-L                      Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate         02NC-002-L                      Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate         02NC-002-L                      Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate         02NC-002-L                      Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate         02NC-002-L                      Pamidronate, a bisphosphonate which is administered intravenously, is
                    02NC-005-L
Computerized Axial Tomography of the Abdomen        A computed tomographic (CT) image is a display of the anatomy of a t
                    02NC-005-L
Computerized Axial Tomography of the Abdomen        A computed tomographic (CT) image is a display of the anatomy of a t
                    02NC-005-L
Computerized Axial Tomography of the Abdomen        A computed tomographic (CT) image is a display of the anatomy of a t
                    02NC-005-L
Computerized Axial Tomography of the Abdomen        A computed tomographic (CT) image is a display of the anatomy of a t
                    02NC-005-L
Computerized Axial Tomography of the Abdomen        A computed tomographic (CT) image is a display of the anatomy of a t
                    02NC-006-L
Computerized Axial Tomography of the Chest/Thorax   A computed tomographic (CT) image is a display of the anatomy of a t
                    02NC-006-L
Computerized Axial Tomography of the Chest/Thorax   A computed tomographic (CT) image is a display of the anatomy of a t
                    02NC-006-L
Computerized Axial Tomography of the Chest/Thorax   A computed tomographic (CT) image is a display of the anatomy of a t
                    02NC-006-L
Computerized Axial Tomography of the Chest/Thorax   A computed tomographic (CT) image is a display of the anatomy of a t
                    02NC-006-L
Computerized Axial Tomography of the Chest/Thorax   A computed tomographic (CT) image is a display of the anatomy of a t
                    PSYCH-016
Psychiatric Partial Hospitalization Program         INTRODUCTION Psychiatric partial hospitalization is a distinct and or
                    PSYCH-016
Psychiatric Partial Hospitalization Program         INTRODUCTION Psychiatric partial hospitalization is a distinct and or
                    PSYCH-016
Psychiatric Partial Hospitalization Program         INTRODUCTION Psychiatric partial hospitalization is a distinct and or
Ambulance Services  2002-8                          Portions of the Medicare Benefit Policy Manual (CMS PUB 100) cited i
Ambulance Services  2002-8                          Portions of the Medicare Benefit Policy Manual (CMS PUB 100) cited i
Ambulance Services  2002-8                          Portions of the Medicare Benefit Policy Manual (CMS PUB 100) cited i
Ambulance Services  2002-8                          Portions of the Medicare Benefit Policy Manual (CMS PUB 100) cited i
Dysphagia           2000-04R1                       Compliance with the provisions in this policy may be monitored and ad
Dysphagia           2000-04R1                       Compliance with the provisions in this policy may be monitored and ad
Dysphagia           2000-04R1                       Compliance with the provisions in this policy may be monitored and ad
Dysphagia           2000-04R1                       Compliance with the provisions in this policy may be monitored and ad
Dysphagia           2000-04R1                       Compliance with the provisions in this policy may be monitored and ad
Dysphagia           2000-04R1                       Compliance with the provisions in this policy may be monitored and ad
Dysphagia           2000-04R1                       Compliance with the provisions in this policy may be monitored and ad
Dysphagia           2000-04R1                       Compliance with the provisions in this policy may be monitored and ad
Dysphagia          2000-04R1                           Compliance with the provisions in this policy may be monitored and ad
                   LAB-720
In Vitro Allergen-Specific IgE                         Testing must be based on a careful and complete history/physical exa
                   PULM-001A / 2001-05R2
Pulmonary Rehabilitation Services                      Patients diagnosed with Chronic Respiratory Diseases have a progres
                   PULM-001A / 2001-05R2
Pulmonary Rehabilitation Services                      Patients diagnosed with Chronic Respiratory Diseases have a progres
                   PULM-001A / 2001-05R2
Pulmonary Rehabilitation Services                      Patients diagnosed with Chronic Respiratory Diseases have a progres
Dental Services 03NC-004-L                             Dental care, including items and services in connection with the care, t
Dental Services 03NC-004-L                             Dental care, including items and services in connection with the care, t
Dental Services 03NC-004-L                             Dental care, including items and services in connection with the care, t
Dental Services 03NC-004-L                             Dental care, including items and services in connection with the care, t
Dental Services 03NC-004-L                             Dental care, including items and services in connection with the care, t
Dental Services 03NC-004-L                             Dental care, including items and services in connection with the care, t
Dental Services 03NC-004-L                             Dental care, including items and services in connection with the care, t
Dental Services 03NC-004-L                             Dental care, including items and services in connection with the care, t
Dental Services 03NC-004-L                             Dental care, including items and services in connection with the care, t
                   03NC-005-L
Upper Gastrointestinal Endoscopy and Visualization     Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   03NC-005-L
Upper Gastrointestinal Endoscopy and Visualization     Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   03NC-005-L
Upper Gastrointestinal Endoscopy and Visualization     Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   03NC-005-L
Upper Gastrointestinal Endoscopy and Visualization     Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   03NC-005-L
Upper Gastrointestinal Endoscopy and Visualization     Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   03NC-005-L
Upper Gastrointestinal Endoscopy and Visualization     Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   03NC-005-L
Upper Gastrointestinal Endoscopy and Visualization     Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   03NC-005-L
Upper Gastrointestinal Endoscopy and Visualization     Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   03NC-005-L
Upper Gastrointestinal Endoscopy and Visualization     Diagnostic and therapeutic EGD is a common endoscopic procedure d
                    Failure To Thrive Syndrome
Hospice The Adult 00AH-001-L                           The adult failure to thrive syndrome is characterized by unexplained w
                    Failure To Thrive Syndrome
Hospice The Adult 00AH-001-L                           The adult failure to thrive syndrome is characterized by unexplained w
                   02HH-005-L
Home Health Speech-Language Pathology                  Speech-language pathology services are part of a constellation of reha
                   02HH-005-L
Home Health Speech-Language Pathology                  Speech-language pathology services are part of a constellation of reha
                   GU-016
The Evaluation and Treatment of Erectile Dysfunction Impotence is defined as the inability of the male to achieve or maintain
                   B2005.12 Studies for Testing Sleep and Respiratory Disorderscontinuous measurement and recording of ph
Polysomnography and Sleep R1                           Polysomnography is the
                   2003-008                            Definitions Bone mass
Bone Mass Measurements (BMMs) (previously Measurement of Bone Density) measurement is a radiologic or radioisotopic p
Sodium Hyaluronate 98A-0007-L                          These devices are viscous solutions consisting of a high molecular we
Sodium Hyaluronate 98A-0007-L                          These devices are viscous solutions consisting of a high molecular we
Sodium Hyaluronate 98A-0007-L                          These devices are viscous solutions consisting of a high molecular we
Sodium Hyaluronate 98A-0007-L                          These devices are viscous solutions consisting of a high molecular we
Sodium Hyaluronate 98A-0007-L                          These devices are viscous solutions consisting of a high molecular we
Sodium Hyaluronate 98A-0007-L                          These devices are viscous solutions consisting of a high molecular we
Sodium Hyaluronate 98A-0007-L                          These devices are viscous solutions consisting of a high molecular we
Sodium Hyaluronate 98A-0007-L                          These devices are viscous solutions consisting of a high molecular we
Sodium Hyaluronate 98A-0007-L                          These devices are viscous solutions consisting of a high molecular we
                   00A-0008-L
Percutaneous Vertebroplasty                            Percutaneous vertebroplasty is a therapeutic, interventional radiologic
                   00A-0008-L
Percutaneous Vertebroplasty                            Percutaneous vertebroplasty is a therapeutic, interventional radiologic
                   00A-0008-L
Percutaneous Vertebroplasty                            Percutaneous vertebroplasty is a therapeutic, interventional radiologic
                   00A-0008-L
Percutaneous Vertebroplasty                            Percutaneous vertebroplasty is a therapeutic, interventional radiologic
                   00A-0008-L
Percutaneous Vertebroplasty                            Percutaneous vertebroplasty is a therapeutic, interventional radiologic
                   00A-0008-L
Percutaneous Vertebroplasty                            Percutaneous vertebroplasty is a therapeutic, interventional radiologic
                   00A-0008-L
Percutaneous Vertebroplasty                            Percutaneous vertebroplasty is a therapeutic, interventional radiologic
Actinic Keratosis B2002.22 R1                          Actinic keratoses are a frequent, disturbing consequence of many yea
                   B2002.21 Removal (formerly Non-malignant Skin Lesion Removal)
Skin Lesion (Non-Melanoma)R1                           This policy applies to the following: seborrheic keratoses, skin tags, mi
Actinic Keratosis B2002.22 R1                          Actinic keratoses are a frequent, disturbing consequence of many yea
                   B2002.21 Removal (formerly Non-malignant Skin Lesion Removal)
Skin Lesion (Non-Melanoma)R1                           This policy applies to the following: seborrheic keratoses, skin tags, mi
Serum Phosphorus   01A-0003-L                          Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus   01A-0003-L                          Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  01A-0003-L                          Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  01A-0003-L                          Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  01A-0003-L                          Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  01A-0003-L                          Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  01A-0003-L                          Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  01A-0003-L                          Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  01A-0003-L                          Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  01A-0003-L                          Disorders of phosphorus homeostasis may be related to many patholo
Serum Phosphorus  01A-0003-L                          Disorders of phosphorus homeostasis may be related to many patholo
                  99A-0021-L
Outpatient Physical Therapy                           Although there is an overlap in services provided by physical and occu
                  99A-0021-L
Outpatient Physical Therapy                           Although there is an overlap in services provided by physical and occu
                  99A-0021-L
Outpatient Physical Therapy                           Although there is an overlap in services provided by physical and occu
                  99A-0021-L
Outpatient Physical Therapy                           Although there is an overlap in services provided by physical and occu
                  99A-0021-L
Outpatient Physical Therapy                           Although there is an overlap in services provided by physical and occu
                  99A-0021-L
Outpatient Physical Therapy                           Although there is an overlap in services provided by physical and occu
                  99A-0021-L
Outpatient Physical Therapy                           Although there is an overlap in services provided by physical and occu
                  99A-0021-L
Outpatient Physical Therapy                           Although there is an overlap in services provided by physical and occu
                  99A-0021-L
Outpatient Physical Therapy                           Although there is an overlap in services provided by physical and occu
                  99A-0021-L
Outpatient Physical Therapy                           Although there is an overlap in services provided by physical and occu
                  99A-0021-L
Outpatient Physical Therapy                           Although there is an overlap in services provided by physical and occu
                  99A-0021-L
Outpatient Physical Therapy                           Although there is an overlap in services provided by physical and occu
Serum Protein     01A-0002-L                          Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein     01A-0002-L                          Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein     01A-0002-L                          Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein     01A-0002-L                          Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein     01A-0002-L                          Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein     01A-0002-L                          Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein     01A-0002-L                          Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein     01A-0002-L                          Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein     01A-0002-L                          Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein     01A-0002-L                          Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein     01A-0002-L                          Protein testing aids in the diagnosis of some inflammatory and neoplas
                  GU-016
The Evaluation and Treatment of Erectile Dysfunction Impotence is defined as the inability of the male to achieve or maintain
                  GU-016
The Evaluation and Treatment of Erectile Dysfunction Impotence is defined as the inability of the male to achieve or maintain
                  B2005.12 Studies for Testing Sleep and Respiratory Disorderscontinuous measurement and recording of ph
Polysomnography and Sleep R1                          Polysomnography is the
                  02A-0011-L
Renal Function Panel                                  This chemistry panel is a disease-oriented panel used in the diagnosis
                  02A-0011-L
Renal Function Panel                                  This chemistry panel is a disease-oriented panel used in the diagnosis
                  02A-0011-L
Renal Function Panel                                  This chemistry panel is a disease-oriented panel used in the diagnosis
                  02A-0011-L
Renal Function Panel                                  This chemistry panel is a disease-oriented panel used in the diagnosis
                  02A-0011-L
Renal Function Panel                                  This chemistry panel is a disease-oriented panel used in the diagnosis
                  02A-0011-L
Renal Function Panel                                  This chemistry panel is a disease-oriented panel used in the diagnosis
                  02A-0011-L
Renal Function Panel                                  This chemistry panel is a disease-oriented panel used in the diagnosis
                  02A-0011-L
Renal Function Panel                                  This chemistry panel is a disease-oriented panel used in the diagnosis
                  02A-0011-L
Renal Function Panel                                  This chemistry panel is a disease-oriented panel used in the diagnosis
                  02A-0011-L
Renal Function Panel                                  This chemistry panel is a disease-oriented panel used in the diagnosis
                    Brow Repair
Blepharoplasty and95A-0008-L Procedures               Cosmetic surgery as defined by the Centers for Medicare and Medicai
                    Brow Repair
Blepharoplasty and95A-0008-L Procedures               Cosmetic surgery as defined by the Centers for Medicare and Medicai
                    Brow Repair
Blepharoplasty and95A-0008-L Procedures               Cosmetic surgery as defined by the Centers for Medicare and Medicai
                  2003-01                             Indications Zevalin,
Monoclonal Antibody Therapy; Ibritumomab Tiuxetan Therapeutic Regimen (Ibritumomab Tiuxetan), as part of a specific ther
                  02A-0015-L
Outpatient Occupational Therapy                       Although rehabilitative services are provided by occupational therapy,
                  02A-0015-L
Outpatient Occupational Therapy                       Although rehabilitative services are provided by occupational therapy,
                  02A-0015-L
Outpatient Occupational Therapy                       Although rehabilitative services are provided by occupational therapy,
                   02A-0015-L
Outpatient Occupational Therapy                          Although rehabilitative services are provided by occupational therapy,
                   02A-0015-L
Outpatient Occupational Therapy                          Although rehabilitative services are provided by occupational therapy,
                   02A-0015-L
Outpatient Occupational Therapy                          Although rehabilitative services are provided by occupational therapy,
                   02A-0015-L
Outpatient Occupational Therapy                          Although rehabilitative services are provided by occupational therapy,
                   02A-0015-L
Outpatient Occupational Therapy                          Although rehabilitative services are provided by occupational therapy,
                   02A-0015-L
Outpatient Occupational Therapy                          Although rehabilitative services are provided by occupational therapy,
                   02A-0015-L
Outpatient Occupational Therapy                          Although rehabilitative services are provided by occupational therapy,
                   02A-0015-L
Outpatient Occupational Therapy                          Although rehabilitative services are provided by occupational therapy,
                   02A-0015-L
Outpatient Occupational Therapy                          Although rehabilitative services are provided by occupational therapy,
                   02HH-0015-L
Home Health - Occupational Therapy                       Although rehabilitative services are provided by occupational therapy,
                   02HH-0015-L
Home Health - Occupational Therapy                       Although rehabilitative services are provided by occupational therapy,
Urinalysis Policy A2003.06 R11                           Note: Providers should seek information related to National Coverage
Urinalysis Policy A2003.06 R11                           Note: Providers should seek information related to National Coverage
Urinalysis Policy A2003.06 R11                           Note: Providers should seek information related to National Coverage
Urinalysis Policy A2003.06 R11                           Note: Providers should seek information related to National Coverage
Urinalysis Policy A2003.06 R11                           Note: Providers should seek information related to National Coverage
Urinalysis Policy A2003.06 R11                           Note: Providers should seek information related to National Coverage
Ambulance Services 03A-0006-L                            Medicare covers ambulance services only if they are furnished to a be
Ambulance Services 03A-0006-L                            Medicare covers ambulance services only if they are furnished to a be
Ambulance Services 03A-0006-L                            Medicare covers ambulance services only if they are furnished to a be
Ambulance Services 03A-0006-L                            Medicare covers ambulance services only if they are furnished to a be
Ambulance Services 03A-0006-L                            Medicare covers ambulance services only if they are furnished to a be
Dental Services 03A-0005-L                               Dental care, including items and services in connection with the care, t
Dental Services 03A-0005-L                               Dental care, including items and services in connection with the care, t
Dental Services 03A-0005-L                               Dental care, including items and services in connection with the care, t
Dental Services 03A-0005-L                               Dental care, including items and services in connection with the care, t
Dental Services 03A-0005-L                               Dental care, including items and services in connection with the care, t
Dental Services 03A-0005-L                               Dental care, including items and services in connection with the care, t
Dental Services 03A-0005-L                               Dental care, including items and services in connection with the care, t
Dental Services 03A-0005-L                               Dental care, including items and services in connection with the care, t
Dental Services 03A-0005-L                               Dental care, including items and services in connection with the care, t
                   L13067                                The 2001 "ACC/AHA Guidelines for the Evaluation hydrochloride (Dob
Outpatient Intermittent Intravenous Positive Inotropic Therapy: Milrinone lactate (Primacor) and Dobutamineand Management o
                   GU-016
The Evaluation and Treatment of Erectile Dysfunction Impotence is defined as the inability of the male to achieve or maintain
                   I-66                                  This
Drugs and Biologicals, Non-Chemotherapeutic - I-66B-R45 LCD explains the coverage criteria for selected drugs and biologic
                   L13531
Ground Ambulance Services                                Ambulance services are frequently the initial step in the chain of delive
                   L13531
Ground Ambulance Services                                Ambulance services are frequently the initial step in the chain of delive
                   L13531
Ground Ambulance Services                                Ambulance services are frequently the initial step in the chain of delive
                   L13531
Ground Ambulance Services                                Ambulance services are frequently the initial step in the chain of delive
                   L13531
Ground Ambulance Services                                Ambulance services are frequently the initial step in the chain of delive
                   L13531
Ground Ambulance Services                                Ambulance services are frequently the initial step in the chain of delive
                   03NC-003-L
Computed Tomography of Pelvis                            Computed tomography of the pelvis (CT of the Pelvis) is a noninvasive
                   03NC-003-L
Computed Tomography of Pelvis                            Computed tomography of the pelvis (CT of the Pelvis) is a noninvasive
                   03NC-003-L
Computed Tomography of Pelvis                            Computed tomography of the pelvis (CT of the Pelvis) is a noninvasive
                   03NC-003-L
Computed Tomography of Pelvis                            Computed tomography of the pelvis (CT of the Pelvis) is a noninvasive
                   03NC-003-L
Computed Tomography of Pelvis                            Computed tomography of the pelvis (CT of the Pelvis) is a noninvasive
Cataract Surgery 03NC-001-L                              Cataract is defined as an opacity or loss of optical uniformity of the cry
Cataract Surgery 03NC-001-L                              Cataract is defined as an opacity or loss of optical uniformity of the cry
Cataract Surgery 03NC-001-L                              Cataract is defined as an opacity or loss of optical uniformity of the cry
Cataract Surgery 03A-0012-L                              Cataract is defined as an opacity or loss of optical uniformity of the cry
Cataract Surgery 03A-0012-L                              Cataract is defined as an opacity or loss of optical uniformity of the cry
Cataract Surgery 03A-0012-L                              Cataract is defined as an opacity or loss of optical uniformity of the cry
                    03A-0011-L
Computed Tomography of the Pelvis                        Computed tomography of the pelvis (CT of the Pelvis) is a noninvasive
                    03A-0011-L
Computed Tomography of the Pelvis                   Computed tomography of the pelvis (CT of the Pelvis) is a noninvasive
                    03A-0011-L
Computed Tomography of the Pelvis                   Computed tomography of the pelvis (CT of the Pelvis) is a noninvasive
                    03A-0011-L
Computed Tomography of the Pelvis                   Computed tomography of the pelvis (CT of the Pelvis) is a noninvasive
                    03A-0011-L
Computed Tomography of the Pelvis                   Computed tomography of the pelvis (CT of the Pelvis) is a noninvasive
                   2003-7
Electrocardiographic Services (EKG/ECG)             EKG/ECG is used in the evaluation of conditions that interfere with nor
                   2003-7
Electrocardiographic Services (EKG/ECG)             EKG/ECG is used in the evaluation of conditions that interfere with nor
                   2003-7
Electrocardiographic Services (EKG/ECG)             EKG/ECG is used in the evaluation of conditions that interfere with nor
                   2003-7
Electrocardiographic Services (EKG/ECG)             EKG/ECG is used in the evaluation of conditions that interfere with nor
                   2003-7
Electrocardiographic Services (EKG/ECG)             EKG/ECG is used in the evaluation of conditions that interfere with nor
                   2003-7
Electrocardiographic Services (EKG/ECG)             EKG/ECG is used in the evaluation of conditions that interfere with nor
                   2003-7
Electrocardiographic Services (EKG/ECG)             EKG/ECG is used in the evaluation of conditions that interfere with nor
                   2003-7
Electrocardiographic Services (EKG/ECG)             EKG/ECG is used in the evaluation of conditions that interfere with nor
                   2003-7
Electrocardiographic Services (EKG/ECG)             EKG/ECG is used in the evaluation of conditions that interfere with nor
                   2003-7
Electrocardiographic Services (EKG/ECG)             EKG/ECG is used in the evaluation of conditions that interfere with nor
Flow Cytometry 04NC-004-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04NC-004-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04NC-004-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04NC-004-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04NC-004-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04NC-004-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04NC-004-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04NC-004-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04NC-004-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04NC-004-L                           Flow cytometry is a complex laboratory process used to examine blood
                   04NC-003-L
Outpatient Psychiatry and Psychology Services       Psychiatry and Psychology are specialized fields for the diagnosis and
                   04NC-003-L
Outpatient Psychiatry and Psychology Services       Psychiatry and Psychology are specialized fields for the diagnosis and
                   04NC-003-L
Outpatient Psychiatry and Psychology Services       Psychiatry and Psychology are specialized fields for the diagnosis and
                   04NC-003-L
Outpatient Psychiatry and Psychology Services       Psychiatry and Psychology are specialized fields for the diagnosis and
                   04NC-003-L
Outpatient Psychiatry and Psychology Services       Psychiatry and Psychology are specialized fields for the diagnosis and
                   04NC-003-L
Outpatient Psychiatry and Psychology Services       Psychiatry and Psychology are specialized fields for the diagnosis and
                   04NC-003-L
Outpatient Psychiatry and Psychology Services       Psychiatry and Psychology are specialized fields for the diagnosis and
                   B2005.12 Sleep Studies
Polysomnography and Other R3                        Polysomnography is the continuous, simultaneous monitoring and reco
                    (MMS) Surgery
Mohs MicrographicB2003.06 R1                        Mohs micrographic surgery (Mohs surgery) is a precise tissue-sparing
                    (MMS) Surgery
Mohs MicrographicB2003.06 R1                        Mohs micrographic surgery (Mohs surgery) is a precise tissue-sparing
                   B2004.11
Application of Bioengineered Skin Substitutes LCD   Coverage will be considered when the following conditions are met an
                   B2004.11
Application of Bioengineered Skin Substitutes LCD   Coverage will be considered when the following conditions are met an
                   04NC-002-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04NC-002-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04NC-002-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04NC-002-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04NC-002-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04NC-002-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04NC-002-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04NC-002-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04NC-002-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04NC-002-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04NC-002-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   03AH-0018-L
Hospice Alzheimer's Disease &Related Disorders      Alzheimer?s Disease and related disorders may support a prognosis o
                   03AH-0018-L
Hospice Alzheimer's Disease &Related Disorders      Alzheimer?s Disease and related disorders may support a prognosis o
                   04A-0003-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04A-0003-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04A-0003-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04A-0003-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04A-0003-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04A-0003-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04A-0003-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04A-0003-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04A-0003-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04A-0003-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
                   04A-0003-L
Respiratory Therapy (Respiratory Care)              Respiratory therapy (respiratory care) is defined as those services pres
Serum MagnesiumA2004.07 R10                         Note: Providers should seek information related to National Coverage
Serum MagnesiumA2004.07 R10                         Note: Providers should seek information related to National Coverage
Serum MagnesiumA2004.07 R10                         Note: Providers should seek information related to National Coverage
Serum MagnesiumA2004.07 R10                         Note: Providers should seek information related to National Coverage
Serum MagnesiumA2004.07 R10                         Note: Providers should seek information related to National Coverage
Serum MagnesiumA2004.07 R10                         Note: Providers should seek information related to National Coverage
Immunizations      ALRG-003                         With the exception of vaccinations for pneumococcal pneumonia, hep
Immunizations      ALRG-003                         With the exception of vaccinations for pneumococcal pneumonia, hep
Immunizations      ALRG-003                         With the exception of vaccinations for pneumococcal pneumonia, hep
Immunizations      ALRG-003                         With the exception of vaccinations for pneumococcal pneumonia, hep
                   L16965
Darbepoetin alfa (Aranesp«)                         Naturally occurring human erythropoietin is a glycoprotein which stimu
                   L16965
Darbepoetin alfa (Aranesp«)                         Naturally occurring human erythropoietin is a glycoprotein which stimu
                   L16965
Darbepoetin alfa (Aranesp«)                         Naturally occurring human erythropoietin is a glycoprotein which stimu
                   L16965
Darbepoetin alfa (Aranesp«)                         Naturally occurring human erythropoietin is a glycoprotein which stimu
                   L16965
Darbepoetin alfa (Aranesp«)                         Naturally occurring human erythropoietin is a glycoprotein which stimu
                   L16965
Darbepoetin alfa (Aranesp«)                         Naturally occurring human erythropoietin is a glycoprotein which stimu
                   L16965
Darbepoetin alfa (Aranesp«)                         Naturally occurring human erythropoietin is a glycoprotein which stimu
                   L16965
Darbepoetin alfa (Aranesp«)                         Naturally occurring human erythropoietin is a glycoprotein which stimu
                   L16965
Darbepoetin alfa (Aranesp«)                         Naturally occurring human erythropoietin is a glycoprotein which stimu
                   L16965
Darbepoetin alfa (Aranesp«)                         Naturally occurring human erythropoietin is a glycoprotein which stimu
                   L16965
Darbepoetin alfa (Aranesp«)                         Naturally occurring human erythropoietin is a glycoprotein which stimu
Flow Cytometry 04A-0006-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04A-0006-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04A-0006-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04A-0006-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04A-0006-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04A-0006-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04A-0006-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04A-0006-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04A-0006-L                           Flow cytometry is a complex laboratory process used to examine blood
Flow Cytometry 04A-0006-L                           Flow cytometry is a complex laboratory process used to examine blood
                   04A-0007-L
Computerized Axial Tomography of the Chest/Thorax   A computed tomographic (CT) image is a display of the anatomy of a t
                   04A-0007-L
Computerized Axial Tomography of the Chest/Thorax   A computed tomographic (CT) image is a display of the anatomy of a t
                   04A-0007-L
Computerized Axial Tomography of the Chest/Thorax   A computed tomographic (CT) image is a display of the anatomy of a t
                   04A-0007-L
Computerized Axial Tomography of the Chest/Thorax   A computed tomographic (CT) image is a display of the anatomy of a t
                   04A-0007-L
Computerized Axial Tomography of the Chest/Thorax   A computed tomographic (CT) image is a display of the anatomy of a t
                   ARA-02-055
Non Invasive Vascular Studies                       Noninvasive vascular studies utilize ultrasonic doppler and physiologic
                   ARA-02-055
Non Invasive Vascular Studies                       Noninvasive vascular studies utilize ultrasonic doppler and physiologic
                   ARA-02-055
Non Invasive Vascular Studies                       Noninvasive vascular studies utilize ultrasonic doppler and physiologic
                   ARA-02-055
Non Invasive Vascular Studies                       Noninvasive vascular studies utilize ultrasonic doppler and physiologic
                   04A-0008-L
Outpatient Psychiatry and Psychology Services       Psychiatry and Psychology are specialized fields for the diagnosis and
                   04A-0008-L
Outpatient Psychiatry and Psychology Services       Psychiatry and Psychology are specialized fields for the diagnosis and
                   04A-0008-L
Outpatient Psychiatry and Psychology Services       Psychiatry and Psychology are specialized fields for the diagnosis and
                   04A-0008-L
Outpatient Psychiatry and Psychology Services       Psychiatry and Psychology are specialized fields for the diagnosis and
                   04A-0008-L
Outpatient Psychiatry and Psychology Services           Psychiatry and Psychology are specialized fields for the diagnosis and
                   04A-0008-L
Outpatient Psychiatry and Psychology Services           Psychiatry and Psychology are specialized fields for the diagnosis and
                   04A-0008-L
Outpatient Psychiatry and Psychology Services           Psychiatry and Psychology are specialized fields for the diagnosis and
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   INJ-023                              Naturally occurring human erythropoietin is a glycoprotein produced m
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)
                   04NC-001-L
Percutaneous Vertebroplasty                             Percutaneous vertebroplasty is a therapeutic, interventional radiologic
                   04NC-001-L
Percutaneous Vertebroplasty                             Percutaneous vertebroplasty is a therapeutic, interventional radiologic
                   04NC-001-L
Percutaneous Vertebroplasty                             Percutaneous vertebroplasty is a therapeutic, interventional radiologic
                   04NC-001-L
Percutaneous Vertebroplasty                             Percutaneous vertebroplasty is a therapeutic, interventional radiologic
                   04NC-001-L
Percutaneous Vertebroplasty                             Percutaneous vertebroplasty is a therapeutic, interventional radiologic
                   04NC-001-L
Percutaneous Vertebroplasty                             Percutaneous vertebroplasty is a therapeutic, interventional radiologic
                   04NC-001-L
Percutaneous Vertebroplasty                             Percutaneous vertebroplasty is a therapeutic, interventional radiologic
CT of the Head     02NC-007-L                           Cranial Computerized Tomographic (CT) Scan is a very useful and info
CT of the Head     02NC-007-L                           Cranial Computerized Tomographic (CT) Scan is a very useful and info
CT of the Head     02NC-007-L                           Cranial Computerized Tomographic (CT) Scan is a very useful and info
CT of the Head     02NC-007-L                           Cranial Computerized Tomographic (CT) Scan is a very useful and info
CT of the Head     02NC-007-L                           Cranial Computerized Tomographic (CT) Scan is a very useful and info
                   ARA-02-014
Transthoracic Echocardiography (TTE)                    1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                   ARA-02-014
Transthoracic Echocardiography (TTE)                    1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                   ARA-02-014
Transthoracic Echocardiography (TTE)                    1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                   ARA-02-014
Transthoracic Echocardiography (TTE)                    1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                   ARA-02-014
Transthoracic Echocardiography (TTE)                    1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                  ARA-02-014
Transthoracic Echocardiography (TTE)                       1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                  ARA-02-014
Transthoracic Echocardiography (TTE)                       1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                  ARA-02-014
Transthoracic Echocardiography (TTE)                       1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                  ARA-02-014
Transthoracic Echocardiography (TTE)                       1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                  ARA-02-014
Transthoracic Echocardiography (TTE)                       1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                  ARA-02-014
Transthoracic Echocardiography (TTE)                       1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                  ARA-02-014
Transthoracic Echocardiography (TTE)                       1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                  ARA-02-014
Transthoracic Echocardiography (TTE)                       1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                  ARA-02-014
Transthoracic Echocardiography (TTE)                       1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                  ARA-02-014
Transthoracic Echocardiography (TTE)                       1.Ventricular Function and Cardiomyopathies Changes in myocardial t
                  PSYCH-013
Psychological Services under the                           The "incident to" provision also applies to coverage for psychological s
                  PSYCH-013
Psychological Services under the                           The "incident to" provision also applies to coverage for psychological s
                  PSYCH-013
Psychological Services under the                           The "incident to" provision also applies to coverage for psychological s
                  PSYCH-013
Psychological Services under the                           The "incident to" provision also applies to coverage for psychological s
                  GSURG-041
The treatment of varicose veins of the lower extremities   Historically varicose veins have been treated by conservative measure
                  GSURG-041
The treatment of varicose veins of the lower extremities   Historically varicose veins have been treated by conservative measure
                  GSURG-041
The treatment of varicose veins of the lower extremities   Historically varicose veins have been treated by conservative measure
                  GSURG-041
The treatment of varicose veins of the lower extremities   Historically varicose veins have been treated by conservative measure
                  P
Cytogenetic Studies ATH-027                                Cytogenetics is the study of chromosomes by light or fluorescent micro
                  P
Cytogenetic Studies ATH-027                                Cytogenetics is the study of chromosomes by light or fluorescent micro
                  P
Cytogenetic Studies ATH-027                                Cytogenetics is the study of chromosomes by light or fluorescent micro
                  ARA-00-005
ALLERGEN IMMUNOTHERAPY                                     The purpose of allergen immunotherapy is to provide protection agains
                  ARA-00-005
ALLERGEN IMMUNOTHERAPY                                     The purpose of allergen immunotherapy is to provide protection agains
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
Chest X-Ray       ARA-01-005                               Radiological examination of the chest (chest x-ray) facilitates the detec
                  ARA-03-006
Immune Globulin, Intravenous                               Intravenous Immune Globulin (IVIg) is a solution of human immunoglo
                  ARA-03-006
Immune Globulin, Intravenous                               Intravenous Immune Globulin (IVIg) is a solution of human immunoglo
                  ARA-03-006
Immune Globulin, Intravenous                               Intravenous Immune Globulin (IVIg) is a solution of human immunoglo
                  ARA-03-010
Magnetic Resonance Angiography (MRA)                       In a National Coverage Analysis decision memorandum (#CAG-00142
                  ARA-03-010
Magnetic Resonance Angiography (MRA)                       In a National Coverage Analysis decision memorandum (#CAG-00142
                  ARA-03-010
Magnetic Resonance Angiography (MRA)                       In a National Coverage Analysis decision memorandum (#CAG-00142
                  ARA-03-010
Magnetic Resonance Angiography (MRA)                       In a National Coverage Analysis decision memorandum (#CAG-00142
                  ARA-03-010
Magnetic Resonance Angiography (MRA)                       In a National Coverage Analysis decision memorandum (#CAG-00142
                  ARA-03-010
Magnetic Resonance Angiography (MRA)                       In a National Coverage Analysis decision memorandum (#CAG-00142
                  ARA-03-010
Magnetic Resonance Angiography (MRA)                       In a National Coverage Analysis decision memorandum (#CAG-00142
                  ARA-03-044
Non Coronary Vascular Stents                               Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents                               Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents                               Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents                               Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents              Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents              Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents              Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents              Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents              Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents              Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents              Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents              Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents              Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents              Vascular stents are used to enhance primary patency in arteries and v
                  ARA-03-044
Non Coronary Vascular Stents              Vascular stents are used to enhance primary patency in arteries and v
                  ARA-99-512
Coronary Angiography                      1. There are several conditions covered in this policy for which corona
                  ARA-99-512
Coronary Angiography                      1. There are several conditions covered in this policy for which corona
                  ARA-03-043
Magnetic Resonance Imaging of the Brain   MRI is useful in examining the head and central nervous system abnor
                  ARA-03-043
Magnetic Resonance Imaging of the Brain   MRI is useful in examining the head and central nervous system abnor
                  ARA-03-043
Magnetic Resonance Imaging of the Brain   MRI is useful in examining the head and central nervous system abnor
                  ARA-03-043
Magnetic Resonance Imaging of the Brain   MRI is useful in examining the head and central nervous system abnor
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-059
Physical Medicine and Rehabilitation      This policy defines the coverage and limitations under Medicare for ph
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-02-030
Right Heart Catheterization               1. All conditions for which right heart catheterizations are allowed are l
                  ARA-03-053
Stress Echocardiography                   Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
                    ARA-03-053
Stress Echocardiography                               Exercise stress testing is an established and reliable test used to detec
Benign Skin Lesions ARA-04-001                        Benign skin lesions are common in the elderly and frequently removed
Benign Skin Lesions ARA-04-001                        Benign skin lesions are common in the elderly and frequently removed
Benign Skin Lesions ARA-04-001                        Benign skin lesions are common in the elderly and frequently removed
                    ARA-02-020
Colonoscopy, Diagnostic, Therapeutic, and Screening   A.The following clinical situations represent Medicare covered indicatio
                    ARA-02-020
Colonoscopy, Diagnostic, Therapeutic, and Screening   A.The following clinical situations represent Medicare covered indicatio
                    ARA-02-020
Colonoscopy, Diagnostic, Therapeutic, and Screening   A.The following clinical situations represent Medicare covered indicatio
                    ARA-02-020
Colonoscopy, Diagnostic, Therapeutic, and Screening   A.The following clinical situations represent Medicare covered indicatio
                    ARA-02-020
Colonoscopy, Diagnostic, Therapeutic, and Screening   A.The following clinical situations represent Medicare covered indicatio
                    ARA-02-020
Colonoscopy, Diagnostic, Therapeutic, and Screening   A.The following clinical situations represent Medicare covered indicatio
                    ARA-02-020
Colonoscopy, Diagnostic, Therapeutic, and Screening   A.The following clinical situations represent Medicare covered indicatio
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033                        Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                    Trigger Points
Local Injections forARA-02-033       Myofascial trigger points are self-sustaining hyper-irritative foci that ma
                   ARA-03-048
Plastic Surgery Procedures of the Eye                The goal of functional or reconstructive surgery is to restore normalcy
                   ARA-03-048
Plastic Surgery Procedures of the Eye                The goal of functional or reconstructive surgery is to restore normalcy
                   ARA-03-048
Plastic Surgery Procedures of the Eye                The goal of functional or reconstructive surgery is to restore normalcy
                   NULL
OPHTHALMOSCOPY, EXTENDED                             Extended ophthalmoscopy is a method of examination of the posterior
                   ARA-00-002                        1.
Diagnostic Abdominal Aortography and Renal AngiographyThe indications for renal arteriography adapted from the American C
                   ARA-00-002                        1.
Diagnostic Abdominal Aortography and Renal AngiographyThe indications for renal arteriography adapted from the American C
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-01-008
EKG and Related Cardiac Studies                      The most common test used to evaluate a patient for heart disease is
                   ARA-02-024
Modified Barium Swallow                              Modified barium swallow studies by videofluoroscopy are used to obje
                   ARA-02-024
Modified Barium Swallow                              Modified barium swallow studies by videofluoroscopy are used to obje
                   ARA-02-024
Modified Barium Swallow                              Modified barium swallow studies by videofluoroscopy are used to obje
                   ARA-02-024
Modified Barium Swallow                              Modified barium swallow studies by videofluoroscopy are used to obje
                   ARA-02-024
Modified Barium Swallow                              Modified barium swallow studies by videofluoroscopy are used to obje
                   ARA-02-024
Modified Barium Swallow                              Modified barium swallow studies by videofluoroscopy are used to obje
                   ARA-02-054
Myocardial Perfusion Testing                         The selection of candidates for testing should be done with the conside
                   ARA-02-054
Myocardial Perfusion Testing                         The selection of candidates for testing should be done with the conside
                   ARA-02-054
Myocardial Perfusion Testing                         The selection of candidates for testing should be done with the conside
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-01-028
Transesophageal Echocardiography                     The information derived from any transesophageal echocardiogram m
                   ARA-03-014                        These endoscopic examinations may be used to evaluate symptoms,
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
                   ARA-03-014                        These endoscopic examinations may be used to evaluate symptoms,
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
                   ARA-03-014                        These endoscopic examinations may be used to evaluate symptoms,
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
                   ARA-03-014                        These endoscopic examinations may be used to evaluate symptoms,
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
                   ARA-03-014                        These endoscopic examinations may be used to evaluate symptoms,
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
                   ARA-03-014                        These endoscopic examinations may be used to evaluate symptoms,
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
                   ARA-03-014                        These endoscopic examinations may be used to evaluate symptoms,
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
                  ARA-03-014                         These endoscopic examinations may be used to evaluate symptoms,
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
                  ARA-03-014                         These endoscopic examinations may be used to evaluate symptoms,
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
                  ARA-03-014                         These endoscopic examinations may be used to evaluate symptoms,
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
                  ARA-03-014                         These endoscopic examinations may be used to evaluate symptoms,
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
                  ARA-03-014                         These endoscopic examinations may be used to evaluate symptoms,
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
Electrolyte Panel 04A-0011-L                         This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 04A-0011-L                         This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 04A-0011-L                         This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 04A-0011-L                         This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 04A-0011-L                         This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 04A-0011-L                         This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 04A-0011-L                         This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 04A-0011-L                         This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 04A-0011-L                         This chemistry panel is a disease oriented panel and used in the diagn
Electrolyte Panel 04A-0011-L                         This chemistry panel is a disease oriented panel and used in the diagn
                  04A-0010-L
Computerized Axial Tomography of the Abdomen         A computed tomographic (CT) image is a display of the anatomy of a t
                  04A-0010-L
Computerized Axial Tomography of the Abdomen         A computed tomographic (CT) image is a display of the anatomy of a t
                  04A-0010-L
Computerized Axial Tomography of the Abdomen         A computed tomographic (CT) image is a display of the anatomy of a t
                  04A-0010-L
Computerized Axial Tomography of the Abdomen         A computed tomographic (CT) image is a display of the anatomy of a t
                  04A-0010-L
Computerized Axial Tomography of the Abdomen         A computed tomographic (CT) image is a display of the anatomy of a t
Botulinum Toxins ARA-01-016                          In carefully selected patients, the following conditions may be alleviate
Botulinum Toxins ARA-01-016                          In carefully selected patients, the following conditions may be alleviate
Botulinum Toxins ARA-01-016                          In carefully selected patients, the following conditions may be alleviate
                  B2002.13 R2
Treatment of Obstructive Sleep Apnea                 Sleep Disordered Breathing, often referred to as Obstructive Sleep Ap
                  B2002.13 R3
Treatment of Obstructive Sleep Apnea                 Sleep Disordered Breathing, often referred to as Obstructive Sleep Ap
                  B2002.13 R2
Treatment of Obstructive Sleep Apnea                 Sleep Disordered Breathing, often referred to as Obstructive Sleep Ap
                  ARA-05-002
Psychiatry/Psychology Services                       Psychiatry and Psychology are specialized fields for the diagnosis and
                  ARA-05-002
Psychiatry/Psychology Services                       Psychiatry and Psychology are specialized fields for the diagnosis and
                  ARA-05-002
Psychiatry/Psychology Services                       Psychiatry and Psychology are specialized fields for the diagnosis and
                  ARA-05-002
Psychiatry/Psychology Services                       Psychiatry and Psychology are specialized fields for the diagnosis and
                  ARA-05-002
Psychiatry/Psychology Services                       Psychiatry and Psychology are specialized fields for the diagnosis and
                  ARA-05-002
Psychiatry/Psychology Services                       Psychiatry and Psychology are specialized fields for the diagnosis and
                  ARA-05-002
Psychiatry/Psychology Services                       Psychiatry and Psychology are specialized fields for the diagnosis and
                  ARA-05-002
Psychiatry/Psychology Services                       Psychiatry and Psychology are specialized fields for the diagnosis and
                  ARA-05-002
Psychiatry/Psychology Services                       Psychiatry and Psychology are specialized fields for the diagnosis and
                  ARA-05-002
Psychiatry/Psychology Services                       Psychiatry and Psychology are specialized fields for the diagnosis and
                  ARA-05-002
Psychiatry/Psychology Services                       Psychiatry and Psychology are specialized fields for the diagnosis and
                  ARA-05-002
Psychiatry/Psychology Services                       Psychiatry and Psychology are specialized fields for the diagnosis and
                  ARA-05-002
Psychiatry/Psychology Services                       Psychiatry and Psychology are specialized fields for the diagnosis and
                  ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                  ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                  ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                  ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                  ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                  ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                  ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                  ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                  ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                  ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                  ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                  ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                  ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                    ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                    ARA-03-032                         Arteriovenous fistula (cannula, shunt) declotting or interventions to res
Percutaneous Thrombectomy of Arteriovenous Fistula/Graft
                    05NC-001-L
Computed Tomographic Angiography of the Chest (CTA)    Multislice or Multidetector Computed Tomography (MDCT) angiograph
                    05NC-001-L
Computed Tomographic Angiography of the Chest (CTA)    Multislice or Multidetector Computed Tomography (MDCT) angiograph
                    05NC-001-L
Computed Tomographic Angiography of the Chest (CTA)    Multislice or Multidetector Computed Tomography (MDCT) angiograph
                    05NC-001-L
Computed Tomographic Angiography of the Chest (CTA)    Multislice or Multidetector Computed Tomography (MDCT) angiograph
                    05NC-001-L
Computed Tomographic Angiography of the Chest (CTA)    Multislice or Multidetector Computed Tomography (MDCT) angiograph
                    3-May
Intravenous Nesiritide (BNP) Infusion Therapy          Heart failure (HF) is a clinical syndrome that is characterized by dyspn
                    05HH-001-L                         This policy addresses a specific category of skilled nursing care curren
Home Health Skilled Nursing Care-Teaching and Training: Alzheimer's Disease and Behavioral Disturbances
                    05HH-001-L                         This policy addresses a specific category of skilled nursing care curren
Home Health Skilled Nursing Care-Teaching and Training: Alzheimer's Disease and Behavioral Disturbances
                    ARA-99-524
Infliximab (Remicade)                                  Infliximab is a chimeric monoclonal antibody which binds specifically to
                    ARA-99-524
Infliximab (Remicade)                                  Infliximab is a chimeric monoclonal antibody which binds specifically to
                    ARA-99-524
Infliximab (Remicade)                                  Infliximab is a chimeric monoclonal antibody which binds specifically to
                    ARA-99-524
Infliximab (Remicade)                                  Infliximab is a chimeric monoclonal antibody which binds specifically to
                    ARA-99-524
Infliximab (Remicade)                                  Infliximab is a chimeric monoclonal antibody which binds specifically to
                    ARA-99-524
Infliximab (Remicade)                                  Infliximab is a chimeric monoclonal antibody which binds specifically to
                    ARA-99-524
Infliximab (Remicade)                                  Infliximab is a chimeric monoclonal antibody which binds specifically to
                    ARA-99-524
Infliximab (Remicade)                                  Infliximab is a chimeric monoclonal antibody which binds specifically to
                    ARA-02-009                          A.
Nerve Conduction Studies (NCS)/Electromyography (EMG) Nerve Conduction Studies Nerve conduction studies (NCS) are us
                    ARA-02-009                          A.
Nerve Conduction Studies (NCS)/Electromyography (EMG) Nerve Conduction Studies Nerve conduction studies (NCS) are us
                    ARA-02-009                          A.
Nerve Conduction Studies (NCS)/Electromyography (EMG) Nerve Conduction Studies Nerve conduction studies (NCS) are us
                    ARA-02-009                          A.
Nerve Conduction Studies (NCS)/Electromyography (EMG) Nerve Conduction Studies Nerve conduction studies (NCS) are us
                    ARA-02-009                          A.
Nerve Conduction Studies (NCS)/Electromyography (EMG) Nerve Conduction Studies Nerve conduction studies (NCS) are us
                    ARA-02-009                          A.
Nerve Conduction Studies (NCS)/Electromyography (EMG) Nerve Conduction Studies Nerve conduction studies (NCS) are us
                    ARA-02-009                          A.
Nerve Conduction Studies (NCS)/Electromyography (EMG) Nerve Conduction Studies Nerve conduction studies (NCS) are us
                    ARA-02-009                          A.
Nerve Conduction Studies (NCS)/Electromyography (EMG) Nerve Conduction Studies Nerve conduction studies (NCS) are us
                    ARA-02-009                          A.
Nerve Conduction Studies (NCS)/Electromyography (EMG) Nerve Conduction Studies Nerve conduction studies (NCS) are us
                    ARA-02-009                          A.
Nerve Conduction Studies (NCS)/Electromyography (EMG) Nerve Conduction Studies Nerve conduction studies (NCS) are us
                    ARA-02-009                          A.
Nerve Conduction Studies (NCS)/Electromyography (EMG) Nerve Conduction Studies Nerve conduction studies (NCS) are us
                    ARA-02-009                          A.
Nerve Conduction Studies (NCS)/Electromyography (EMG) Nerve Conduction Studies Nerve conduction studies (NCS) are us
Chest X-Ray Policy  A2005.01 R8                        Note: Providers should seek information related to National Coverage
Chest X-Ray Policy  A2005.01 R8                        Note: Providers should seek information related to National Coverage
Chest X-Ray Policy  A2005.01 R8                        Note: Providers should seek information related to National Coverage
Chest X-Ray Policy  A2005.01 R8                        Note: Providers should seek information related to National Coverage
Chest X-Ray Policy  A2005.01 R8                        Note: Providers should seek information related to National Coverage
                    L19861
Inpatient Rehabilitation Facility (IRF) Services       This Local Coverage Determination (LCD) addresses Medicare covera
                    *(formerly Intravenous Immune Globulin IVIG)
Immune Globulins INJ-012/2005-04D                       Indications and Limitations of Coverage And/or Medical Necessity: *I
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                    ARA-02-052
Granulocyte Colony-Stimulating Factors
                  ARA-02-052
Granulocyte Colony-Stimulating Factors
Urinalysis Policy A2005.02 R9                        Note: Providers should seek information related to National Coverage
Urinalysis Policy A2005.02 R9                        Note: Providers should seek information related to National Coverage
Urinalysis Policy A2005.02 R9                        Note: Providers should seek information related to National Coverage
Urinalysis Policy A2005.02 R9                        Note: Providers should seek information related to National Coverage
Urinalysis Policy A2005.02 R9                        Note: Providers should seek information related to National Coverage
Urinalysis Policy A2005.02 R9                        Note: Providers should seek information related to National Coverage
Chest X-Ray PolicyA2005.01 R8                        Note: Providers should seek information related to National Coverage
Chest X-Ray PolicyA2005.01 R8                        Note: Providers should seek information related to National Coverage
Chest X-Ray PolicyA2005.01 R8                        Note: Providers should seek information related to National Coverage
Chest X-Ray PolicyA2005.01 R8                        Note: Providers should seek information related to National Coverage
Chest X-Ray PolicyA2005.01 R8                        Note: Providers should seek information related to National Coverage
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-004                         Erythropoietin (EPO) is a glycoprotein that stimulates red blood cell pro
EPO/Darbepoetin Alfa Administration for Secondary Anemia
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-005                         Epoetin alfa is a
EPO/Darbepoetin Alfa for Treatment of Anemia Associated AZT Therapy biologically engineered protein, which stimulates the b
                  ARA-05-007                         The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                  ARA-05-007                         The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                  ARA-05-007                         The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                  ARA-05-007                         The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                  ARA-05-007                         The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                  ARA-05-007                         The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                  ARA-05-007                         The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                  ARA-05-007                         The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                   ARA-05-007                        The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                   ARA-05-007                        The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                   ARA-05-007                        The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                   ARA-05-007                        The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                   ARA-05-007                        The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                   ARA-05-007                        The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                   ARA-05-007                        The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                   ARA-05-007                        The FDA approved labeling states that it is indicated in the treatment o
EPO/Darbepotein Alfa for Treatment of Anemia Associated with Chronic Renal Failure
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   ARA-05-006
EPO/Darbepoetin Alfa-Preoperative                    The Canadian Orthopedic Perioperative Study Group clinical trial on ef
                   Draft 05-004
Computerized Axial Tomography (CT) Scan Head         A computerized axial tomography (CT) scan is a form of x-ray that cre
                   Draft 05-004
Computerized Axial Tomography (CT) Scan Head         A computerized axial tomography (CT) scan is a form of x-ray that cre
                   Draft 05-004
Computerized Axial Tomography (CT) Scan Head         A computerized axial tomography (CT) scan is a form of x-ray that cre
                   Draft 05-004
Computerized Axial Tomography (CT) Scan Head         A computerized axial tomography (CT) scan is a form of x-ray that cre
                   Draft 05-004
Computerized Axial Tomography (CT) Scan Head         A computerized axial tomography (CT) scan is a form of x-ray that cre
                   Draft 05-004
Computerized Axial Tomography (CT) Scan Head         A computerized axial tomography (CT) scan is a form of x-ray that cre
                   Draft 05-004
Computerized Axial Tomography (CT) Scan Head         A computerized axial tomography (CT) scan is a form of x-ray that cre
                   Draft 05-004
Computerized Axial Tomography (CT) Scan Head         A computerized axial tomography (CT) scan is a form of x-ray that cre
                   Draft 05-004
Computerized Axial Tomography (CT) Scan Head         A computerized axial tomography (CT) scan is a form of x-ray that cre
                   B2002.11
Implantable Infusion Pump R1                         This policy addresses the three indications for the implantable infusion
                   A2005.07 R14
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                   A2005.07 R14
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                   A2005.07 R14
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                   A2005.07 R14
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                   A2005.07 R14
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                   A2005.07 R15
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                   A2005.07 R15
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                   A2005.07 R15
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                   A2005.07 R15
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                   A2005.07 R15
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                   NULL
PEGAPTANIB SODIUM, INJECTION                         Pegaptanib sodium is the first drug of a class of vascular endothelial g
Serum Protein      05NC-004-L                        Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein      05NC-004-L                        Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein      05NC-004-L                        Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein      05NC-004-L                        Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein      05NC-004-L                        Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein      05NC-004-L                        Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein      05NC-004-L                        Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein    05NC-004-L       Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein    05NC-004-L       Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein    05NC-004-L       Protein testing aids in the diagnosis of some inflammatory and neoplas
Serum Protein    05NC-004-L       Protein testing aids in the diagnosis of some inflammatory and neoplas
                 05NC-006-L
Sodium Hyaluronate                These devices are viscous solutions consisting of a high molecular we
                 05NC-006-L
Sodium Hyaluronate                These devices are viscous solutions consisting of a high molecular we
                 05NC-006-L
Sodium Hyaluronate                These devices are viscous solutions consisting of a high molecular we
                 05NC-006-L
Sodium Hyaluronate                These devices are viscous solutions consisting of a high molecular we
                 05NC-006-L
Sodium Hyaluronate                These devices are viscous solutions consisting of a high molecular we
                 05NC-006-L
Sodium Hyaluronate                These devices are viscous solutions consisting of a high molecular we
                 05NC-006-L
Sodium Hyaluronate                These devices are viscous solutions consisting of a high molecular we
                 05NC-006-L
Sodium Hyaluronate                These devices are viscous solutions consisting of a high molecular we
                 05NC-006-L
Sodium Hyaluronate                These devices are viscous solutions consisting of a high molecular we
Zoledronic Acid 05NC-005-L        Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 05NC-005-L        Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 05NC-005-L        Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 05NC-005-L        Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 05NC-005-L        Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 05NC-005-L        Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 05NC-005-L        Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 05NC-005-L        Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 05NC-005-L        Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 A
Capsule Endoscopy RA-03-013       Small Intestinal Imaging is a noninvasive diagnostic imaging device for
                 ARA-99-516
External Counterpulsation (ECP)   External counterpulsation ECP is a non-invasive outpatient treatment f
                 ARA-99-516
External Counterpulsation (ECP)   External counterpulsation ECP is a non-invasive outpatient treatment f
Hylan Polymers ARA-01-011         Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011         Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011         Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011         Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011         Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011         Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011         Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011         Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011         Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011         Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011         Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011         Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011         Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011                               Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011                               Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
Hylan Polymers ARA-01-011                               Hyaluronic acid is a natural constituent of synovial fluid and cartilage. T
                   ARA-03-028
Intravascular Ultrasound                                Intravascular ultrasound (IVUS) is an imaging technique in which a min
                   ARA-03-028
Intravascular Ultrasound                                Intravascular ultrasound (IVUS) is an imaging technique in which a min
                   ARA-03-028
Intravascular Ultrasound                                Intravascular ultrasound (IVUS) is an imaging technique in which a min
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   ARA-01-002                           Radiological imaging should
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (Rev 1) adhere to the standards established by th
                   A2005.14 Skin                        Note: Providers should
Application of Bioengineered R10 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
                   A2005.14 Skin                        Note: Providers should
Application of Bioengineered R10 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
                   A2005.14 Skin                        Note: Providers should
Application of Bioengineered R10 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
                   A2005.14 Skin                        Note: Providers should
Application of Bioengineered R10 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
                   A2005.14 Skin                        Note: Providers should
Application of Bioengineered R10 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
                   A2005.14 Skin                        Note: Providers should
Application of Bioengineered R11 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
                   A2005.14 Skin                        Note: Providers should
Application of Bioengineered R11 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
                   A2005.14 Skin                        Note: Providers should
Application of Bioengineered R11 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
                   A2005.14 Skin                        Note: Providers should
Application of Bioengineered R11 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
                   A2005.14 Skin                        Note: Providers should
Application of Bioengineered R11 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
                   A2006.02 R8                           Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                   A2006.02 R8                           Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                   A2006.02 R8                           Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                   A2006.02 R8                           Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                   A2006.02 R8                           Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                   A2006.02 R9                           Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                   A2006.02 R9                           Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                   A2006.02 R9                           Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                   A2006.02 R9                           Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                   A2006.02 R9                           Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                   ARA-01-010
Holter Monitor - Long Term EKG Monitoring               Long term EKG recording is a diagnostic procedure which provides a c
                   ARA-01-010
Holter Monitor - Long Term EKG Monitoring               Long term EKG recording is a diagnostic procedure which provides a c
                   ARA-01-010
Holter Monitor - Long Term EKG Monitoring               Long term EKG recording is a diagnostic procedure which provides a c
                   ARA-01-010
Holter Monitor - Long Term EKG Monitoring               Long term EKG recording is a diagnostic procedure which provides a c
                   ARA-01-010
Holter Monitor - Long Term EKG Monitoring               Long term EKG recording is a diagnostic procedure which provides a c
                   ARA-01-010
Holter Monitor - Long Term EKG Monitoring               Long term EKG recording is a diagnostic procedure which provides a c
                   ARA-01-010
Holter Monitor - Long Term EKG Monitoring               Long term EKG recording is a diagnostic procedure which provides a c
                   ARA-01-010
Holter Monitor - Long Term EKG Monitoring               Long term EKG recording is a diagnostic procedure which provides a c
                   ARA-01-010
Holter Monitor - Long Term EKG Monitoring               Long term EKG recording is a diagnostic procedure which provides a c
                   ARA-01-010
Holter Monitor - Long Term EKG Monitoring               Long term EKG recording is a diagnostic procedure which provides a c
                   ARA-01-010
Holter Monitor - Long Term EKG Monitoring               Long term EKG recording is a diagnostic procedure which provides a c
                    ARA-01-010
Holter Monitor - Long Term EKG Monitoring                  Long term EKG recording is a diagnostic procedure which provides a c
                    ARA-01-010
Holter Monitor - Long Term EKG Monitoring                  Long term EKG recording is a diagnostic procedure which provides a c
                    ARA-01-010
Holter Monitor - Long Term EKG Monitoring                  Long term EKG recording is a diagnostic procedure which provides a c
                    EDX.0506
Neuromuscular Electrodiagnostic (EDX) Studies               Description Electrodiagnostic Medicine (EDX) Studies are considered
                    ARA-02-038                             In this Bursa
Arthrocentesis, Aspiration, and/or Injection of the Major Joint orprocedure, a needle is inserted into a major joint for the purpose
                    ARA-02-038                             In this Bursa
Arthrocentesis, Aspiration, and/or Injection of the Major Joint orprocedure, a needle is inserted into a major joint for the purpose
                    ARA-02-038                             In this Bursa
Arthrocentesis, Aspiration, and/or Injection of the Major Joint orprocedure, a needle is inserted into a major joint for the purpose
                    ARA-02-038                             In this Bursa
Arthrocentesis, Aspiration, and/or Injection of the Major Joint orprocedure, a needle is inserted into a major joint for the purpose
Epidural Injections ARA-03-005                             Spinal pain generates from multiple structures in the spine with a nerve
Epidural Injections ARA-03-005                             Spinal pain generates from multiple structures in the spine with a nerve
Epidural Injections ARA-03-005                             Spinal pain generates from multiple structures in the spine with a nerve
                    ARA-02-034                             Facet Joint
Paravertebral Facet Joint Nerve Block (Diagnostic or Therapeutic) Nerve Block is a type of local anesthetic procedure to temp
                    ARA-02-034                             Facet Joint
Paravertebral Facet Joint Nerve Block (Diagnostic or Therapeutic) Nerve Block is a type of local anesthetic procedure to temp
                    ARA-02-034                             Facet Joint
Paravertebral Facet Joint Nerve Block (Diagnostic or Therapeutic) Nerve Block is a type of local anesthetic procedure to temp
                    ARA-02-034                             Facet Joint
Paravertebral Facet Joint Nerve Block (Diagnostic or Therapeutic) Nerve Block is a type of local anesthetic procedure to temp
                    ARA-02-034                             Facet Joint
Paravertebral Facet Joint Nerve Block (Diagnostic or Therapeutic) Nerve Block is a type of local anesthetic procedure to temp
                    ARA-02-035
Paravertebral Facet Nerve Denervation                      The diagnosis of facet joint pain can be suspected if back pain does no
                    ARA-02-035
Paravertebral Facet Nerve Denervation                      The diagnosis of facet joint pain can be suspected if back pain does no
                    ARA-02-035
Paravertebral Facet Nerve Denervation                      The diagnosis of facet joint pain can be suspected if back pain does no
                    ARA-02-035
Paravertebral Facet Nerve Denervation                      The diagnosis of facet joint pain can be suspected if back pain does no
                    ARA-02-035
Paravertebral Facet Nerve Denervation                      The diagnosis of facet joint pain can be suspected if back pain does no
                    ARA-02-042
Vagal Nerve Stimulation                                    The basic premise of Vagus Nerve Stimulation in this treatment is that
Serum MagnesiumA2006.05 R7                                 Note: Providers should seek information related to National Coverage
Serum MagnesiumA2006.05 R7                                 Note: Providers should seek information related to National Coverage
Serum MagnesiumA2006.05 R7                                 Note: Providers should seek information related to National Coverage
Serum MagnesiumA2006.05 R7                                 Note: Providers should seek information related to National Coverage
Serum MagnesiumA2006.05 R7                                 Note: Providers should seek information related to National Coverage
Serum MagnesiumA2006.05 R7                                 Note: Providers should seek information related to National Coverage
                    ARA-03-033
Spinal Cord Stimulators                                    Spinal cord stimulation blocks pain conduction pathway and stimulate
                    ARA-03-033
Spinal Cord Stimulators                                    Spinal cord stimulation blocks pain conduction pathway and stimulate
                    R-18
Proton Beam Radiotherapy-R18B                              Proton beam therapy is a radiation treatment modality that delivers hig
                    Endoscopy - X-44B
Wireless Capsule X-44                                      Wireless capsule endoscopy (WCE) is an ingestible telemetric gastroin
                    006-01-04                               Definitions Bone mass
Bone Mass Measurements (BMMs) (previously Measurement of Bone Density) measurement is a radiologic or radioisotopic p
                    Draft
Molecular Diagnostics 06-012                               Molecular diagnostic testing may be used for analysis of the nucleic ac
                    Draft
Molecular Diagnostics 06-012                               Molecular diagnostic testing may be used for analysis of the nucleic ac
                    Draft
Molecular Diagnostics 06-012                               Molecular diagnostic testing may be used for analysis of the nucleic ac
                    Draft
Molecular Diagnostics 06-012                               Molecular diagnostic testing may be used for analysis of the nucleic ac
                    Draft
Molecular Diagnostics 06-012                               Molecular diagnostic testing may be used for analysis of the nucleic ac
                    Draft
Molecular Diagnostics 06-012                               Molecular diagnostic testing may be used for analysis of the nucleic ac
                    Draft
Molecular Diagnostics 06-012                               Molecular diagnostic testing may be used for analysis of the nucleic ac
                    Draft
Molecular Diagnostics 06-012                               Molecular diagnostic testing may be used for analysis of the nucleic ac
                    L22580
Bone Mass Measurement                                      Bone mass measurement is a radiologic or radioisotopic procedure tha
                    L22580
Bone Mass Measurement                                      Bone mass measurement is a radiologic or radioisotopic procedure tha
                    L22580
Bone Mass Measurement                                      Bone mass measurement is a radiologic or radioisotopic procedure tha
                    L22580
Bone Mass Measurement                                      Bone mass measurement is a radiologic or radioisotopic procedure tha
                    L22580
Bone Mass Measurement                                      Bone mass measurement is a radiologic or radioisotopic procedure tha
                    L22580
Bone Mass Measurement                                      Bone mass measurement is a radiologic or radioisotopic procedure tha
                    L22580
Bone Mass Measurement                                      Bone mass measurement is a radiologic or radioisotopic procedure tha
Coverage of DrugsNULL                                      An
                     for Labeled and Off-Labeled Indications off-label/unlabeled use of a drug is defined as a use for a non-Food
Chronic Wound Care  ARA-02-025                              Indications: Chronic wound care is generally necessary for the followin
Chronic Wound Care  ARA-02-025                              Indications: Chronic wound care is generally necessary for the followin
Chronic Wound Care  ARA-02-025                              Indications: Chronic wound care is generally necessary for the followin
Chronic Wound CareARA-02-025           Indications: Chronic wound care is generally necessary for the followin
Chronic Wound CareARA-02-025           Indications: Chronic wound care is generally necessary for the followin
Chronic Wound CareARA-02-025           Indications: Chronic wound care is generally necessary for the followin
Chronic Wound CareARA-02-025           Indications: Chronic wound care is generally necessary for the followin
Chronic Wound CareARA-02-025           Indications: Chronic wound care is generally necessary for the followin
Chronic Wound CareARA-02-025           Indications: Chronic wound care is generally necessary for the followin
Chronic Wound CareARA-02-025           Indications: Chronic wound care is generally necessary for the followin
Chronic Wound CareARA-02-025           Indications: Chronic wound care is generally necessary for the followin
                  06NC-005-L
Positron Emission Tomography           The definition for Positron Emission Tomography is found in the CMS
                  06NC-005-L
Positron Emission Tomography           The definition for Positron Emission Tomography is found in the CMS
                  06NC-005-L
Positron Emission Tomography           The definition for Positron Emission Tomography is found in the CMS
                  06NC-005-L
Positron Emission Tomography           The definition for Positron Emission Tomography is found in the CMS
                  06NC-005-L
Positron Emission Tomography           The definition for Positron Emission Tomography is found in the CMS
Ablative Therapy B2006.07              Ablative procedures have been in the armamentarium of tumor therap
                  B2006.08
Non-Covered Services                   Medicare does not cover items and services that are not reasonable a
Ablative Therapy B2006.07              Ablative procedures have been in the armamentarium of tumor therap
                  B2006.08
Non-Covered Services                   Medicare does not cover items and services that are not reasonable a
B12 Injection     06A-0001-L           Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     06A-0001-L           Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     06A-0001-L           Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     06A-0001-L           Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     06A-0001-L           Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     06A-0001-L           Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     06A-0001-L           Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     06A-0001-L           Vitamin B12 (cobalamin) is essential to red blood cell production and n
B12 Injection     06A-0001-L           Vitamin B12 (cobalamin) is essential to red blood cell production and n
Zoledronic Acid 06A-0002-L             Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 06A-0002-L             Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 06A-0002-L             Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 06A-0002-L             Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 06A-0002-L             Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 06A-0002-L             Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 06A-0002-L             Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 06A-0002-L             Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
Zoledronic Acid 06A-0002-L             Zoledronic acid is a FDA-approved intravenous bisphosphonate for the
                  06NC-004-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                A diagnostic mammography is a
                  06NC-004-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                A diagnostic mammography is a
                  06NC-004-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                A diagnostic mammography is a
                  06NC-004-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                A diagnostic mammography is a
                  06NC-004-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                A diagnostic mammography is a
                  06NC-004-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                A diagnostic mammography is a
                  06NC-004-L
Diagnostic and Screening Mammography    Diagnostic Mammograms                A diagnostic mammography is a
                  06NC-001-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  06NC-001-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  06NC-001-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  06NC-001-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  06NC-001-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  06NC-001-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  06NC-001-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  06NC-001-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  06NC-001-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                  06NC-001-L
Diagnostic Pap Smear                   Pap Smear (Papanicolaou) Smear/Test is a cytological examination of
                   S-129
Skin Substitutes/Replacements S-129B-R11          The provisions of this LCD address payment for skin substitute/replace
Chest X-Ray Policy A2006.08 R6                    Note: Providers should seek information related to National Coverage
Chest X-Ray Policy A2006.08 R6                    Note: Providers should seek information related to National Coverage
Chest X-Ray Policy A2006.08 R6                    Note: Providers should seek information related to National Coverage
Chest X-Ray Policy A2006.08 R6                    Note: Providers should seek information related to National Coverage
Chest X-Ray Policy A2006.08 R6                    Note: Providers should seek information related to National Coverage
                   INJ-523A/2006-09
Erythropoiesis Stimulating Agents*                Discussion Naturally occurring human erythropoietin (EPO) is a glycop
                   INJ-523A/2006-09
Erythropoiesis Stimulating Agents*                Discussion Naturally occurring human erythropoietin (EPO) is a glycop
                   INJ-523A/2006-09
Erythropoiesis Stimulating Agents*                Discussion Naturally occurring human erythropoietin (EPO) is a glycop
                   INJ-523A/2006-09
Erythropoiesis Stimulating Agents*                Discussion Naturally occurring human erythropoietin (EPO) is a glycop
                   INJ-523A/2006-09
Erythropoiesis Stimulating Agents*                Discussion Naturally occurring human erythropoietin (EPO) is a glycop
                   INJ-523A/2006-09
Erythropoiesis Stimulating Agents*                Discussion Naturally occurring human erythropoietin (EPO) is a glycop
                   INJ-523A/2006-09
Erythropoiesis Stimulating Agents*                Discussion Naturally occurring human erythropoietin (EPO) is a glycop
                   INJ-523A/2006-09
Erythropoiesis Stimulating Agents*                Discussion Naturally occurring human erythropoietin (EPO) is a glycop
                    Factors
Colony Stimulating06NC-002-L                      Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06NC-002-L                      Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06NC-002-L                      Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06NC-002-L                      Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06NC-002-L                      Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06NC-002-L                      Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06NC-002-L                      Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06NC-002-L                      Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06NC-002-L                      Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                   06A-0007-L                     Multislice or Multidetector Computed Tomography (MDCT) angiograph
Computed Tomographic Angiography of the Chest (CTA)
                   06A-0007-L                     Multislice or Multidetector Computed Tomography (MDCT) angiograph
Computed Tomographic Angiography of the Chest (CTA)
                   06A-0007-L                     Multislice or Multidetector Computed Tomography (MDCT) angiograph
Computed Tomographic Angiography of the Chest (CTA)
                   06A-0007-L                     Multislice or Multidetector Computed Tomography (MDCT) angiograph
Computed Tomographic Angiography of the Chest (CTA)
                   06A-0007-L                     Multislice or Multidetector Computed Tomography (MDCT) angiograph
Computed Tomographic Angiography of the Chest (CTA)
Pamidronate        06A-0009-L                     Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate        06A-0009-L                     Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate        06A-0009-L                     Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate        06A-0009-L                     Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate        06A-0009-L                     Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate        06A-0009-L                     Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate        06A-0009-L                     Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate        06A-0009-L                     Pamidronate, a bisphosphonate which is administered intravenously, is
Pamidronate        06A-0009-L                     Pamidronate, a bisphosphonate which is administered intravenously, is
Echocardiography 06NC-003-L                       Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06NC-003-L                       Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06NC-003-L                       Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06NC-003-L                       Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06NC-003-L                       Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06NC-003-L                       Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06NC-003-L                       Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06NC-003-L                       Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06NC-003-L                       Echocardiography is a non-invasive technique in which pulsed high-fre
                   06A-0005-L
Chemotherapy Agents, Anti-Cancer, Selected         J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06A-0005-L
Chemotherapy Agents, Anti-Cancer, Selected         J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06A-0005-L
Chemotherapy Agents, Anti-Cancer, Selected         J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06A-0005-L
Chemotherapy Agents, Anti-Cancer, Selected         J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06A-0005-L
Chemotherapy Agents, Anti-Cancer, Selected         J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06A-0005-L
Chemotherapy Agents, Anti-Cancer, Selected         J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06A-0005-L
Chemotherapy Agents, Anti-Cancer, Selected             J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06A-0005-L
Chemotherapy Agents, Anti-Cancer, Selected             J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06A-0005-L
Chemotherapy Agents, Anti-Cancer, Selected             J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06NC-006-L
Chemotherapy Agents, Anti-Cancer, Selected              J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06NC-006-L
Chemotherapy Agents, Anti-Cancer, Selected              J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06NC-006-L
Chemotherapy Agents, Anti-Cancer, Selected              J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06NC-006-L
Chemotherapy Agents, Anti-Cancer, Selected              J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06NC-006-L
Chemotherapy Agents, Anti-Cancer, Selected              J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06NC-006-L
Chemotherapy Agents, Anti-Cancer, Selected              J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06NC-006-L
Chemotherapy Agents, Anti-Cancer, Selected              J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06NC-006-L
Chemotherapy Agents, Anti-Cancer, Selected              J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06NC-006-L
Chemotherapy Agents, Anti-Cancer, Selected              J9045 Carboplatin is indicated for: ?Palliative treatment of epithelial o
                   06A-0006-L
Upper Gastrointestinal Endoscopy and Visualization   Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   06A-0006-L
Upper Gastrointestinal Endoscopy and Visualization   Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   06A-0006-L
Upper Gastrointestinal Endoscopy and Visualization   Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   06A-0006-L
Upper Gastrointestinal Endoscopy and Visualization   Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   06A-0006-L
Upper Gastrointestinal Endoscopy and Visualization   Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   06A-0006-L
Upper Gastrointestinal Endoscopy and Visualization   Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   06A-0006-L
Upper Gastrointestinal Endoscopy and Visualization   Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   06A-0006-L
Upper Gastrointestinal Endoscopy and Visualization   Diagnostic and therapeutic EGD is a common endoscopic procedure d
                   06A-0006-L
Upper Gastrointestinal Endoscopy and Visualization   Diagnostic and therapeutic EGD is a common endoscopic procedure d
                    Factors
Colony Stimulating06A-0010-L                         Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06A-0010-L                         Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06A-0010-L                         Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06A-0010-L                         Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06A-0010-L                         Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06A-0010-L                         Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06A-0010-L                         Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06A-0010-L                         Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
                    Factors
Colony Stimulating06A-0010-L                         Colony Stimulating Factors (CSF) are hematopoietic growth factors, w
Echocardiography 06A-0011-L                          Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06A-0011-L                          Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06A-0011-L                          Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06A-0011-L                          Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06A-0011-L                          Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06A-0011-L                          Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06A-0011-L                          Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06A-0011-L                          Echocardiography is a non-invasive technique in which pulsed high-fre
Echocardiography 06A-0011-L                          Echocardiography is a non-invasive technique in which pulsed high-fre
                   2006-10                           Bariatric surgery is surgery performed to treat morbid obesity. For purp
Bariatric Surgery (Surgical Management of Morbid Obesity)
                   06A-0008-L
Intravenous Immunoglobulin (IVIG)                    Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                   06A-0008-L
Intravenous Immunoglobulin (IVIG)                    Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                   06A-0008-L
Intravenous Immunoglobulin (IVIG)                    Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                   06A-0008-L
Intravenous Immunoglobulin (IVIG)                    Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                   06A-0008-L
Intravenous Immunoglobulin (IVIG)                    Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                   06A-0008-L
Intravenous Immunoglobulin (IVIG)                    Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                   06A-0008-L
Intravenous Immunoglobulin (IVIG)                    Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                   06A-0008-L
Intravenous Immunoglobulin (IVIG)                    Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
                   06A-0008-L
Intravenous Immunoglobulin (IVIG)                    Intravenous Immune Globulin (IVIG) is a solution of human immunoglo
Infliximab         06A-0013-L                        Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab         06A-0013-L                        Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab         06A-0013-L                        Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab          06A-0013-L                         Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab          06A-0013-L                         Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab          06A-0013-L                         Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab          06A-0013-L                         Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab          06A-0013-L                         Infliximab is a chimeric monoclonal antibody that binds specifically to tu
Infliximab          06A-0013-L                         Infliximab is a chimeric monoclonal antibody that binds specifically to tu
                    06A-0012-L
Vagal Nerve Stimulation (VNS) for Epilepsy             Vagus nerve stimulation has been shown to be an effective adjunctive
                    06A-0012-L
Vagal Nerve Stimulation (VNS) for Epilepsy             Vagus nerve stimulation has been shown to be an effective adjunctive
                    06A-0012-L
Vagal Nerve Stimulation (VNS) for Epilepsy             Vagus nerve stimulation has been shown to be an effective adjunctive
                    06A-0012-L
Vagal Nerve Stimulation (VNS) for Epilepsy             Vagus nerve stimulation has been shown to be an effective adjunctive
                    06A-0012-L
Vagal Nerve Stimulation (VNS) for Epilepsy             Vagus nerve stimulation has been shown to be an effective adjunctive
Plastic Surgery     B2007.04 R4                        According to the American Society of Plastic Surgeons, the specialty o
                    B2007.07 R5
Ablative Therapy: Intra-thoracic and Intra-abdominal   Ablative procedures have been in the armamentarium of tumor therap
Artificial Disc     B2007.11 R1                        Effective May 16, 2006 , The Centers for Medicare and Medicaid Serv
                    B2007.15 R1
Blocks and Destruction of Somatic and Sympathetic NervesNerve Blocks: Nerve blocks cause the temporary interruption of condu
                    B2007.15 R1
Blocks and Destruction of Somatic and Sympathetic NervesNerve Blocks: Nerve blocks cause the temporary interruption of condu
                    B2007.15 R1
Blocks and Destruction of Somatic and Sympathetic NervesNerve Blocks: Nerve blocks cause the temporary interruption of condu
CT Colonography B2007.30                               Computed tomographic (CT) colonography, also known as virtual colo
CT Colonography B2007.30                               Computed tomographic (CT) colonography, also known as virtual colo
CT Colonography B2007.30                               Computed tomographic (CT) colonography, also known as virtual colo
                    B2007.90
Stereotactic Body Radiation Therapy                    Stereotactic body radiation therapy (SBRT) is a treatment that couples
                    B2007.90
Stereotactic Body Radiation Therapy                    Stereotactic body radiation therapy (SBRT) is a treatment that couples
                    B2007.90
Stereotactic Body Radiation Therapy                    Stereotactic body radiation therapy (SBRT) is a treatment that couples
                    B2007.13
Wireless Capsule Enteroscopy                           Wireless capsule enteroscopy is an ingestible telemetric gastrointestin
                    B2007.13
Wireless Capsule Enteroscopy                           Wireless capsule enteroscopy is an ingestible telemetric gastrointestin
                    B2007.13
Wireless Capsule Enteroscopy                           Wireless capsule enteroscopy is an ingestible telemetric gastrointestin
                    B2007.36
Endoscopic Treatment of GERD                           Benefits are not available for endoluminal treatment for Gastroesopha
                    B2007.36
Endoscopic Treatment of GERD                           Benefits are not available for endoluminal treatment for Gastroesopha
                    B2007.36
Endoscopic Treatment of GERD                           Benefits are not available for endoluminal treatment for Gastroesopha
                    B2007.68 R2                        This policy addresses Neuroma
Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton'sthe injection of chemical substances, such as lo
                    B2007.95
Intensity Modulated Radiation Therapy (IMRT)           Intensity Modulated Radiation Therapy (IMRT) is a computer-based m
                    B2007.95
Intensity Modulated Radiation Therapy (IMRT)           Intensity Modulated Radiation Therapy (IMRT) is a computer-based m
                    B2007.95
Intensity Modulated Radiation Therapy (IMRT)           Intensity Modulated Radiation Therapy (IMRT) is a computer-based m
                    B2007.102
Treatment of Varicose Veins of the Lower Extremities Historically, varicose veins have been treated by conservative measure
                    B2007.102
Treatment of Varicose Veins of the Lower Extremities Historically, varicose veins have been treated by conservative measure
                    B2007.102
Treatment of Varicose Veins of the Lower Extremities Historically, varicose veins have been treated by conservative measure
                    B2007.93
Symptomatic, Pathological Nail and Its Treatment       Routine foot care, which includes trimming or debridement of the Asym
                    B2007.93
Symptomatic, Pathological Nail and Its Treatment       Routine foot care, which includes trimming or debridement of the Asym
                    B2007.93
Symptomatic, Pathological Nail and Its Treatment       Routine foot care, which includes trimming or debridement of the Asym
                    R-19
 Stereotactic Radiosurgery R-19B                       Stereotactic radiosurgery involves the delivery of a single high dose of
                    Z-14
 Non-Covered Services Z-14-R22                         Medicare does not cover items and services that are not reasonable a
                    Z-14
 Non-Covered Services Z-14-R22                         Medicare does not cover items and services that are not reasonable a
                    Z-14
 Non-Covered Services Z-14-R22                         Medicare does not cover items and services that are not reasonable a
                    Z-14
 Non-Covered Services Z-14-R22                         Medicare does not cover items and services that are not reasonable a
                    Z-14
 Non-Covered Services Z-14-R22                         Medicare does not cover items and services that are not reasonable a
                    2006-10                            Bariatric surgery is surgery performed to treat morbid obesity. For purp
Bariatric Surgery (Surgical Management of Morbid Obesity)
                    2007-002
Intraoperative Neurophysiological Monitoring           Based on information in the scientific literature, it is recommended tha
                    NULL
Trigger Point Injections                               Trigger point injection is one of the many modalities utilized in the man
                    NULL
Trigger Point Injections                               Trigger point injection is one of the many modalities utilized in the man
                    2007-002
Intraoperative Neurophysiological Monitoring           Based on information in the scientific literature, it is recommended tha
Artificial Disc     J3 CB2006.73 R2                    Effective May 16, 2006, the Centers for Medicare and Medicaid Servic
Artificial Disc     J3 CB2006.73 R2                    Effective May 16, 2006, the Centers for Medicare and Medicaid Servic
Artificial Disc    J3 CB2006.73 R2                     Effective May 16, 2006, the Centers for Medicare and Medicaid Servic
Artificial Disc    J3 CB2006.73 R2                     Effective May 16, 2006, the Centers for Medicare and Medicaid Servic
Artificial Disc    J3 CB2006.73 R2                     Effective May 16, 2006, the Centers for Medicare and Medicaid Servic
Artificial Disc    J3 CB2006.73 R2                     Effective May 16, 2006, the Centers for Medicare and Medicaid Servic
                   J3 CB2006.02 R2
Blocks and Destruction of Somatic and Sympathetic NervesNerve Blocks: Nerve blocks cause the temporary interruption of condu
                   J3 CB2006.02 R2
Blocks and Destruction of Somatic and Sympathetic NervesNerve Blocks: Nerve blocks cause the temporary interruption of condu
                   J3 CB2006.02 R2
Blocks and Destruction of Somatic and Sympathetic NervesNerve Blocks: Nerve blocks cause the temporary interruption of condu
                   J3 CB2006.02 R2
Blocks and Destruction of Somatic and Sympathetic NervesNerve Blocks: Nerve blocks cause the temporary interruption of condu
                   J3 CB2006.02 R2
Blocks and Destruction of Somatic and Sympathetic NervesNerve Blocks: Nerve blocks cause the temporary interruption of condu
                   J3 CB2006.02 R2
Blocks and Destruction of Somatic and Sympathetic NervesNerve Blocks: Nerve blocks cause the temporary interruption of condu
                   J3 CB2006.20
Botulinum Toxin Types A and B R2                       Botulinum toxin injections are used to treat various focal muscle spast
                   J3 CB2006.20
Botulinum Toxin Types A and B R2                       Botulinum toxin injections are used to treat various focal muscle spast
                   J3 CB2006.20
Botulinum Toxin Types A and B R2                       Botulinum toxin injections are used to treat various focal muscle spast
                   J3 CB2006.20
Botulinum Toxin Types A and B R2                       Botulinum toxin injections are used to treat various focal muscle spast
                   J3 CB2006.20
Botulinum Toxin Types A and B R2                       Botulinum toxin injections are used to treat various focal muscle spast
                   J3 CB2006.20
Botulinum Toxin Types A and B R2                       Botulinum toxin injections are used to treat various focal muscle spast
CT Colonography J3 CB2006.19                           Computed tomographic (CT) colonography, also known as virtual colo
CT Colonography J3 CB2006.19                           Computed tomographic (CT) colonography, also known as virtual colo
CT Colonography J3 CB2006.19                           Computed tomographic (CT) colonography, also known as virtual colo
CT Colonography J3 CB2006.19                           Computed tomographic (CT) colonography, also known as virtual colo
CT Colonography J3 CB2006.19                           Computed tomographic (CT) colonography, also known as virtual colo
CT Colonography J3 CB2006.19                           Computed tomographic (CT) colonography, also known as virtual colo
                   J3 CB2006.48
Endoscopic Treatment of GERD R1                        Benefits are not available for endoluminal treatment for Gastroesopha
                   J3 CB2006.48
Endoscopic Treatment of GERD R1                        Benefits are not available for endoluminal treatment for Gastroesopha
                   J3 CB2006.48
Endoscopic Treatment of GERD R1                        Benefits are not available for endoluminal treatment for Gastroesopha
                   J3 CB2006.48
Endoscopic Treatment of GERD R1                        Benefits are not available for endoluminal treatment for Gastroesopha
                   J3 CB2006.48
Endoscopic Treatment of GERD R1                        Benefits are not available for endoluminal treatment for Gastroesopha
                   J3 CB2006.48
Endoscopic Treatment of GERD R1                        Benefits are not available for endoluminal treatment for Gastroesopha
                   J3 CB2006.16 R2
Gonadotropin Releasing Hormone Analogs                 Goserelin acetate (J9202), leuprolide acetate (J9217, J9218, J9219, a
                   J3 CB2006.16 R2
Gonadotropin Releasing Hormone Analogs                 Goserelin acetate (J9202), leuprolide acetate (J9217, J9218, J9219, a
                   J3 CB2006.16 R2
Gonadotropin Releasing Hormone Analogs                 Goserelin acetate (J9202), leuprolide acetate (J9217, J9218, J9219, a
                   J3 CB2006.16 R2
Gonadotropin Releasing Hormone Analogs                 Goserelin acetate (J9202), leuprolide acetate (J9217, J9218, J9219, a
                   J3 CB2006.16 R2
Gonadotropin Releasing Hormone Analogs                 Goserelin acetate (J9202), leuprolide acetate (J9217, J9218, J9219, a
                   J3 CB2006.16 R2
Gonadotropin Releasing Hormone Analogs                 Goserelin acetate (J9202), leuprolide acetate (J9217, J9218, J9219, a
                   J3 CB2006.68 R2                     This policy addresses Neuroma
Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton'sthe injection of chemical substances, such as lo
                   J3 CB2006.68 R2                     This policy addresses Neuroma
Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton'sthe injection of chemical substances, such as lo
                   J3 CB2006.68 R2                     This policy addresses Neuroma
Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton'sthe injection of chemical substances, such as lo
                   J3 CB2006.68 R2                     This policy addresses Neuroma
Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton'sthe injection of chemical substances, such as lo
                   J3 CB2006.68 R2                     This policy addresses Neuroma
Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton'sthe injection of chemical substances, such as lo
                   J3 CB2006.68 R2                     This policy addresses Neuroma
Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton'sthe injection of chemical substances, such as lo
                   J3 CB2006.95
Intensity Modulated Radiation Therapy (IMRT)           Intensity Modulated Radiation Therapy (IMRT) is a computer-based m
                   J3 CB2006.95
Intensity Modulated Radiation Therapy (IMRT)           Intensity Modulated Radiation Therapy (IMRT) is a computer-based m
                   J3 CB2006.95
Intensity Modulated Radiation Therapy (IMRT)           Intensity Modulated Radiation Therapy (IMRT) is a computer-based m
                   J3 CB2006.95
Intensity Modulated Radiation Therapy (IMRT)           Intensity Modulated Radiation Therapy (IMRT) is a computer-based m
                   J3 CB2006.95
Intensity Modulated Radiation Therapy (IMRT)           Intensity Modulated Radiation Therapy (IMRT) is a computer-based m
                   J3 CB2006.95
Intensity Modulated Radiation Therapy (IMRT)           Intensity Modulated Radiation Therapy (IMRT) is a computer-based m
Plastic Surgery    J3 CB2006.15 R4                     According to the American Society of Plastic Surgeons, the specialty o
Plastic Surgery    J3 CB2006.15 R4                     According to the American Society of Plastic Surgeons, the specialty o
Plastic Surgery    J3 CB2006.15 R4                     According to the American Society of Plastic Surgeons, the specialty o
Plastic Surgery    J3 CB2006.15 R4                     According to the American Society of Plastic Surgeons, the specialty o
Plastic Surgery    J3 CB2006.15 R4                     According to the American Society of Plastic Surgeons, the specialty o
Plastic Surgery    J3 CB2006.15 R4                     According to the American Society of Plastic Surgeons, the specialty o
                   J3 CB 2006.84 R2
Polysomnography and Other Sleep Studies                Polysomnography is the continuous, simultaneous monitoring and reco
                   J3 CB 2006.84 R2
Polysomnography and Other Sleep Studies                Polysomnography is the continuous, simultaneous monitoring and reco
                   J3 CB 2006.84 R2
Polysomnography and Other Sleep Studies                Polysomnography is the continuous, simultaneous monitoring and reco
                   J3 CB 2006.84 R2
Polysomnography and Other Sleep Studies                Polysomnography is the continuous, simultaneous monitoring and reco
                   J3 CB 2006.84 R2
Polysomnography and Other Sleep Studies                Polysomnography is the continuous, simultaneous monitoring and reco
                   J3 CB 2006.84 R2
Polysomnography and Other Sleep Studies                Polysomnography is the continuous, simultaneous monitoring and reco
                   J3 (Includes AK and Excludes MOHS)
Skin Lesion Removal CB2006.93 R4                       This policy applies to the following: seborrheic keratoses, skin tags, mi
                   J3 (Includes AK and Excludes MOHS)
Skin Lesion Removal CB2006.93 R4                       This policy applies to the following: seborrheic keratoses, skin tags, mi
                   J3 (Includes AK and Excludes MOHS)
Skin Lesion Removal CB2006.93 R4                       This policy applies to the following: seborrheic keratoses, skin tags, mi
                   J3 (Includes AK and Excludes MOHS)
Skin Lesion Removal CB2006.93 R4                       This policy applies to the following: seborrheic keratoses, skin tags, mi
                   J3 (Includes AK and Excludes MOHS)
Skin Lesion Removal CB2006.93 R4                       This policy applies to the following: seborrheic keratoses, skin tags, mi
                   J3 (Includes AK and Excludes MOHS)
Skin Lesion Removal CB2006.93 R4                       This policy applies to the following: seborrheic keratoses, skin tags, mi
                   J3 CB2006.108 R1
Stereotactic Body Radiation Therapy                    Stereotactic body radiation therapy (SBRT) is a treatment that couples
                   J3 CB2006.108 R1
Stereotactic Body Radiation Therapy                    Stereotactic body radiation therapy (SBRT) is a treatment that couples
                   J3 CB2006.108 R1
Stereotactic Body Radiation Therapy                    Stereotactic body radiation therapy (SBRT) is a treatment that couples
                   J3 CB2006.108 R1
Stereotactic Body Radiation Therapy                    Stereotactic body radiation therapy (SBRT) is a treatment that couples
                   J3 CB2006.108 R1
Stereotactic Body Radiation Therapy                    Stereotactic body radiation therapy (SBRT) is a treatment that couples
                   J3 CB2006.108 R1
Stereotactic Body Radiation Therapy                    Stereotactic body radiation therapy (SBRT) is a treatment that couples
                   J3 CB2006.42 R2                     Recent advances
Stereotactic Computer Assisted Volumetric &/or Navigational Procedure in technology have led to numerous advances in ima
                   J3 CB2006.42 R2                     Recent advances
Stereotactic Computer Assisted Volumetric &/or Navigational Procedure in technology have led to numerous advances in ima
                   J3 CB2006.42 R2                     Recent advances
Stereotactic Computer Assisted Volumetric &/or Navigational Procedure in technology have led to numerous advances in ima
                   J3 CB2006.42 R2                     Recent advances
Stereotactic Computer Assisted Volumetric &/or Navigational Procedure in technology have led to numerous advances in ima
                   J3 CB2006.42 R2                     Recent advances
Stereotactic Computer Assisted Volumetric &/or Navigational Procedure in technology have led to numerous advances in ima
                   J3 CB2006.42 R2                     Recent advances
Stereotactic Computer Assisted Volumetric &/or Navigational Procedure in technology have led to numerous advances in ima
                   J3 CB2006.96
Symptomatic, Pathological Nail and Its Treatment       Routine foot care, which includes trimming or debridement of the Asym
                   J3 CB2006.96
Symptomatic, Pathological Nail and Its Treatment       Routine foot care, which includes trimming or debridement of the Asym
                   J3 CB2006.96
Symptomatic, Pathological Nail and Its Treatment       Routine foot care, which includes trimming or debridement of the Asym
                   J3 CB2006.96
Symptomatic, Pathological Nail and Its Treatment       Routine foot care, which includes trimming or debridement of the Asym
                   J3 CB2006.96
Symptomatic, Pathological Nail and Its Treatment       Routine foot care, which includes trimming or debridement of the Asym
                   J3 CB2006.96
Symptomatic, Pathological Nail and Its Treatment       Routine foot care, which includes trimming or debridement of the Asym
                   J3 CB2006.45 R1
Treatment of Obstructive Sleep Apnea                   Sleep Disordered Breathing, often referred to as Obstructive Sleep Ap
                   J3 CB2006.45 R1
Treatment of Obstructive Sleep Apnea                   Sleep Disordered Breathing, often referred to as Obstructive Sleep Ap
                   J3 CB2006.45 R1
Treatment of Obstructive Sleep Apnea                   Sleep Disordered Breathing, often referred to as Obstructive Sleep Ap
                   J3 CB2006.45 R1
Treatment of Obstructive Sleep Apnea                   Sleep Disordered Breathing, often referred to as Obstructive Sleep Ap
                   J3 CB2006.45 R1
Treatment of Obstructive Sleep Apnea                   Sleep Disordered Breathing, often referred to as Obstructive Sleep Ap
                   J3 CB2006.45 R1
Treatment of Obstructive Sleep Apnea                   Sleep Disordered Breathing, often referred to as Obstructive Sleep Ap
                   J3 CB2006.80
Treatment of Varicose Veins of the Lower Extremities Historically, varicose veins have been treated by conservative measure
                   J3 CB2006.80
Treatment of Varicose Veins of the Lower Extremities Historically, varicose veins have been treated by conservative measure
                   J3 CB2006.80
Treatment of Varicose Veins of the Lower Extremities Historically, varicose veins have been treated by conservative measure
                   J3 CB2006.80
Treatment of Varicose Veins of the Lower Extremities Historically, varicose veins have been treated by conservative measure
                   J3 CB2006.80
Treatment of Varicose Veins of the Lower Extremities Historically, varicose veins have been treated by conservative measure
                   J3 CB2006.80
Treatment of Varicose Veins of the Lower Extremities Historically, varicose veins have been treated by conservative measure
                   J3 CB2006.09
Wireless Capsule Enteroscopy R1                        Wireless capsule enteroscopy is an ingestible telemetric gastrointestin
                   J3 CB2006.09
Wireless Capsule Enteroscopy R1                        Wireless capsule enteroscopy is an ingestible telemetric gastrointestin
                   J3 CB2006.09
Wireless Capsule Enteroscopy R1                        Wireless capsule enteroscopy is an ingestible telemetric gastrointestin
                   J3 CB2006.09
Wireless Capsule Enteroscopy R1                        Wireless capsule enteroscopy is an ingestible telemetric gastrointestin
                   J3 CB2006.09
Wireless Capsule Enteroscopy R1                        Wireless capsule enteroscopy is an ingestible telemetric gastrointestin
                   J3 CB2006.09
Wireless Capsule Enteroscopy R1                        Wireless capsule enteroscopy is an ingestible telemetric gastrointestin
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3 CA2006.02 Substitutes: Ulcers of the Lower Extremities seek information related to National Coverage
Application of Bioengineered SkinR10                   Note: Providers should
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                   J3
Chest X-Ray Policy CA2006.05 R5                        Note: Providers should seek information related to National Coverage
                 J3
Chest X-Ray Policy CA2006.05 R5      Note: Providers should seek information related to National Coverage
                 J3
Chest X-Ray Policy CA2006.05 R5      Note: Providers should seek information related to National Coverage
                 J3
Chest X-Ray Policy CA2006.05 R5      Note: Providers should seek information related to National Coverage
                 J3
Chest X-Ray Policy CA2006.05 R5      Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
                 J3 CA2006.11 R9
Immune Globulin Intravenous (IGIV)   Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
Serum MagnesiumJ3 CA2006.12 R4                       Note: Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  J3 CA2006.15 R5                     Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                    Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                    Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                    Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                    Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
Urinalysis Policy J3 CA2006.20 R6                         Note: Providers should seek information related to National Coverage
                   L24482
Drugs and Biologicals: Colony Stimulating Factors         Indications Filgrastim and Sargramostim: * Acceleration of myeloid r
                   L24482
Drugs and Biologicals: Colony Stimulating Factors         Indications Filgrastim and Sargramostim: * Acceleration of myeloid r
                   L24482
Drugs and Biologicals: Colony Stimulating Factors         Indications Filgrastim and Sargramostim: * Acceleration of myeloid r
                   L24532                                 Indications This
Surgery: Arthrocentesis, Aspiration, and/or Injection; Major Joint or Bursa procedure may be for diagnostic and/or therapeutic p
                   L24532                                 Indications This
Surgery: Arthrocentesis, Aspiration, and/or Injection; Major Joint or Bursa procedure may be for diagnostic and/or therapeutic p
                   L24532                                 Indications This
Surgery: Arthrocentesis, Aspiration, and/or Injection; Major Joint or Bursa procedure may be for diagnostic and/or therapeutic p
                   J3 CB2006.100 R5
Ablative Therapy: Intra-thoracic and Intra-abdominal      Ablative procedures have been in the armamentarium of tumor therap
                   J3 CB2006.100 R5
Ablative Therapy: Intra-thoracic and Intra-abdominal      Ablative procedures have been in the armamentarium of tumor therap
                   J3 CB2006.100 R5
Ablative Therapy: Intra-thoracic and Intra-abdominal      Ablative procedures have been in the armamentarium of tumor therap
                   J3 CB2006.100 R5
Ablative Therapy: Intra-thoracic and Intra-abdominal      Ablative procedures have been in the armamentarium of tumor therap
                   J3 CB2006.100 R5
Ablative Therapy: Intra-thoracic and Intra-abdominal      Ablative procedures have been in the armamentarium of tumor therap
                   J3 CB2006.100 R5
Ablative Therapy: Intra-thoracic and Intra-abdominal      Ablative procedures have been in the armamentarium of tumor therap
                   R-17
Intensity Modulated Radiation Therapy (IMRT)-R-17B-DSee Intensity Modulated Radiation Therapy (IMRT) - R-17-Revision 5
                   Y-2R
Occupational Therapy Services                             Compliance with the provisions in this policy may be monitored and ad
                   Y-2R
Occupational Therapy Services                             Compliance with the provisions in this policy may be monitored and ad
                   Y-2R
Occupational Therapy Services                             Compliance with the provisions in this policy may be monitored and ad
                   Y-2R
Occupational Therapy Services                             Compliance with the provisions in this policy may be monitored and ad
                   Y-2R
Occupational Therapy Services                             Compliance with the provisions in this policy may be monitored and ad
                   Y-2R
Occupational Therapy Services                             Compliance with the provisions in this policy may be monitored and ad
                   Y-2R
Occupational Therapy Services                             Compliance with the provisions in this policy may be monitored and ad
                  Y-2R
Occupational Therapy Services                        Compliance with the provisions in this policy may be monitored and ad
                  Y-2R
Occupational Therapy Services                        Compliance with the provisions in this policy may be monitored and ad
                  Y-2R
Occupational Therapy Services                        Compliance with the provisions in this policy may be monitored and ad
                  Y-2R
Occupational Therapy Services                        Compliance with the provisions in this policy may be monitored and ad
                  Y-2R
Occupational Therapy Services                        Compliance with the provisions in this policy may be monitored and ad
                  Y-2R
Occupational Therapy Services                        Compliance with the provisions in this policy may be monitored and ad
                  Y-2R
Occupational Therapy Services                        Compliance with the provisions in this policy may be monitored and ad
                  Y-2R
Occupational Therapy Services                        Compliance with the provisions in this policy may be monitored and ad
                  Y-2R
Occupational Therapy Services                        Compliance with the provisions in this policy may be monitored and ad
                  Y-2R
Occupational Therapy Services                        Compliance with the provisions in this policy may be monitored and ad
                  Y-2R
Occupational Therapy Services                        Compliance with the provisions in this policy may be monitored and ad
Urinalysis Policy A2007.12 R4                        Note: Providers should seek information related to National Coverage
Urinalysis Policy A2007.12 R4                        Note: Providers should seek information related to National Coverage
Urinalysis Policy A2007.12 R4                        Note: Providers should seek information related to National Coverage
Urinalysis Policy A2007.12 R4                        Note: Providers should seek information related to National Coverage
Urinalysis Policy A2007.12 R4                        Note: Providers should seek information related to National Coverage
Urinalysis Policy A2007.12 R4                        Note: Providers should seek information related to National Coverage
                  A2007.08 R8
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                  A2007.08 R8
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                  A2007.08 R8
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                  A2007.08 R8
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
                  A2007.08 R8
Immune Globulin Intravenous (IGIV)                   Note: Providers should seek information related to National Coverage
Serum MagnesiumA2007.09 R2                           Note: Providers should seek information related to National Coverage
Serum MagnesiumA2007.09 R2                           Note: Providers should seek information related to National Coverage
Serum MagnesiumA2007.09 R2                           Note: Providers should seek information related to National Coverage
Serum MagnesiumA2007.09 R2                           Note: Providers should seek information related to National Coverage
Serum MagnesiumA2007.09 R2                           Note: Providers should seek information related to National Coverage
Serum MagnesiumA2007.09 R2                           Note: Providers should seek information related to National Coverage
                  A2007.10 R4                        Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  A2007.10 R4                        Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  A2007.10 R4                        Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  A2007.10 R4                        Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  A2007.10 R4                        Note:
Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Providers should seek information related to National Coverage
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                  A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   A2007.19 R2                           Note: Providers should seek information related to National Coverage
Multidetector Computed Tomography of the Heart and Great Vessels
                   ARA-03-025
Implantable Infusion Pump                                 A.INDICATIONS: 1.Anti-Spasmodic Drugs for Severe Spasticity: An im
                   ARA-03-023
Extracorporeal Shock Wave Therapy (ESWT)                 Extracorporeal shock wave therapy (ESWT) is a non-invasive treatme
                   ARA-03-023
Extracorporeal Shock Wave Therapy (ESWT)                 Extracorporeal shock wave therapy (ESWT) is a non-invasive treatme
                   ARA-03-023
Extracorporeal Shock Wave Therapy (ESWT)                 Extracorporeal shock wave therapy (ESWT) is a non-invasive treatme
                   ARA-03-023
Extracorporeal Shock Wave Therapy (ESWT)                 Extracorporeal shock wave therapy (ESWT) is a non-invasive treatme
                   ARA-03-023
Extracorporeal Shock Wave Therapy (ESWT)                 Extracorporeal shock wave therapy (ESWT) is a non-invasive treatme
                   ARA-03-023
Extracorporeal Shock Wave Therapy (ESWT)                 Extracorporeal shock wave therapy (ESWT) is a non-invasive treatme
                   ARA-03-039
Hemophilia Clotting Factors                              For purposes of Medicare coverage, hemophilia encompasses: * Fact
                   ARA-03-039
Hemophilia Clotting Factors                              For purposes of Medicare coverage, hemophilia encompasses: * Fact
                   ARA-03-039
Hemophilia Clotting Factors                              For purposes of Medicare coverage, hemophilia encompasses: * Fact
                   ARA-03-039
Hemophilia Clotting Factors                              For purposes of Medicare coverage, hemophilia encompasses: * Fact
                   ARA-06-003
EEG ? 24 Hour Monitoring                                 An electroencephalogram (EEG) is a diagnostic test that measures the
                   ARA-06-003
EEG ? 24 Hour Monitoring                                 An electroencephalogram (EEG) is a diagnostic test that measures the
                   ARA-06-003
EEG ? 24 Hour Monitoring                                 An electroencephalogram (EEG) is a diagnostic test that measures the
                   ARA-06-003
EEG ? 24 Hour Monitoring                                 An electroencephalogram (EEG) is a diagnostic test that measures the
                   ARA-06-003
EEG ? 24 Hour Monitoring                                 An electroencephalogram (EEG) is a diagnostic test that measures the
                   ARA-06-003
EEG ? 24 Hour Monitoring                                 An electroencephalogram (EEG) is a diagnostic test that measures the
                   ARA-06-003
EEG ? 24 Hour Monitoring                                 An electroencephalogram (EEG) is a diagnostic test that measures the
                   ARA-06-003
EEG ? 24 Hour Monitoring                                 An electroencephalogram (EEG) is a diagnostic test that measures the
                   ARA-06-003
EEG ? 24 Hour Monitoring                                 An electroencephalogram (EEG) is a diagnostic test that measures the
                   ARA-06-003
EEG ? 24 Hour Monitoring                                 An electroencephalogram (EEG) is a diagnostic test that measures the
                   ARA-06-003
EEG ? 24 Hour Monitoring                                 An electroencephalogram (EEG) is a diagnostic test that measures the
                   ARA-06-003
EEG ? 24 Hour Monitoring                                 An electroencephalogram (EEG) is a diagnostic test that measures the
                    Tomography
Cardiac ComputedARA-05-010 (CCT)                          A.Indications: The Multi-detector Computed Tomography) (MDCT) (ca
                    Tomography
Cardiac ComputedARA-05-010 (CCT)                          A.Indications: The Multi-detector Computed Tomography) (MDCT) (ca
                   L18291                                 Indications * Palliative management of
Drugs and Biologicals: Octreotide Acetate for Injectable Suspension (Sandostatin LAR« Depot) gastrointestinal endocrine tum
                  L18291                                  Indications * Palliative management of
Drugs and Biologicals: Octreotide Acetate for Injectable Suspension (Sandostatin LAR« Depot) gastrointestinal endocrine tum
                  L18291                                  Indications * Palliative management of
Drugs and Biologicals: Octreotide Acetate for Injectable Suspension (Sandostatin LAR« Depot) gastrointestinal endocrine tum
                  07A-0002-L
Right Cardiac Catheterization                            A cardiac catheterization procedure typically includes insertion of a flex
                  07A-0002-L
Right Cardiac Catheterization                            A cardiac catheterization procedure typically includes insertion of a flex
                  07A-0002-L
Right Cardiac Catheterization                            A cardiac catheterization procedure typically includes insertion of a flex
                  07A-0001-L
Magnetic Resonance Angiography                           The coverage criteria and definition of magnetic resonance angiograph
                  07A-0001-L
Magnetic Resonance Angiography                           The coverage criteria and definition of magnetic resonance angiograph
                  07A-0001-L
Magnetic Resonance Angiography                           The coverage criteria and definition of magnetic resonance angiograph
                  L24814
Surgery: Blepharoplasty                                   Indications Blepharoplasty procedures and repair of blepharoptosis a
                  L24814
Surgery: Blepharoplasty                                   Indications Blepharoplasty procedures and repair of blepharoptosis a
                  L24814
Surgery: Blepharoplasty                                   Indications Blepharoplasty procedures and repair of blepharoptosis a
                  L24817
Drugs and Biologicals: Botulinum Toxins                   Indications Because Botulinum Toxins (BT) are invasive their use sho
                  L24817
Drugs and Biologicals: Botulinum Toxins                   Indications Because Botulinum Toxins (BT) are invasive their use sho
                  L24817
Drugs and Biologicals: Botulinum Toxins                   Indications Because Botulinum Toxins (BT) are invasive their use sho
                  L24837
Medicine: Cardiac Catheterization/Coronary Angiography Indications Cardiac catheterization provides access for the study of c
                  L24837
Medicine: Cardiac Catheterization/Coronary Angiography Indications Cardiac catheterization provides access for the study of c
                  L24837
Medicine: Cardiac Catheterization/Coronary Angiography Indications Cardiac catheterization provides access for the study of c
                  L24838
Surgery: Cataract Extraction                              Indications It is anticipated by this Carrier that, in most cases, all of t
                  L24838
Surgery: Cataract Extraction                              Indications It is anticipated by this Carrier that, in most cases, all of t
                  L24838
Surgery: Cataract Extraction                              Indications It is anticipated by this Carrier that, in most cases, all of t
                  L24844
Surgery: Colonoscopy (Diagnostic)                         Indications Refer to the Medicare Benefit Policy Manual (Pub. 100-02
                  L24844
Surgery: Colonoscopy (Diagnostic)                         Indications Refer to the Medicare Benefit Policy Manual (Pub. 100-02
                  L24844
Surgery: Colonoscopy (Diagnostic)                         Indications Refer to the Medicare Benefit Policy Manual (Pub. 100-02
                  L24846
Radiology: Computed Tomography of the Abdomen and Pelvis  Indications * Evaluation of abdominal or pelvic pain. * Evaluation of
                  L24846
Radiology: Computed Tomography of the Abdomen and Pelvis  Indications * Evaluation of abdominal or pelvic pain. * Evaluation of
                  L24846
Radiology: Computed Tomography of the Abdomen and Pelvis  Indications * Evaluation of abdominal or pelvic pain. * Evaluation of
                  L24847
Radiology: Computed Tomography of the Thorax              Indications Indications for the use of thoracic CT include, but are not
                  L24847
Radiology: Computed Tomography of the Thorax              Indications Indications for the use of thoracic CT include, but are not
                  L24847
Radiology: Computed Tomography of the Thorax              Indications Indications for the use of thoracic CT include, but are not
                  L24848                                  Indications * As an alternative to invasive coronary angiography follow
Radiology: Computed Tomographic Angiography of the Heart and Coronary Vessels
                  L24848                                  Indications * As an alternative to invasive coronary angiography follow
Radiology: Computed Tomographic Angiography of the Heart and Coronary Vessels
                  L24848                                  Indications * As an alternative to invasive coronary angiography follow
Radiology: Computed Tomographic Angiography of the Heart and Coronary Vessels
                  L24849
Radiology: Computed Tomography of the Head or Brain Indications CT scan of the head or brain is indicated to aid in the diag
                  L24849
Radiology: Computed Tomography of the Head or Brain Indications CT scan of the head or brain is indicated to aid in the diag
                  L24849
Radiology: Computed Tomography of the Head or Brain Indications CT scan of the head or brain is indicated to aid in the diag
                  L24853                                  Indications Medical necessity will be based on the guidelines publishe
Coronary Computed Tomograpy Angiography and Electron Beam Computed Tomography of the Coronary Vessels
                  L24853                                  Indications Medical necessity will be based on the guidelines publishe
Coronary Computed Tomograpy Angiography and Electron Beam Computed Tomography of the Coronary Vessels
                  Supporting Diagnoses                   Non-Supporting Diagnoses                      Coding Guidelines
 ion, psychotherapy and teaching activities needed by patients suffering from a diagnosed psychiatric disorder that requires active treatment b
 ion, psychotherapy and teaching activities needed by patients suffering from a diagnosed psychiatric disorder that requires active treatment b
c Lateral Sclerosis (ALS) may support a prognosis of six months or less under many clinical scenarios. Medicare rules and regulations addre
c Lateral Sclerosis (ALS) may support a prognosis of six months or less under many clinical scenarios. Medicare rules and regulations addre
  rapy services are part of a constellation of rehabilitative services designed to improve or restore physical functioning following disease, injury
  rapy services are part of a constellation of rehabilitative services designed to improve or restore physical functioning following disease, injury
overage of hospice care depends upon a physician's certification of an individual's prognosis of a life expectancy of six months or less, if the
overage of hospice care depends upon a physician's certification of an individual's prognosis of a life expectancy of six months or less, if the
overage of hospice care depends upon a physician?s certification of an individual?s prognosis of a life expectancy of six months or less if the
overage of hospice care depends upon a physician?s certification of an individual?s prognosis of a life expectancy of six months or less if the
enal disease (ESRD) may support a prognosis of six months or less under many clinical scenarios. The identification of specific structural/fun
enal disease (ESRD) may support a prognosis of six months or less under many clinical scenarios. The identification of specific structural/fun
overage of hospice care depends upon a physician?s certification of an individual?s prognosis of a life expectancy of six months or less if the
overage of hospice care depends upon a physician?s certification of an individual?s prognosis of a life expectancy of six months or less if the
guage pathology services are those services necessary for the diagnosis and treatment of speech-language pathology disorders that result in
guage pathology services are those services necessary for the diagnosis and treatment of speech-language pathology disorders that result in
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 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. It has demonstrated clinical efficacy in patients with
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. It has demonstrated clinical efficacy in patients with
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. It has demonstrated clinical efficacy in patients with
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. It has demonstrated clinical efficacy in patients with
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. It has demonstrated clinical efficacy in patients with
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. It has demonstrated clinical efficacy in patients with
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. It has demonstrated clinical efficacy in patients with
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. It has demonstrated clinical efficacy in patients with
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. It has demonstrated clinical efficacy in patients with
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. It has demonstrated clinical efficacy in patients with
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rium swallow studies by video fluoroscopy used to more objectively diagnose disorders of swallowing and aspiration and aid in selecting an a
rium swallow studies by video fluoroscopy used to more objectively diagnose disorders of swallowing and aspiration and aid in selecting an a
rium swallow studies by video fluoroscopy used to more objectively diagnose disorders of swallowing and aspiration and aid in selecting an a
rium swallow studies by video fluoroscopy used to more objectively diagnose disorders of swallowing and aspiration and aid in selecting an a
rium swallow studies by video fluoroscopy used to more objectively diagnose disorders of swallowing and aspiration and aid in selecting an a
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lso known as folate, is a B complex vitamin which serves as a carrier of one-carbon groups in many metabolic reactions. As tetrahydrofolate
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lso known as folate, is a B complex vitamin which serves as a carrier of one-carbon groups in many metabolic reactions. As tetrahydrofolate
                                                   N/A
lso known as folate, is a B complex vitamin which serves as a carrier of one-carbon groups in many metabolic reactions. As tetrahydrofolate
                                                   N/A
lso known as folate, is a B complex vitamin which serves as a carrier of one-carbon groups in many metabolic reactions. As tetrahydrofolate
                                                   N/A
lso known as folate, is a B complex vitamin which serves as a carrier of one-carbon groups in many metabolic reactions. As tetrahydrofolate
                                                   N/A
lso known as folate, is a B complex vitamin which serves as a carrier of one-carbon groups in many metabolic reactions. As tetrahydrofolate
                                                    N/A
lso known as folate, is a B complex vitamin which serves as a carrier of one-carbon groups in many metabolic reactions. As tetrahydrofolate
                                                    N/A
lso known as folate, is a B complex vitamin which serves as a carrier of one-carbon groups in many metabolic reactions. As tetrahydrofolate
                                                    N/A
lso known as folate, is a B complex vitamin which serves as a carrier of one-carbon groups in many metabolic reactions. As tetrahydrofolate
                                                    N/A
lso known as folate, is a B complex vitamin which serves as a carrier of one-carbon groups in many metabolic reactions. As tetrahydrofolate
              N/A
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try panel is an organ specific panel used in the diagnosis and management of various illnesses and injuries related to the liver. The panel mu
try panel is an organ specific panel used in the diagnosis and management of various illnesses and injuries related to the liver. The panel mu
try panel is an organ specific panel used in the diagnosis and management of various illnesses and injuries related to the liver. The panel mu
try panel is an organ specific panel used in the diagnosis and management of various illnesses and injuries related to the liver. The panel mu
try panel is an organ specific panel used in the diagnosis and management of various illnesses and injuries related to the liver. The panel mu
try panel is an organ specific panel used in the diagnosis and management of various illnesses and injuries related to the liver. The panel mu
try panel is an organ specific panel used in the diagnosis and management of various illnesses and injuries related to the liver. The panel mu
try panel is an organ specific panel used in the diagnosis and management of various illnesses and injuries related to the liver. The panel mu
try panel is an organ specific panel used in the diagnosis and management of various illnesses and injuries related to the liver. The panel mu
try panel is an organ specific panel used in the diagnosis and management of various illnesses and injuries related to the liver. The panel mu
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                                                       detection, diagnosis, staging and management of pathophysiologic processes involving
examination of the chest (chest X-ray) facilitates theN/A
                                                       detection, diagnosis, staging and management of pathophysiologic processes involving
examination of the chest (chest X-ray) facilitates theN/A
                                                       detection, diagnosis, staging and management of pathophysiologic processes involving
examination of the chest (chest X-ray) facilitates theN/A
                                                       detection, diagnosis, staging and management of pathophysiologic processes involving
examination of the chest (chest X-ray) facilitates theN/A
                                                       detection, diagnosis, staging and management of pathophysiologic processes involving
examination of the chest (chest X-ray) facilitates theN/A
                                                       detection, diagnosis, staging and management of pathophysiologic processes involving
examination of the chest (chest X-ray) facilitates theN/A
                                                       detection, diagnosis, staging and management of pathophysiologic processes involving
examination of the chest (chest X-ray) facilitates theN/A
                                                       detection, diagnosis, staging and management of pathophysiologic processes involving
examination of the chest (chest X-ray) facilitates theN/A
                                                       detection, diagnosis, staging and management of pathophysiologic processes involving
examination of the chest (chest X-ray) facilitates theN/A
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panel codes are similar in that they include laboratory studies that evaluate the body?s effectiveness in carrying on its metabolic processes.
panel codes are similar in that they include laboratory studies that evaluate the body?s effectiveness in carrying on its metabolic processes.
panel codes are similar in that they include laboratory studies that evaluate the body?s effectiveness in carrying on its metabolic processes.
panel codes are similar in that they include laboratory studies that evaluate the body?s effectiveness in carrying on its metabolic processes.
panel codes are similar in that they include laboratory studies that evaluate the body?s effectiveness in carrying on its metabolic processes.
panel codes are similar in that they include laboratory studies that evaluate the body?s effectiveness in carrying on its metabolic processes.
panel codes are similar in that they include laboratory studies that evaluate the body?s effectiveness in carrying on its metabolic processes.
panel codes are similar in that they include laboratory studies that evaluate the body?s effectiveness in carrying on its metabolic processes.
panel codes are similar in that they include laboratory studies that evaluate the body?s effectiveness in carrying on its metabolic processes.
panel codes are similar in that they include laboratory studies that evaluate the body?s effectiveness in carrying on its metabolic processes.
habilitative services are provided by occupational therapy, speech therapy and physical therapy, this policy only addresses occupational thera
habilitative services are provided by occupational therapy, speech therapy and physical therapy, this policy only addresses occupational thera
habilitative services are provided by occupational therapy, speech therapy and physical therapy, this policy only addresses occupational thera
habilitative services are provided by occupational therapy, speech therapy and physical therapy, this policy only addresses occupational thera
habilitative services are provided by occupational therapy, speech therapy and physical therapy, this policy only addresses occupational thera
habilitative services are provided by occupational therapy, speech therapy and physical therapy, this policy only addresses occupational thera
habilitative services are provided by occupational therapy, speech therapy and physical therapy, this policy only addresses occupational thera
habilitative services are provided by occupational therapy, speech therapy and physical therapy, this policy only addresses occupational thera
habilitative services are provided by occupational therapy, speech therapy and physical therapy, this policy only addresses occupational thera
habilitative services are provided by occupational therapy, speech therapy and physical therapy, this policy only addresses occupational thera
habilitative services are provided by occupational therapy, speech therapy and physical therapy, this policy only addresses occupational thera
hospital psychiatric services represent a continuum of ambulatory psychiatric services. These services provide active treatment to individuals
hospital psychiatric services represent a continuum of ambulatory psychiatric services. These services provide active treatment to individuals
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nsiderations Patients with diagnosed Chronic Respiratory Diseases have a progressive increase in the mechanical work of breathing and lim
nsiderations Patients with diagnosed Chronic Respiratory Diseases have a progressive increase in the mechanical work of breathing and lim
nsiderations Patients with diagnosed Chronic Respiratory Diseases have a progressive increase in the mechanical work of breathing and lim
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italization is a distinct and organized intensive psychiatric outpatient treatment of less than 24 hours of daily care. It is designed to furnish se
italization is a distinct and organized intensive psychiatric outpatient treatment of less than 24 hours of daily care. It is designed to furnish se
 italization is a distinct and organized intensive psychiatric outpatient treatment of less than 24 hours of daily care. It is designed to furnish se
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   factor (RF) testing is the examination of the blood to determine the presence of rheumatoid factors (IgG or IgM molecules which react with
   factor (RF) testing is the examination of the blood to determine the presence of rheumatoid factors (IgG or IgM molecules which react with
   factor (RF) testing is the examination of the blood to determine the presence of rheumatoid factors (IgG or IgM molecules which react with
   factor (RF) testing is the examination of the blood to determine the presence of rheumatoid factors (IgG or IgM molecules which react with
   factor (RF) testing is the examination of the blood to determine the presence of rheumatoid factors (IgG or IgM molecules which react with
   factor (RF) testing is the examination of the blood to determine the presence of rheumatoid factors (IgG or IgM molecules which react with
   factor (RF) testing is the examination of the blood to determine the presence of rheumatoid factors (IgG or IgM molecules which react with
   factor (RF) testing is the examination of the blood to determine the presence of rheumatoid factors (IgG or IgM molecules which react with
   factor (RF) testing is the examination of the blood to determine the presence of rheumatoid factors (IgG or IgM molecules which react with
   factor (RF) testing is the examination of the blood to determine the presence of rheumatoid factors (IgG or IgM molecules which react with
                                                       N/A
cinoma Sentinel lymph node biopsy in breast carcinoma is a technique that allows sampling of the lymph node or nodes that directly drain an
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cinoma Sentinel lymph node biopsy in breast carcinoma is a technique that allows sampling of the lymph node or nodes that directly drain an
                                                       N/A
cinoma Sentinel lymph node biopsy in breast carcinoma is a technique that allows sampling of the lymph node or nodes that directly drain an
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meTM is a tubular braided mesh cylinder made of high strength implant grade superalloy wire. The braided mesh is designed to expand radia
meTM is a tubular braided mesh cylinder made of high strength implant grade superalloy wire. The braided mesh is designed to expand radia
meTM is a tubular braided mesh cylinder made of high strength implant grade superalloy wire. The braided mesh is designed to expand radia
meTM is a tubular braided mesh cylinder made of high strength implant grade superalloy wire. The braided mesh is designed to expand radia
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 useful in the diagnosis of myocardial damage and in estimating the degree of cardiac damage. A blood assay for cardiac markers has promi
 useful in the diagnosis of myocardial damage and in estimating the degree of cardiac damage. A blood assay for cardiac markers has promi
 useful in the diagnosis of myocardial damage and in estimating the degree of cardiac damage. A blood assay for cardiac markers has promi
 useful in the diagnosis of myocardial damage and in estimating the degree of cardiac damage. A blood assay for cardiac markers has promi
 useful in the diagnosis of myocardial damage and in estimating the degree of cardiac damage. A blood assay for cardiac markers has promi
 useful in the diagnosis of myocardial damage and in estimating the degree of cardiac damage. A blood assay for cardiac markers has promi
 useful in the diagnosis of myocardial damage and in estimating the degree of cardiac damage. A blood assay for cardiac markers has promi
 useful in the diagnosis of myocardial damage and in estimating the degree of cardiac damage. A blood assay for cardiac markers has promi
 useful in the diagnosis of myocardial damage and in estimating the degree of cardiac damage. A blood assay for cardiac markers has promi
 useful in the diagnosis of myocardial damage and in estimating the degree of cardiac damage. A blood assay for cardiac markers has promi
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Not applicable.
Not applicable.
Not applicable.
Medical Necessity is not based exclusively on diagnosis (ICD-9-CM codes)
Medical Necessity is not based exclusively on diagnosis (ICD-9-CM codes)
Medical Necessity is not based exclusively on diagnosis (ICD-9-CM codes)
Medical Necessity is not based exclusively on diagnosis (ICD-9-CM codes)
See ?ICD-9 Codes That Support Medical Necessity? Section
See ?ICD-9 Codes That Support Medical Necessity? Section
See ?ICD-9 Codes That Support Medical Necessity? Section
See ?ICD-9 Codes That Support Medical Necessity? Section
See ?ICD-9 Codes That Support Medical Necessity? Section
See ?ICD-9 Codes That Support Medical Necessity? Section
See ?ICD-9 Codes That Support Medical Necessity? Section
See ?ICD-9 Codes That Support Medical Necessity? Section
               See ?ICD-9 Codes That Support Medical Necessity? Section
st be based on a careful and complete history/physical examination which suggests IgE-mediated disease. In vitro testing for allergen specif
gnosed with Chronic Respiratory Diseases have a progressive increase in the mechanical work of breathing and limited respiratory reserve c
gnosed with Chronic Respiratory Diseases have a progressive increase in the mechanical work of breathing and limited respiratory reserve c
gnosed with Chronic Respiratory Diseases have a progressive increase in the mechanical work of breathing and limited respiratory reserve c
                                                      See diagnoses listed in ICD-9-CM replacement of teeth, or structures Necessity
  including items and services in connection with the care, treatment, filling, removal, orCodes That Do Not Support Medicaldirectly supporting
                                                      See diagnoses listed in ICD-9-CM replacement of teeth, or structures Necessity
  including items and services in connection with the care, treatment, filling, removal, orCodes That Do Not Support Medicaldirectly supporting
                                                      See diagnoses listed in ICD-9-CM replacement of teeth, or structures Necessity
  including items and services in connection with the care, treatment, filling, removal, orCodes That Do Not Support Medicaldirectly supporting
                                                      See diagnoses listed in ICD-9-CM replacement of teeth, or structures Necessity
  including items and services in connection with the care, treatment, filling, removal, orCodes That Do Not Support Medicaldirectly supporting
                                                      See diagnoses listed in ICD-9-CM replacement of teeth, or structures Necessity
  including items and services in connection with the care, treatment, filling, removal, orCodes That Do Not Support Medicaldirectly supporting
                                                      See diagnoses listed in ICD-9-CM replacement of teeth, or structures Necessity
  including items and services in connection with the care, treatment, filling, removal, orCodes That Do Not Support Medicaldirectly supporting
                                                      See diagnoses listed in ICD-9-CM replacement of teeth, or structures Necessity
  including items and services in connection with the care, treatment, filling, removal, orCodes That Do Not Support Medicaldirectly supporting
                                                      See diagnoses listed in ICD-9-CM replacement of teeth, or structures Necessity
  including items and services in connection with the care, treatment, filling, removal, orCodes That Do Not Support Medicaldirectly supporting
                                                      See diagnoses listed in ICD-9-CM replacement of teeth, or structures Necessity
  including items and services in connection with the care, treatment, filling, removal, orCodes That Do Not Support Medicaldirectly supporting
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guage pathology services are part of a constellation of rehabilitative services designed to improve or restore cognitive functioning, communic
guage pathology services are part of a constellation of rehabilitative services designed to improve or restore cognitive functioning, communic
s defined as the inability of the male to achieve or maintain an erection sufficient for satisfactory sexual performance. Causes contributing to
                                                        All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
               Those listed in "Indications and Limitations" section of this policy.
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                                                        All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                        All codes not listed above under ?Covered ICD-9-CM
                All codes listed above under ?Covered ICD-9-CM Codes that Support Medical Necessity?. Codes that Support Medical Nec
                                                        All ICD-9-CM codes not listed in this policy under ICD-9-CM Codes
                All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above. that Support Medic
                                                        All ICD-9-CM codes not listed Medical Necessity?.
                All codes listed above under ?Covered ICD-9-CM Codes that Supportin this policy under "ICD-9-CM Codes that Support Medic
               N/A                                    N/A
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s defined as the inability of the male to achieve or maintain an erection sufficient for satisfactory sexual performance. Causes contributing to
s defined as the inability of the male to achieve or maintain an erection sufficient for satisfactory sexual performance. Causes contributing to
                                                        All ICD-9-CM codes not that in this Medical Necessity above.
                 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
               N/A                                     N/A
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 Zevalin, (Ibritumomab Tiuxetan), as part of a specific therapeutic regimen, is indicated for the treatment of patients with relapsed or refracto
               N/A                                     N/A
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ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
              N/A                                    N/A
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              N/A                                    See diagnosis listed in ICD-9-CM Codes That Do Not Support Medical Necessity.
              N/A                                    See diagnosis listed in ICD-9-CM Codes That Do Not Support Medical Necessity.
              N/A                                    See diagnosis listed in ICD-9-CM Codes That Do Not Support Medical Necessity.
              N/A                                    See diagnosis listed in ICD-9-CM Codes That Do Not Support Medical Necessity.
              N/A                                    See diagnosis listed in ICD-9-CM Codes That Do Not Support Medical Necessity.
              N/A                                    See diagnosis listed in ICD-9-CM Codes That Do Not Support Medical Necessity.
              N/A                                    See diagnosis listed in ICD-9-CM Codes That Do Not Support Medical Necessity.
              N/A                                    See diagnosis listed in ICD-9-CM Codes That Do Not Support Medical Necessity.
              N/A                                    See diagnosis listed in ICD-9-CM Codes That Do Not Support Medical Necessity.
              N/A                                    N/A
s defined as the inability of the male to achieve or maintain an erection sufficient for satisfactory sexual performance. Causes contributing to
              N/A                                    All diagnoses not listed in the ?ICD-9-CM Codes That Support Medical Necessity? sectio
              N/A                                    N/A
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s used in the evaluation of conditions that interfere with normal heart functions, such as disturbances of rate or rhythm, disorders of conductio
s used in the evaluation of conditions that interfere with normal heart functions, such as disturbances of rate or rhythm, disorders of conductio
s used in the evaluation of conditions that interfere with normal heart functions, such as disturbances of rate or rhythm, disorders of conductio
s used in the evaluation of conditions that interfere with normal heart functions, such as disturbances of rate or rhythm, disorders of conductio
s used in the evaluation of conditions that interfere with normal heart functions, such as disturbances of rate or rhythm, disorders of conductio
s used in the evaluation of conditions that interfere with normal heart functions, such as disturbances of rate or rhythm, disorders of conductio
s used in the evaluation of conditions that interfere with normal heart functions, such as disturbances of rate or rhythm, disorders of conductio
s used in the evaluation of conditions that interfere with normal heart functions, such as disturbances of rate or rhythm, disorders of conductio
s used in the evaluation of conditions that interfere with normal heart functions, such as disturbances of rate or rhythm, disorders of conductio
s used in the evaluation of conditions that interfere with normal heart functions, such as disturbances of rate or rhythm, disorders of conductio
                                                      N/A
etry is a complex laboratory process used to examine blood, body fluids, bone marrow, and tissues. Flow cytometry (FCM) counts and analyz
                                                      N/A
etry is a complex laboratory process used to examine blood, body fluids, bone marrow, and tissues. Flow cytometry (FCM) counts and analyz
                                                      N/A
etry is a complex laboratory process used to examine blood, body fluids, bone marrow, and tissues. Flow cytometry (FCM) counts and analyz
                                                      N/A
etry is a complex laboratory process used to examine blood, body fluids, bone marrow, and tissues. Flow cytometry (FCM) counts and analyz
                                                      N/A
etry is a complex laboratory process used to examine blood, body fluids, bone marrow, and tissues. Flow cytometry (FCM) counts and analyz
                                                      N/A
etry is a complex laboratory process used to examine blood, body fluids, bone marrow, and tissues. Flow cytometry (FCM) counts and analyz
                                                      N/A
etry is a complex laboratory process used to examine blood, body fluids, bone marrow, and tissues. Flow cytometry (FCM) counts and analyz
                                                      N/A
etry is a complex laboratory process used to examine blood, body fluids, bone marrow, and tissues. Flow cytometry (FCM) counts and analyz
                                                      N/A
etry is a complex laboratory process used to examine blood, body fluids, bone marrow, and tissues. Flow cytometry (FCM) counts and analyz
                                                      N/A
etry is a complex laboratory process used to examine blood, body fluids, bone marrow, and tissues. Flow cytometry (FCM) counts and analyz
              N/A                                     Any diagnosis or condition not listed in the ?Indications and Limitations of Coverage and
              N/A                                     Any diagnosis or condition not listed in the ?Indications and Limitations of Coverage and
              N/A                                     Any diagnosis or condition not listed in the ?Indications and Limitations of Coverage and
              N/A                                     Any diagnosis or condition not listed in the ?Indications and Limitations of Coverage and
              N/A                                     Any diagnosis or condition not listed in the ?Indications and Limitations of Coverage and
              N/A                                     Any diagnosis or condition not listed in the ?Indications and Limitations of Coverage and
              N/A                                     Any diagnosis or condition not listed in the ?Indications and Limitations of Coverage and
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
               All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes that in this policy under ?ICD-9-CM Codes that Support Medi
                                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes that in this policy under ?ICD-9-CM Codes that Support Medi
                                                      All ICD-9-CM codes not listed that Support Medical Necessity? above will be denied as n
              All ICD-9-CM codes not listed in this policy under ?ICD-9-CM Codesin this policy under ?ICD-9-CM Codes that Support Medica
                                                      All ICD-9-CM codes not listed that Support Medical Necessity? above will be denied as n
              All ICD-9-CM codes not listed in this policy under ?ICD-9-CM Codesin this policy under ?ICD-9-CM Codes that Support Medica
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
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              N/A                                     N/A
              N/A
              N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                    N/A
              N/A                                    N/A
              N/A                                    N/A
              N/A                                    N/A
              N/A                                    N/A
              N/A                                    N/A
              N/A                                    N/A
              N/A                                    N/A
                                                      All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                      All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                      All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                      All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                      All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                      All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
 ception of vaccinations for pneumococcal pneumonia, hepatitis B, and influenza, which are specifically covered under the law, vaccinations o
 ception of vaccinations for pneumococcal pneumonia, hepatitis B, and influenza, which are specifically covered under the law, vaccinations o
 ception of vaccinations for pneumococcal pneumonia, hepatitis B, and influenza, which are specifically covered under the law, vaccinations o
 ception of vaccinations for pneumococcal pneumonia, hepatitis B, and influenza, which are specifically covered under the law, vaccinations o
              N/A                                    N/A
              N/A                                    N/A
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              N/A                                    N/A
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              N/A                                    N/A
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              N/A                                    N/A
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              N/A                                    N/A
              N/A                                    N/A
              N/A                                    N/A
              N/A                                    N/A
              N/A                                    N/A
              N/A                                    N/A
e vascular studies utilize ultrasonic doppler and physiologic principles to assess irregularities in blood flow in arterial and venous systems. Th
e vascular studies utilize ultrasonic doppler and physiologic principles to assess irregularities in blood flow in arterial and venous systems. Th
e vascular studies utilize ultrasonic doppler and physiologic principles to assess irregularities in blood flow in arterial and venous systems. Th
e vascular studies utilize ultrasonic doppler and physiologic principles to assess irregularities in blood flow in arterial and venous systems. Th
              N/A                                    Any diagnosis or condition not listed in the "Indications and Limitations of Coverage and
              N/A                                    Any diagnosis or condition not listed in the "Indications and Limitations of Coverage and
              N/A                                    Any diagnosis or condition not listed in the "Indications and Limitations of Coverage and
              N/A                                    Any diagnosis or condition not listed in the "Indications and Limitations of Coverage and
N/A                Any diagnosis or condition not listed in the "Indications and Limitations of Coverage and
N/A                Any diagnosis or condition not listed in the "Indications and Limitations of Coverage and
N/A                Any diagnosis or condition not listed in the "Indications and Limitations of Coverage and
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not Listed above
Any Listed above   Any Not Listed above
Any Listed above   Any Not Listed above
Any Listed above   Any Not Listed above
Any Listed above   Any Not Listed above
Any Listed above   Any Not Listed above
Any Listed above   Any Not Listed above
Any Listed above   Any Not Listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
Any Listed above   Any Not listed above
N/A                N/A
N/A                N/A
N/A                N/A
N/A                N/A
N/A                N/A
N/A                N/A
N/A                N/A
N/A                N/A
N/A                N/A
N/A                N/A
N/A                N/A
N/A                N/A
Not applicable     Not applicable
Not applicable     Not applicable
Not applicable     Not applicable
Not applicable     Not applicable
Not applicable     Not applicable
               Not applicable                          Not applicable
               Not applicable                          Not applicable
               Not applicable                          Not applicable
               Not applicable                          Not applicable
               Not applicable                          Not applicable
               Not applicable                          Not applicable
               Not applicable                          Not applicable
               Not applicable                          Not applicable
               Not applicable                          Not applicable
               Not applicable                          Not applicable
nt to" provision also applies to coverage for psychological services furnished "incident to" the professional services of non-physician practition
nt to" provision also applies to coverage for psychological services furnished "incident to" the professional services of non-physician practition
nt to" provision also applies to coverage for psychological services furnished "incident to" the professional services of non-physician practition
nt to" provision also applies to coverage for psychological services furnished "incident to" the professional services of non-physician practition
varicose veins have been treated by conservative measures such as exercise, periodic leg elevation, weight loss, compressive therapy and a
varicose veins have been treated by conservative measures such as exercise, periodic leg elevation, weight loss, compressive therapy and a
varicose veins have been treated by conservative measures such as exercise, periodic leg elevation, weight loss, compressive therapy and a
varicose veins have been treated by conservative measures such as exercise, periodic leg elevation, weight loss, compressive therapy and a
 s is the study of chromosomes by light or fluorescent microscopy. Cytogenetic testing is used to study an individual?s chromosome makeup.
 s is the study of chromosomes by light or fluorescent microscopy. Cytogenetic testing is used to study an individual?s chromosome makeup.
 s is the study of chromosomes by light or fluorescent microscopy. Cytogenetic testing is used to study an individual?s chromosome makeup.
e of allergen immunotherapy is to provide protection against the allergic symptoms and inflammatory reaction(s) associated with natural expo
e of allergen immunotherapy is to provide protection against the allergic symptoms and inflammatory reaction(s) associated with natural expo
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
l examination of the chest (chest x-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving
  Immune Globulin (IVIg) is a solution of human immunoglobulins specifically prepared for intravenous infusion. Immunoglobulin contains a br
  Immune Globulin (IVIg) is a solution of human immunoglobulins specifically prepared for intravenous infusion. Immunoglobulin contains a br
  Immune Globulin (IVIg) is a solution of human immunoglobulins specifically prepared for intravenous infusion. Immunoglobulin contains a br
 l Coverage Analysis decision memorandum (#CAG-00142N), issued on April 15, 2003, CMS reviewed scientific and clinical literature on MR
 l Coverage Analysis decision memorandum (#CAG-00142N), issued on April 15, 2003, CMS reviewed scientific and clinical literature on MR
 l Coverage Analysis decision memorandum (#CAG-00142N), issued on April 15, 2003, CMS reviewed scientific and clinical literature on MR
 l Coverage Analysis decision memorandum (#CAG-00142N), issued on April 15, 2003, CMS reviewed scientific and clinical literature on MR
 l Coverage Analysis decision memorandum (#CAG-00142N), issued on April 15, 2003, CMS reviewed scientific and clinical literature on MR
 l Coverage Analysis decision memorandum (#CAG-00142N), issued on April 15, 2003, CMS reviewed scientific and clinical literature on MR
 l Coverage Analysis decision memorandum (#CAG-00142N), issued on April 15, 2003, CMS reviewed scientific and clinical literature on MR
               Not applicable                          Not applicable
               Not applicable                          Not applicable
               Not applicable                          Not applicable
               Not applicable                          Not applicable
              Not applicable                         Not applicable
              Not applicable                         Not applicable
              Not applicable                         Not applicable
              Not applicable                         Not applicable
              Not applicable                         Not applicable
              Not applicable                         Not applicable
              Not applicable                         Not applicable
              Not applicable                         Not applicable
              Not applicable                         Not applicable
              Not applicable                         Not applicable
              Not applicable                         Not applicable
e several conditions covered in this policy for which coronary angiography is appropriate and medically necessary. 2. Catheterization is nev
e several conditions covered in this policy for which coronary angiography is appropriate and medically necessary. 2. Catheterization is nev
              Not applicable                         Not applicable
              Not applicable                         Not applicable
              Not applicable                         Not applicable
              Not applicable                         Not applicable
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
 ons for which right heart catheterizations are allowed are listed in the "ICD-9 Codes That Support Medical Necessity" section. 2. Right heart
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
ess testing is an established and reliable test used to detect ischemic heart disease. Its use has been increasingly extended so that it is now
 lesions are common in the elderly and frequently removed at the patient?s request to improve appearance. Removals of certain benign skin
 lesions are common in the elderly and frequently removed at the patient?s request to improve appearance. Removals of certain benign skin
 lesions are common in the elderly and frequently removed at the patient?s request to improve appearance. Removals of certain benign skin
              Not applicable                            Not applicable
              Not applicable                            Not applicable
              Not applicable                            Not applicable
              Not applicable                            Not applicable
              Not applicable                            Not applicable
              Not applicable                            Not applicable
              Not applicable                            Not applicable
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
rigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic
 functional or reconstructive surgery is to restore normalcy to a structure that has been altered by trauma, infection, inflammation, degenerati
 functional or reconstructive surgery is to restore normalcy to a structure that has been altered by trauma, infection, inflammation, degenerati
 functional or reconstructive surgery is to restore normalcy to a structure that has been altered by trauma, infection, inflammation, degenerati
               N/A                                    N/A
ations for renal arteriography adapted from the American College of Radiology (1999) include the following: Severe and/or difficult to contro
ations for renal arteriography adapted from the American College of Radiology (1999) include the following: Severe and/or difficult to contro
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
ommon test used to evaluate a patient for heart disease is the 12-lead electrocardiogram. Although the importance of this test in the manage
rium swallow studies by videofluoroscopy are used to objectively diagnose disorders of swallowing and aspiration and aid in selecting an app
rium swallow studies by videofluoroscopy are used to objectively diagnose disorders of swallowing and aspiration and aid in selecting an app
rium swallow studies by videofluoroscopy are used to objectively diagnose disorders of swallowing and aspiration and aid in selecting an app
rium swallow studies by videofluoroscopy are used to objectively diagnose disorders of swallowing and aspiration and aid in selecting an app
rium swallow studies by videofluoroscopy are used to objectively diagnose disorders of swallowing and aspiration and aid in selecting an app
rium swallow studies by videofluoroscopy are used to objectively diagnose disorders of swallowing and aspiration and aid in selecting an app
 n of candidates for testing should be done with the consideration that the post test probability of disease depends not only on the test sensiti
 n of candidates for testing should be done with the consideration that the post test probability of disease depends not only on the test sensiti
 n of candidates for testing should be done with the consideration that the post test probability of disease depends not only on the test sensiti
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
 tion derived from any transesophageal echocardiogram must affect a medical management decision in order to be covered by Medicare. Me
               Not applicable                         Not applicable
               Not applicable                         Not applicable
               Not applicable                         Not applicable
               Not applicable                         Not applicable
               Not applicable                         Not applicable
               Not applicable                         Not applicable
               Not applicable                         Not applicable
               Not applicable                         Not applicable
               Not applicable                         Not applicable
               Not applicable                         Not applicable
               Not applicable                         Not applicable
               Not applicable                         Not applicable
               N/A                                    N/A
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               N/A                                    N/A
               N/A                                    N/A
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               N/A                                    N/A
selected patients, the following conditions may be alleviated by BT: blepharospasm, hemifacial spasm, cervical dystonia (Torticollis), spastic
selected patients, the following conditions may be alleviated by BT: blepharospasm, hemifacial spasm, cervical dystonia (Torticollis), spastic
selected patients, the following conditions may be alleviated by BT: blepharospasm, hemifacial spasm, cervical dystonia (Torticollis), spastic
                                                        All ICD-9-CM codes not listed Support Medical Necessity? above.
                All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes that in this policy under ?ICD-9-CM Codes that Support Medi
                                                        All ICD-9-CM codes not listed Support Medical Necessity? above.
                All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes that in this policy under ?ICD-9-CM Codes that Support Medi
                                                        All ICD-9-CM codes not listed Support Medical Necessity? above.
                All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes that in this policy under ?ICD-9-CM Codes that Support Medi
 nd Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. Some of the essen
 nd Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. Some of the essen
 nd Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. Some of the essen
 nd Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. Some of the essen
 nd Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. Some of the essen
 nd Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. Some of the essen
 nd Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. Some of the essen
 nd Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. Some of the essen
 nd Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. Some of the essen
 nd Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. Some of the essen
 nd Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. Some of the essen
 nd Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. Some of the essen
 nd Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. Some of the essen
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
us fistula (cannula, shunt) declotting or interventions to restore and/or maintain functional patency may encompass a number of open surgica
                N/A                                    N/A
                N/A                                    N/A
                N/A                                    N/A
                N/A                                    N/A
                N/A                                    N/A
e (HF) is a clinical syndrome that is characterized by dyspnea, fatigue and fluid retention. Since there is currently no diagnostic test for HF, di
                N/A                                    N/A
                N/A                                    N/A
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. Its clinical efficacy is in patients with moderate to se
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. Its clinical efficacy is in patients with moderate to se
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. Its clinical efficacy is in patients with moderate to se
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. Its clinical efficacy is in patients with moderate to se
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. Its clinical efficacy is in patients with moderate to se
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. Its clinical efficacy is in patients with moderate to se
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. Its clinical efficacy is in patients with moderate to se
 a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. Its clinical efficacy is in patients with moderate to se
onduction Studies Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation recorde
onduction Studies Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation recorde
onduction Studies Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation recorde
onduction Studies Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation recorde
onduction Studies Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation recorde
onduction Studies Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation recorde
onduction Studies Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation recorde
onduction Studies Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation recorde
onduction Studies Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation recorde
onduction Studies Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation recorde
onduction Studies Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation recorde
onduction Studies Nerve conduction studies (NCS) are used to measure action potentials resulting from peripheral nerve stimulation recorde
                                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
                 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
                 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
                 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
                 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
                 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                N/A                                    N/A
 and Limitations of Coverage And/or Medical Necessity: *INTRODUCTION Immune serums (immune globulin) provide passive immunity to
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
                                                         All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
                 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                                         All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
                 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                                         All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
                 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                                         All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
                 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                                         All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
                 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
               Not applicable                           Not applicable
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 is a biologically engineered protein, which stimulates the bone marrow to make new red blood cells. Darbepoetin Alfa is an erythropoiesis st
 proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
 proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
 proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
 proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
 proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
 proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
 proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
 proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
proved labeling states that it is indicated in the treatment of anemia associated with chronic renal failure when furnished incident to a physici
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
             Not applicable                            Not applicable
zed axial tomography (CT) scan is a form of x-ray that creates cross-sectional images. Thinly collimated x-ray beams pass through the head
zed axial tomography (CT) scan is a form of x-ray that creates cross-sectional images. Thinly collimated x-ray beams pass through the head
zed axial tomography (CT) scan is a form of x-ray that creates cross-sectional images. Thinly collimated x-ray beams pass through the head
zed axial tomography (CT) scan is a form of x-ray that creates cross-sectional images. Thinly collimated x-ray beams pass through the head
zed axial tomography (CT) scan is a form of x-ray that creates cross-sectional images. Thinly collimated x-ray beams pass through the head
zed axial tomography (CT) scan is a form of x-ray that creates cross-sectional images. Thinly collimated x-ray beams pass through the head
zed axial tomography (CT) scan is a form of x-ray that creates cross-sectional images. Thinly collimated x-ray beams pass through the head
zed axial tomography (CT) scan is a form of x-ray that creates cross-sectional images. Thinly collimated x-ray beams pass through the head
zed axial tomography (CT) scan is a form of x-ray that creates cross-sectional images. Thinly collimated x-ray beams pass through the head
                                                        All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes that in this policy under "ICD-9-CM Codes that Support Medic
                                                       All diagnoses attached article related to the attached article as supporting medical nece
             See above list of ICD-9-CM codes and those on thenot listed in this policy or inthe National Coverage Policy and support medic
                                                       All diagnoses attached article related to the attached article as supporting medical nece
             See above list of ICD-9-CM codes and those on thenot listed in this policy or inthe National Coverage Policy and support medic
                                                       All diagnoses attached article related to the attached article as supporting medical nece
             See above list of ICD-9-CM codes and those on thenot listed in this policy or inthe National Coverage Policy and support medic
                                                       All diagnoses attached article related to the attached article as supporting medical nece
             See above list of ICD-9-CM codes and those on thenot listed in this policy or inthe National Coverage Policy and support medic
                                                       All diagnoses attached article related to the attached article as supporting medical nece
             See above list of ICD-9-CM codes and those on thenot listed in this policy or inthe National Coverage Policy and support medic
                                                       All diagnoses not listed article related in the attached article as supporting as medical ne
             See above list of ICD-9-CM codes and those on the attachedin this policy or to National Coverage Policy and support medical n
                                                       All diagnoses not listed article related in the attached article as supporting as medical ne
             See above list of ICD-9-CM codes and those on the attachedin this policy or to National Coverage Policy and support medical n
                                                       All diagnoses not listed article related in the attached article as supporting as medical ne
             See above list of ICD-9-CM codes and those on the attachedin this policy or to National Coverage Policy and support medical n
                                                       All diagnoses not listed article related in the attached article as supporting as medical ne
             See above list of ICD-9-CM codes and those on the attachedin this policy or to National Coverage Policy and support medical n
                                                       All diagnoses not listed article related in the attached article as supporting as medical ne
             See above list of ICD-9-CM codes and those on the attachedin this policy or to National Coverage Policy and support medical n
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              Not applicable                        Not applicable
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              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
unterpulsation ECP is a non-invasive outpatient treatment for coronary artery disease refractory to medical and/or surgical therapy. The patie
unterpulsation ECP is a non-invasive outpatient treatment for coronary artery disease refractory to medical and/or surgical therapy. The patie
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
              Not applicable                        Not applicable
               Not applicable                        Not applicable
               Not applicable                        Not applicable
               Not applicable                        Not applicable
  r ultrasound (IVUS) is an imaging technique in which a miniaturized ultrasound transducer and rotational mirror are mounted on the tip of a c
  r ultrasound (IVUS) is an imaging technique in which a miniaturized ultrasound transducer and rotational mirror are mounted on the tip of a c
  r ultrasound (IVUS) is an imaging technique in which a miniaturized ultrasound transducer and rotational mirror are mounted on the tip of a c
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
 l imaging should adhere to the standards established by the American College of Radiology, American College of Cardiology, or Society of V
                                                      All ICD-9-CM codes not listed under ICD-9-CM Codes
                 All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                                      All ICD-9-CM codes not listed under ICD-9-CM Codes
                 All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                                      All ICD-9-CM codes not listed under ICD-9-CM Codes
                 All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                                      All ICD-9-CM codes not listed under ICD-9-CM Codes
                 All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                                      All ICD-9-CM codes not listed under ICD-9-CM Codes
                 All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                                      All ICD-9-CM that Support Medical Necessity? above.
                 All ICD-9-CM codes listed under ?ICD-9-CM Codes codes not listed under ICD-9-CM Codes that ?Support Medical Necessity
                                                      All ICD-9-CM that Support Medical Necessity? above.
                 All ICD-9-CM codes listed under ?ICD-9-CM Codes codes not listed under ICD-9-CM Codes that ?Support Medical Necessity
                                                      All ICD-9-CM that Support Medical Necessity? above.
                 All ICD-9-CM codes listed under ?ICD-9-CM Codes codes not listed under ICD-9-CM Codes that ?Support Medical Necessity
                                                      All ICD-9-CM that Support Medical Necessity? above.
                 All ICD-9-CM codes listed under ?ICD-9-CM Codes codes not listed under ICD-9-CM Codes that ?Support Medical Necessity
                                                      All ICD-9-CM that Support Medical Necessity? above.
                 All ICD-9-CM codes listed under ?ICD-9-CM Codes codes not listed under ICD-9-CM Codes that ?Support Medical Necessity
                                                      support medical necessity and this policy under
               See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                      support medical necessity and this policy under
               See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                      support medical necessity and this policy under
               See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                      support medical necessity and this policy under
               See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                      support medical necessity and this policy under
               See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                      support medical necessity and this policy under
               See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                      support medical necessity and this policy under
               See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                      support medical necessity and this policy under
               See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                      support medical necessity and this policy under
               See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                      support medical necessity and this policy under
               See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
EKG recording is a diagnostic procedure which provides a continuous record of the electrocardiographic activity of a patient?s heart while the
  Electrodiagnostic Medicine (EDX) Studies are considered to be an extension of the clinical evaluation of patients with disorders of the periph
edure, a needle is inserted into a major joint for the purpose of aspirating specimens for diagnostic analysis and/or injection of a solution for tr
edure, a needle is inserted into a major joint for the purpose of aspirating specimens for diagnostic analysis and/or injection of a solution for tr
edure, a needle is inserted into a major joint for the purpose of aspirating specimens for diagnostic analysis and/or injection of a solution for tr
edure, a needle is inserted into a major joint for the purpose of aspirating specimens for diagnostic analysis and/or injection of a solution for tr
                Not applicable                         Not applicable
                Not applicable                         Not applicable
                Not applicable                         Not applicable
                Not applicable                         Not applicable
                Not applicable                         Not applicable
                Not applicable                         Not applicable
                Not applicable                         Not applicable
                Not applicable                         Not applicable
sis of facet joint pain can be suspected if back pain does not have a strong radicular component, does not have an associated neurologic def
sis of facet joint pain can be suspected if back pain does not have a strong radicular component, does not have an associated neurologic def
sis of facet joint pain can be suspected if back pain does not have a strong radicular component, does not have an associated neurologic def
sis of facet joint pain can be suspected if back pain does not have a strong radicular component, does not have an associated neurologic def
sis of facet joint pain can be suspected if back pain does not have a strong radicular component, does not have an associated neurologic def
                Not applicable                         Not applicable
                                                        All ICD-9-CM codes not listed Support Medical Necessity? above.
                 All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                        All ICD-9-CM codes not listed Support Medical Necessity? above.
                 All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                        All ICD-9-CM codes not listed Support Medical Necessity? above.
                 All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                        All ICD-9-CM codes not listed Support Medical Necessity? above.
                 All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                        All ICD-9-CM codes not listed Support Medical Necessity? above.
                 All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                        All ICD-9-CM codes not listed Support Medical Necessity? above.
                 All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
 stimulation blocks pain conduction pathway and stimulate endorphins. The neurostimulator electrodes used for this purpose are implanted p
 stimulation blocks pain conduction pathway and stimulate endorphins. The neurostimulator electrodes used for this purpose are implanted p
                N/A                                    All diagnoses not listed in the ICD-9-CM Codes that Support Medical Necessity? section o
                N/A                                    All diagnoses not listed in the ?ICD-9-CM Codes that Support Medical Necessity? section
                Those listed in "Indications and Limitations" section of this policy.
 agnostic testing may be used for analysis of the nucleic acids, DNA and RNA. Nucleic acids are of great importance in metabolism and as a
 agnostic testing may be used for analysis of the nucleic acids, DNA and RNA. Nucleic acids are of great importance in metabolism and as a
 agnostic testing may be used for analysis of the nucleic acids, DNA and RNA. Nucleic acids are of great importance in metabolism and as a
 agnostic testing may be used for analysis of the nucleic acids, DNA and RNA. Nucleic acids are of great importance in metabolism and as a
 agnostic testing may be used for analysis of the nucleic acids, DNA and RNA. Nucleic acids are of great importance in metabolism and as a
 agnostic testing may be used for analysis of the nucleic acids, DNA and RNA. Nucleic acids are of great importance in metabolism and as a
 agnostic testing may be used for analysis of the nucleic acids, DNA and RNA. Nucleic acids are of great importance in metabolism and as a
 agnostic testing may be used for analysis of the nucleic acids, DNA and RNA. Nucleic acids are of great importance in metabolism and as a
                N/A                                    N/A
                N/A                                    N/A
                N/A                                    N/A
                N/A                                    N/A
                N/A                                    N/A
                N/A                                    N/A
                N/A                                    N/A
 unlabeled use of a drug is defined as a use for a non-Food and Drug Administration (FDA) approved indication; that is, one that is not listed
                Not applicable                         Not applicable
                Not applicable                         Not applicable
                Not applicable                         Not applicable
              Not applicable                          Not applicable
              Not applicable                          Not applicable
              Not applicable                          Not applicable
              Not applicable                          Not applicable
              Not applicable                          Not applicable
              Not applicable                          Not applicable
              Not applicable                          Not applicable
              Not applicable                          Not applicable
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
oes not cover items and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
oes not cover items and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
              N/A                                     N/A
N/A                                    All diagnoses not listed in the ?ICD-9-CM Codes That Support Medical Necessity? sectio
                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
Any listed above.                      Any not listed above.
Any listed above.                      Any not listed above.
Any listed above.                      Any not listed above.
Any listed above.                      Any not listed above.
Any listed above.                      Any not listed above.
Any listed above.                      Any not listed above.
Any listed above.                      Any not listed above.
Any listed above.                      Any not listed above.
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A                                    N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   Any not listed above
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
                N/A                                     N/A
                N/A                                     N/A
                N/A                                     N/A
                N/A                                     N/A
                N/A                                     N/A
                N/A                                     N/A
                N/A                                     N/A
                N/A                                     N/A
                N/A                                     N/A
                N/A                                     N/A
                N/A                                     N/A
                                                         All ICD-9-CM codes not listed above under ICD-9-CM Codes that Support Medical Nec
                 All ICD-9-CM codes listed above under ICD-9-CM Codes that Support Medical Necessity above.
                                                         All ICD-9-CM codes not that in this Medical Necessity above.
                 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
ay 16, 2006 , The Centers for Medicare and Medicaid Services (CMS) has found that lumbar artificial disc replacement (LADR) with the Char
ks: Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local ane
ks: Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local ane
ks: Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local ane
                                                         All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                 All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                         All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                 All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                         All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                 All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                         All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                 All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                         All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                 All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                         All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                 All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                         All ICD-9-CM codes not that in this Medical Necessity above.
                 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                         All ICD-9-CM codes not that in this Medical Necessity above.
                 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                         All ICD-9-CM codes not that in this Medical Necessity above.
                 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
  not available for endoluminal treatment for Gastroesophageal Reflux Disease (GERD) using the Stretta« procedure, the Bard« EndoCinch?
  not available for endoluminal treatment for Gastroesophageal Reflux Disease (GERD) using the Stretta« procedure, the Bard« EndoCinch?
  not available for endoluminal treatment for Gastroesophageal Reflux Disease (GERD) using the Stretta« procedure, the Bard« EndoCinch?
                                                         All ICD-9-CM codes not listed in this policy under ICD-9-CM Codes that Support Medica
                 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes that Support Medical Necessity above.
                                                         All ICD-9-CM codes not listed in this policy under ICD-9-CM Codes that Support Medica
                 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes that Support Medical Necessity above.
                                                         All ICD-9-CM codes not listed in this policy under ICD-9-CM Codes that Support Medica
                 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes that Support Medical Necessity above.
                                                         All ICD-9-CM codes not listed in this policy under ICD-9-CM Codes that Support Medica
                 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes that Support Medical Necessity above.
                                                         All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                 All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                         All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                 All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                         All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                 All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                         ICD-9-CM Codes that Support Medical Necessity.
                 All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                         ICD-9-CM Codes that Support Medical Necessity.
                 All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                         ICD-9-CM Codes that Support Medical Necessity.
                 All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                N/A                                     All diagnoses not listed in the ?ICD-9-CM Codes That Support Medical Necessity? sectio
                None                                    N/A
                None                                    N/A
                None                                    N/A
                None                                    N/A
                None                                    N/A
                N/A                                     Any not listed above
                N/A                                     N/A
 t injection is one of the many modalities utilized in the management of chronic pain. Myofascial trigger points are self-sustaining hyper-irritati
 t injection is one of the many modalities utilized in the management of chronic pain. Myofascial trigger points are self-sustaining hyper-irritati
                N/A                                     N/A
ay 16, 2006, the Centers for Medicare and Medicaid Services (CMS) has found that lumbar artificial disc replacement (LADR) with the Charit
ay 16, 2006, the Centers for Medicare and Medicaid Services (CMS) has found that lumbar artificial disc replacement (LADR) with the Charit
ay 16, 2006, the Centers for Medicare and Medicaid Services (CMS) has found that lumbar artificial disc replacement (LADR) with the Charit
ay 16, 2006, the Centers for Medicare and Medicaid Services (CMS) has found that lumbar artificial disc replacement (LADR) with the Charit
ay 16, 2006, the Centers for Medicare and Medicaid Services (CMS) has found that lumbar artificial disc replacement (LADR) with the Charit
ay 16, 2006, the Centers for Medicare and Medicaid Services (CMS) has found that lumbar artificial disc replacement (LADR) with the Charit
ks: Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local ane
ks: Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local ane
ks: Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local ane
ks: Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local ane
ks: Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local ane
ks: Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local ane
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                       All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                       All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                       All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                       All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                       All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
                All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
 not available for endoluminal treatment for Gastroesophageal Reflux Disease (GERD) using the Stretta procedure, the Bard« EndoCinch? S
 not available for endoluminal treatment for Gastroesophageal Reflux Disease (GERD) using the Stretta procedure, the Bard« EndoCinch? S
 not available for endoluminal treatment for Gastroesophageal Reflux Disease (GERD) using the Stretta procedure, the Bard« EndoCinch? S
 not available for endoluminal treatment for Gastroesophageal Reflux Disease (GERD) using the Stretta procedure, the Bard« EndoCinch? S
 not available for endoluminal treatment for Gastroesophageal Reflux Disease (GERD) using the Stretta procedure, the Bard« EndoCinch? S
 not available for endoluminal treatment for Gastroesophageal Reflux Disease (GERD) using the Stretta procedure, the Bard« EndoCinch? S
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not listed Medical Necessity above.
                All ICD-9-CM codes listed above under ICD-9-CM Codes that Supportabove under ICD-9-CM Codes that Support Medical Ne
                                                       All ICD-9-CM codes not listed Medical Necessity above.
                All ICD-9-CM codes listed above under ICD-9-CM Codes that Supportabove under ICD-9-CM Codes that Support Medical Ne
                                                       All ICD-9-CM codes not listed Medical Necessity above.
                All ICD-9-CM codes listed above under ICD-9-CM Codes that Supportabove under ICD-9-CM Codes that Support Medical Ne
                                                       All ICD-9-CM codes not listed Medical Necessity above.
                All ICD-9-CM codes listed above under ICD-9-CM Codes that Supportabove under ICD-9-CM Codes that Support Medical Ne
                                                       All ICD-9-CM codes not listed Medical Necessity above.
                All ICD-9-CM codes listed above under ICD-9-CM Codes that Supportabove under ICD-9-CM Codes that Support Medical Ne
                                                       All ICD-9-CM codes not listed Medical Necessity above.
                All ICD-9-CM codes listed above under ICD-9-CM Codes that Supportabove under ICD-9-CM Codes that Support Medical Ne
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     ICD-9-CM Codes that Support Medical Necessity.
              All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                     ICD-9-CM Codes that Support Medical Necessity.
              All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                     ICD-9-CM Codes that Support Medical Necessity.
              All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                     ICD-9-CM Codes that Support Medical Necessity.
              All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                     ICD-9-CM Codes that Support Medical Necessity.
              All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                     ICD-9-CM Codes that Support Medical Necessity.
              All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                     All ICD-9-CM codes not listed in above.
              All diagnoses listed in ICD-9-CM Codes that Support Medical Necessity this policy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed in above.
              All diagnoses listed in ICD-9-CM Codes that Support Medical Necessity this policy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed in above.
              All diagnoses listed in ICD-9-CM Codes that Support Medical Necessity this policy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed in above.
              All diagnoses listed in ICD-9-CM Codes that Support Medical Necessity this policy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed in above.
              All diagnoses listed in ICD-9-CM Codes that Support Medical Necessity this policy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed in above.
              All diagnoses listed in ICD-9-CM Codes that Support Medical Necessity this policy under ICD-9-CM Codes that Support Medic
ances in technology have led to numerous advances in imaging technology, more specifically for the purposes of this LCD, imaging as relate
ances in technology have led to numerous advances in imaging technology, more specifically for the purposes of this LCD, imaging as relate
ances in technology have led to numerous advances in imaging technology, more specifically for the purposes of this LCD, imaging as relate
ances in technology have led to numerous advances in imaging technology, more specifically for the purposes of this LCD, imaging as relate
ances in technology have led to numerous advances in imaging technology, more specifically for the purposes of this LCD, imaging as relate
ances in technology have led to numerous advances in imaging technology, more specifically for the purposes of this LCD, imaging as relate
                                                     ICD-9-CM Codes that Support Medical Necessity.
              All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                     ICD-9-CM Codes that Support Medical Necessity.
              All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                     ICD-9-CM Codes that Support Medical Necessity.
              All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                     ICD-9-CM Codes that Support Medical Necessity.
              All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                     ICD-9-CM Codes that Support Medical Necessity.
              All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                     ICD-9-CM Codes that Support Medical Necessity.
              All codes listed above under Covered All codes not listed above under Covered ICD-9-CM Codes that Support Medical Nece
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
              All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                     All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
              All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                     All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
              All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                     All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
              All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                     All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
              All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                     All diagnoses Medical in ICD-9-CM Codes that Support Medical Necessity above.
              All diagnoses listed in ICD-9-CM Codes that Support not listedNecessity above.
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not that in this Medical Necessity above.
              All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed under ICD-9-CM Codes
              All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                                     All ICD-9-CM codes not listed under ICD-9-CM Codes
              All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                                     All ICD-9-CM codes not listed under ICD-9-CM Codes
              All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                                     All ICD-9-CM codes not listed under ICD-9-CM Codes
              All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed under ICD-9-CM Codes
All, ICD-9-CM codes listed under ?ICD-9-CM Codes that Support Medical Necessity? above. that ?Support Medical Necessity
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                        All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medic
 All ICD-9-CM codes listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All diagnoses attached article related to the attached article as supporting as medical n
See above list of ICD-9-CM codes and those on thenot listed in this policy or inNational Coverage Policy and support medical ne
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                       All ICD-9-CM codes not listed Support Medical Necessity? above.
All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                     All ICD-9-CM codes not listed Support Medical Necessity? above.
              All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
                                                    Any diagnosis codes other than reasonableness.
             See above list of ICD-9-CM codes that support medical necessity and those listed in the covered ICD-9-CM codes will be denie
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
ders should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS
              NA                                      Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
              NA                                      Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
              NA                                      Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
              NA                                      Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
              NA                                      Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
              NA                                      Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
              N/A                                     All diagnoses not listed in the "ICD-9-CM Codes That Support Medical Necessity" section
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
                                                      Conditions that are not listed payment data analysis and subsequent medical review aud
e with the provisions in this policy may be monitored and addressed through postin the "ICD-9-CM Codes that Support Medical Necessity" se
ders should seek information related to National Coverage Determination (NCD) and other Centers for Medicare & Medicaid Services (CMS)
ders should seek information related to National Coverage Determination (NCD) and other Centers for Medicare & Medicaid Services (CMS)
ders should seek information related to National Coverage Determination (NCD) and other Centers for Medicare & Medicaid Services (CMS)
ders should seek information related to National Coverage Determination (NCD) and other Centers for Medicare & Medicaid Services (CMS)
ders should seek information related to National Coverage Determination (NCD) and other Centers for Medicare & Medicaid Services (CMS)
ders should seek information related to National Coverage Determination (NCD) and other Centers for Medicare & Medicaid Services (CMS)
                                                      All diagnoses attached article related to the attached article as supporting medical nece
              See above list of ICD-9-CM codes and those on thenot listed in this policy or inthe National Coverage Policy and support medic
                                                      All diagnoses attached article related to the attached article as supporting medical nece
              See above list of ICD-9-CM codes and those on thenot listed in this policy or inthe National Coverage Policy and support medic
                                                      All diagnoses attached article related to the attached article as supporting medical nece
              See above list of ICD-9-CM codes and those on thenot listed in this policy or inthe National Coverage Policy and support medic
                                                      All diagnoses attached article related to the attached article as supporting medical nece
              See above list of ICD-9-CM codes and those on thenot listed in this policy or inthe National Coverage Policy and support medic
                                                      All diagnoses attached article related to the attached article as supporting medical nece
              See above list of ICD-9-CM codes and those on thenot listed in this policy or inthe National Coverage Policy and support medic
                                                      All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                      All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                      All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                      All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                      All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                      All ICD-9-CM codes not listed Support Medical Necessity? above.
               All ICD-9-CM codes listed in this policy under ?ICD-9-CM Codes thatin this policy under ?ICD-9-CM Codes that Support Medic
                                                       support medical necessity and this policy under
              See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                       support medical necessity and this policy under
              See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                       support medical necessity and this policy under
              See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                       support medical necessity and this policy under
              See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                       support medical necessity and this policy under
              See above list of ICD-9-CM codes thatAll ICD-9-CM codes not listed inreasonableness. "ICD-9-CM Codes that Support Medica
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                                       All ICD-9-CM codes not that in this Medical Necessity above.
                All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
                                        All ICD-9-CM codes not that in this Medical Necessity above.
 All ICD-9-CM codes listed in this policy under ICD-9-CM Codes listedSupportpolicy under ICD-9-CM Codes that Support Medic
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
Not applicable                         Not applicable
NA                                     Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
N/A   N/A
NA    Any diagnoses that are not listed in the "ICD-9 Code that Support Medical Necessity" sec
NA    Any diagnoses that are not listed in the "ICD-9 Code that Support Medical Necessity" sec
NA    Any diagnoses that are not listed in the "ICD-9 Code that Support Medical Necessity" sec
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the "ICD-9 Codes that Support Medical Necessity" se
NA    Any diagnoses that are not listed in the "ICD-9 Codes that Support Medical Necessity" se
NA    Any diagnoses that are not listed in the "ICD-9 Codes that Support Medical Necessity" se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
NA    Any diagnoses that are not listed in the ?ICD-9 Codes that Support Medical Necessity? se
  Documentation Requirements                       Status              Billing Code
                                            A                    HHA-inpatient or home health visits (Part B only)
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                            A                    HHA-outpatient in the patient?s
1. Documentation supporting the medical necessity should be legible, maintained (HHA-A also) medical record, and must be
                                            A                    Special facility or ASC surgery-hospice (non-hospital based)
1.Documentation certifying terminal status must contain enough information to confirm terminal status upon review. Documenta
                                            A                    Special facility or ASC surgery-hospice (hospital based)
1.Documentation certifying terminal status must contain enough information to confirm terminal status upon review. Documenta
                                            A                    HHA-inpatient or home health visits (Part B only)
1. HCFA forms 700/701 are not required. 2. The plan of treatment written by and approved by the certifying physician must be
                                            A                    HHA-outpatient approved by
1. HCFA forms 700/701 are not required. 2. The plan of treatment written by and (HHA-A also)the certifying physician must be
                                            A                    Special facility in the surgery-hospice record, and based)
1.Documentation supporting the medical necessity should be legible, maintainedor ASCpatient?s medical(non-hospitalmust be m
                                            A                    Special facility in the surgery-hospice record, based)
1.Documentation supporting the medical necessity should be legible, maintainedor ASCpatient?s medical(hospitaland must be m
                                            A                    Special facility or in the patient?s medical record, and must
1. Documentation supporting the medical necessity should be legible, maintained ASC surgery-hospice (non-hospital based)be
                                            A                    Special facility or in the patient?s medical record, and must be
1. Documentation supporting the medical necessity should be legible, maintained ASC surgery-hospice (hospital based)
                                            A                    Special facility or in the patient?s medical record, and must
1. Documentation supporting the medical necessity should be legible, maintained ASC surgery-hospice (non-hospital based)be
                                            A                    Special facility or in the patient?s medical record, and must be
1. Documentation supporting the medical necessity should be legible, maintained ASC surgery-hospice (hospital based)
                                            A                    Special facility or ASC surgery-hospice (non-hospital based)
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                            A                    Special facility or ASC surgery-hospice (hospital based)
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                            A                    HHA-inpatient or specific. Documentation must be
I. General Requirements The medical information supporting a final claim must be home health visits (Part B only) objective, c
                                            A                    HHA-outpatient (HHA-A also)
I. General Requirements The medical information supporting a final claim must be specific. Documentation must be objective, c
                                            A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                            A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                            A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                            A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                            A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                            A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                            A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                            A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                            A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                            A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                            A                    Hospital-inpatient the patient?s medical record, and
1.Documentation supporting the medical necessity should be legible, maintained in or home health visits (Part B only) must be m
                                            A                    Hospital-outpatient (HHA-A also) (under OPPS and
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, 13X must be u   m
                                            A                    Non-Patient Laboratory Specimens
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                            A                    Hospital-swing in the
1.Documentation supporting the medical necessity should be legible, maintained beds patient?s medical record, and must be m
                                            A                    SNF-inpatient, in the
1.Documentation supporting the medical necessity should be legible, maintainedPart A patient?s medical record, and must be m
                                            A                    SNF-inpatient or the patient?s medical record, and must be m
1.Documentation supporting the medical necessity should be legible, maintained inhome health visits (Part B only)
                                            A                    SNF-outpatient (HHA-A also)
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                            A                    Clinic-rural health
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                            A                    Clinic-hospital in the patient?s medical record, and must
1.Documentation supporting the medical necessity should be legible, maintainedbased or independent renal dialysis facility be m
                                            A                    Clinic-independent provider based FQHC (eff 10/91)
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                            A                    Special facility in the surgery-rural primary care hospital be
1.Documentation supporting the medical necessity should be legible, maintainedor ASCpatient?s medical record, and must (effm
                                            A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                            A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                            A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                            A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                            A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                            A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                            A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                            A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                            A                    Clinic-hospital based or independent renal dialysis facility
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                            A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                            A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                            A                    Hospital-inpatient or home health submitted B only)
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be visits (Part with each claim.
                                            A                    Hospital-outpatient (HHA-A also) submitted with each claim.
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be(under OPPS 13X must be u
                                            A                    Non-Patient Laboratory Specimens
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim.
                                                A                   Hospital-swing beds
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim.
                                                A                   SNF-inpatient, Part A
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim.
                                                A                   SNF-inpatient or codes, must be submitted with
1. Documentation supporting the medical necessity of this item, such as ICD-9-CMhome health visits (Part B only) each claim.
                                                A                   SNF-outpatient (HHA-A also)
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim.
                                                A                   Clinic-rural health
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim.
                                                A                   Clinic-hospital based or independent renal dialysis facility
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim.
                                                A                   Clinic-independent provider based FQHC (eff 10/91)
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim.
                                                A                   Special facility or codes, must be submitted with hospital (eff
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM ASC surgery-rural primary care each claim.
                                                A                   Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                A                   Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                   Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                A                   SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                A                   SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                A                   Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                A                   Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                A                   Hospital-inpatient or home health the beneficiary's condition t
It is the responsibility of the ambulance supplier to furnish complete and accurate documentation of visits (Part B only)
                                                A                   Hospital-outpatient (HHA-A also) the beneficiary's must be u
It is the responsibility of the ambulance supplier to furnish complete and accurate documentation of(under OPPS 13Xcondition t
                                                A                   SNF-inpatient or home health visits (Part B only)
It is the responsibility of the ambulance supplier to furnish complete and accurate documentation of the beneficiary's condition t
                                                A                   SNF-outpatient documentation
It is the responsibility of the ambulance supplier to furnish complete and accurate (HHA-A also) of the beneficiary's condition t
                                                A                   Special facility or ASC surgery-rural primary care hospital (eff
It is the responsibility of the ambulance supplier to furnish complete and accurate documentation of the beneficiary's condition t
                                                of                   ICD-9-CM codes, must be submitted with each claim.
Documentation supporting medical necessity A this item, such asHospital-inpatient or home health visits (Part B only) Claims
                                                of                   ICD-9-CM codes, (HHA-A also) (under OPPS claim. Claims
Documentation supporting medical necessity A this item, such asHospital-outpatient must be submitted with each13X must be u
                                                of                   ICD-9-CM codes, must be submitted with each claim. Claims
Documentation supporting medical necessity A this item, such asHospital-swing beds
                                                of                   ICD-9-CM codes, A
Documentation supporting medical necessity A this item, such asSNF-inpatient, Partmust be submitted with each claim. Claims
                                                of                   ICD-9-CM codes, must be submitted with only)
Documentation supporting medical necessity A this item, such asSNF-inpatient or home health visits (Part Beach claim. Claims
                                                of                   ICD-9-CM codes, must be submitted with each claim. Claims
Documentation supporting medical necessity A this item, such asSNF-outpatient (HHA-A also)
                                                of                   ICD-9-CM codes,
Documentation supporting medical necessity A this item, such asClinic-rural health must be submitted with each claim. Claims
                                                of                   ICD-9-CM codes, provider based FQHC each claim.
Documentation supporting medical necessity A this item, such asClinic-independent must be submitted with(eff 10/91) Claims
                                                of                   ICD-9-CM codes, must be submitted with each hospital (eff
Documentation supporting medical necessity A this item, such asSpecial facility or ASC surgery-rural primary careclaim. Claims
                                                A                   Hospital-inpatient (including should
An appropriate diagnosis code must be submitted on the claim. The patient?s medical record Part A) indicate the signs/symptom
                                                A                   Hospital-inpatient or record should indicate B signs/symptom
An appropriate diagnosis code must be submitted on the claim. The patient?s medicalhome health visits (Parttheonly)
                                                A                   Hospital-outpatient (HHA-A should indicate the signs/symptom
An appropriate diagnosis code must be submitted on the claim. The patient?s medical record also) (under OPPS 13X must be u
                                                A                   Non-Patient medical record should
An appropriate diagnosis code must be submitted on the claim. The patient?s Laboratory Specimens indicate the signs/symptom
                                                A                   Hospital-swing beds
An appropriate diagnosis code must be submitted on the claim. The patient?s medical record should indicate the signs/symptom
                                                A                   SNF-inpatient, Part A
An appropriate diagnosis code must be submitted on the claim. The patient?s medical record should indicate the signs/symptom
                                                A                   SNF-inpatient or home health visits (Part B the
An appropriate diagnosis code must be submitted on the claim. The patient?s medical record should indicateonly)signs/symptom
                                                A                   SNF-outpatient (HHA-A also)
An appropriate diagnosis code must be submitted on the claim. The patient?s medical record should indicate the signs/symptom
                                                A                   Clinic-rural health
An appropriate diagnosis code must be submitted on the claim. The patient?s medical record should indicate the signs/symptom
                                                A                   Clinic-ORF only (eff record should CMHC the signs/symptom
An appropriate diagnosis code must be submitted on the claim. The patient?s medical4/97); ORF andindicate (10/91 - 3/97)
                                                A                   Clinic-CORF
An appropriate diagnosis code must be submitted on the claim. The patient?s medical record should indicate the signs/symptom
                                                A                   Special facility or ASC surgery-rural primary care hospital (eff
An appropriate diagnosis code must be submitted on the claim. The patient?s medical record should indicate the signs/symptom
                                                A                   Hospital-inpatient or home health visits (Part B only)
1. History and Physical Exam 2. Physician progress notes (or operative report) which document consistency with the patient?s
                                                A                   Hospital-outpatient (HHA-A also) (under OPPS the must be
1. History and Physical Exam 2. Physician progress notes (or operative report) which document consistency with13X patient?su
                                                A                   Special facility or ASC surgery-rural primary care hospital (eff
1. History and Physical Exam 2. Physician progress notes (or operative report) which document consistency with the patient?s
                                                A                   Hospital-inpatient or home the Botulinum toxin only)
Documentation should include the following elements: Support for the medical necessity of health visits (Part B injection A co
                                                A                   Hospital-outpatient (HHA-A also) (under toxin 13X must be u
Documentation should include the following elements: Support for the medical necessity of the BotulinumOPPS injection A co
                                                A                   SNF-inpatient, Part A
Documentation should include the following elements: Support for the medical necessity of the Botulinum toxin injection A co
                                                A                   SNF-inpatient necessity of the Botulinum toxin injection A co
Documentation should include the following elements: Support for the medical or home health visits (Part B only)
                                                A                   SNF-outpatient (HHA-A of the
Documentation should include the following elements: Support for the medical necessity also) Botulinum toxin injection A co
                                                A                   Clinic-rural health
Documentation should include the following elements: Support for the medical necessity of the Botulinum toxin injection A co
                                                 A                    Clinic-independent provider based FQHC (eff injection A co
Documentation should include the following elements: Support for the medical necessity of the Botulinum toxin10/91)
                                                 A                    Special facility or ASC surgery-rural primary care hospital (eff
Documentation should include the following elements: Support for the medical necessity of the Botulinum toxin injection A co
                                                 A                    Hospital-inpatient or home health visits (Part B only)
Claims submitted for indications which are generally not covered must include documentation that supports the medical necess
                                                 A                    Hospital-outpatient (HHA-A that (under OPPS 13X must be u
Claims submitted for indications which are generally not covered must include documentationalso) supports the medical necess
                                                 A                    Non-Patient documentation that supports the medical necess
Claims submitted for indications which are generally not covered must includeLaboratory Specimens
                                                 A                    Hospital-swing beds
Claims submitted for indications which are generally not covered must include documentation that supports the medical necess
                                                 A                    SNF-inpatient, Part A
Claims submitted for indications which are generally not covered must include documentation that supports the medical necess
                                                 A                    SNF-inpatient or home health visits (Part the medical necess
Claims submitted for indications which are generally not covered must include documentation that supportsB only)
                                                 A                    SNF-outpatient (HHA-A also)
Claims submitted for indications which are generally not covered must include documentation that supports the medical necess
                                                 A                    Clinic-rural health
Claims submitted for indications which are generally not covered must include documentation that supports the medical necess
                                                 A                    Clinic-independent provider that supports the medical
Claims submitted for indications which are generally not covered must include documentationbased FQHC (eff 10/91) necess
                                                 A                    Special facility or ASC surgery-rural primary care hospital (eff
Claims submitted for indications which are generally not covered must include documentation that supports the medical necess
                                                  a                   Hospital-inpatient (including Part A)
The medical records should clearly documentA current history and physical exam, M.D. orders/progress notes, medication adm
                                                  a                   Hospital-inpatient or home health visits notes, only)
The medical records should clearly documentA current history and physical exam, M.D. orders/progress (Part Bmedication adm
                                                  a                   Hospital-outpatient (HHA-A also) (under OPPS 13X must adm
The medical records should clearly documentA current history and physical exam, M.D. orders/progress notes, medication be u
                                                  a                   Hospital-swing beds
The medical records should clearly documentA current history and physical exam, M.D. orders/progress notes, medication adm
                                                  a                   Special facility or M.D. orders/progress notes, medication adm
The medical records should clearly documentA current history and physical exam, ASC surgery-rural primary care hospital (eff
                                                 A                     the specific screening test performed. All studies must have
The attending/consulting physician must supply a written order forHospital-inpatient or home health visits (Part B only)
                                                 A                     the specific screening test also) (under OPPS 13X must be u
The attending/consulting physician must supply a written order forHospital-outpatient (HHA-A performed. All studies must have
                                                 A                     the specific screening Specimens
The attending/consulting physician must supply a written order forNon-Patient Laboratorytest performed. All studies must have
                                                 A                     the specific screening health visits (Part B only)
The attending/consulting physician must supply a written order forSNF-inpatient or home test performed. All studies must have
                                                 A                     the specific screening also)
The attending/consulting physician must supply a written order forSNF-outpatient (HHA-Atest performed. All studies must have
                                                 A                     the specific screening test performed. All studies must have
The attending/consulting physician must supply a written order forClinic-rural health
                                                 A                     the specific screening test based FQHC (eff 10/91)
The attending/consulting physician must supply a written order forClinic-independent provider performed. All studies must have
                                                 A                     the specific screening test performed. All studies must have
The attending/consulting physician must supply a written order forSpecial facility or ASC surgery-rural primary care hospital (eff
                                                 A                    Hospital-inpatient (including Part A)
The medical record must substantiate the medical necessity for the use of infliximab by clearly indicating the clinical signs and s
                                                 A                    Hospital-inpatient or home health visits the clinical signs and s
The medical record must substantiate the medical necessity for the use of infliximab by clearly indicating (Part B only)
                                                 A                    Hospital-outpatient (HHA-A also) (under OPPS 13X must be s
The medical record must substantiate the medical necessity for the use of infliximab by clearly indicating the clinical signs and u
                                                 A                    Non-Patient Laboratory Specimens
The medical record must substantiate the medical necessity for the use of infliximab by clearly indicating the clinical signs and s
                                                 A                    Hospital-swing beds
The medical record must substantiate the medical necessity for the use of infliximab by clearly indicating the clinical signs and s
                                                 A                    SNF-inpatient, Part A
The medical record must substantiate the medical necessity for the use of infliximab by clearly indicating the clinical signs and s
                                                 A                    SNF-inpatient or home health visits (Part B only)
The medical record must substantiate the medical necessity for the use of infliximab by clearly indicating the clinical signs and s
                                                 A                    SNF-outpatient (HHA-A also)
The medical record must substantiate the medical necessity for the use of infliximab by clearly indicating the clinical signs and s
                                                 A                    Clinic-rural health
The medical record must substantiate the medical necessity for the use of infliximab by clearly indicating the clinical signs and s
                                                 A                    Special facility or ASC surgery-rural primary care hospital (eff
The medical record must substantiate the medical necessity for the use of infliximab by clearly indicating the clinical signs and s
                                                 A                    code submitted on the claim. The patient?s medical record u
Documentation supporting the medical necessity of the diagnosis Hospital-outpatient (HHA-A also) (under OPPS 13X must bem
                                                 A                    code submitted on the Specimens
Documentation supporting the medical necessity of the diagnosis Non-Patient Laboratoryclaim. The patient?s medical record m
                                                 A                    code submitted ASC claim. The patient?s medical record m
Documentation supporting the medical necessity of the diagnosis Special facility oron thesurgery-ambulatory surgical center (Di
                                                 A                    code submitted ASC claim. The patient?s care hospital (eff
Documentation supporting the medical necessity of the diagnosis Special facility oron thesurgery-rural primary medical record m
                                                 A                    Hospital-inpatient (including Part A)
The medical necessity for the test must be established in the patient?s medical record. The test must be ordered by the patien
                                                 A                    Hospital-inpatient or home test must be ordered by
The medical necessity for the test must be established in the patient?s medical record. The health visits (Part B only)the patien
                                                 A                    Hospital-outpatient (HHA-A also) (under OPPS by must be u
The medical necessity for the test must be established in the patient?s medical record. The test must be ordered13Xthe patien
                                                 A                    Hospital-swing beds
The medical necessity for the test must be established in the patient?s medical record. The test must be ordered by the patien
                                                 A                    Special facility or ASC surgery-rural be ordered hospital (eff
The medical necessity for the test must be established in the patient?s medical record. The test mustprimary careby the patien
                                                 A                    Hospital-outpatient (HHA-A also) (under OPPS to the partial
Certification Upon admission, a certification by the physician (M.D./D.O.) must be made that the patient admitted13X must be u
                                                 A                    Clinic-CMHC be 4/97)
Certification Upon admission, a certification by the physician (M.D./D.O.) must (effmade that the patient admitted to the partial
                                                 A                    Special must or ASC that the patient admitted to the partial
Certification Upon admission, a certification by the physician (M.D./D.O.) facilitybe madesurgery-rural primary care hospital (eff
                                                 ordering/referring physician, that provider must health visits (Part B only)
If the provider of the service is other than the A                    Hospital-inpatient or home maintain hard copy documentation
                                                 ordering/referring physician, that provider must maintain hard copy documentation
If the provider of the service is other than the A                    Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
                                                 ordering/referring physician, that provider must maintain hard copy documentation
If the provider of the service is other than the A                    Hospital-swing beds
                                                 ordering/referring physician, that provider must maintain hard copy documentation
If the provider of the service is other than the A                    SNF-inpatient, Part A
                                                 ordering/referring physician, that provider must maintain(Part B only)
If the provider of the service is other than the A                    SNF-inpatient or home health visits hard copy documentation
                                                 ordering/referring physician, that provider must maintain hard copy documentation
If the provider of the service is other than the A                    SNF-outpatient (HHA-A also)
                                                 ordering/referring physician, that provider must maintain hard copy documentation
If the provider of the service is other than the A                    Clinic-rural health
                                                 ordering/referring physician, that provider or independent hard copy documentation
If the provider of the service is other than the A                    Clinic-hospital based must maintain renal dialysis facility
                                                 ordering/referring physician, that provider must maintain hard copy documentation
If the provider of the service is other than the A                    Clinic-independent provider based FQHC (eff 10/91)
                                                 ordering/referring physician, that provider must maintain hard copy documentation
If the provider of the service is other than the A                    Clinic-CORF
                                                 ordering/referring physician,facility or ASCmust maintain primary care hospital (eff
If the provider of the service is other than the A                    Special that provider surgery-rural hard copy documentation
                                                 A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                 A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                 A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                 A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                 A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                 A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                 A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                 A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                 A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                 A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                 A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                 A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                 A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                 A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                 A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                 A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-hospital based or independent renal dialysis facility
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                 A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                 A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                 A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                A                Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                A                Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 to              Hospital-inpatient or home health visits (Part available
Information in the patient?s record is requiredA support the medical necessity of the procedure and should beB only) to Med
                                                 to              Hospital-outpatient procedure and should be available to Med
Information in the patient?s record is requiredA support the medical necessity of the(HHA-A also) (under OPPS 13X must be u
                                                 to              Special facility or ASC surgery-rural primary care hospital (eff
Information in the patient?s record is requiredA support the medical necessity of the procedure and should be available to Med
                                                and              Hospital-inpatient or home health at the request of a
All studies must have an interpretation on file A should be available for review. For studies done visits (Part B only) referring
                                                and              Hospital-outpatient studies done at the OPPS of a referring
All studies must have an interpretation on file A should be available for review. For(HHA-A also) (under request13X must be u
                                                and              Non-Patient Laboratory Specimens
All studies must have an interpretation on file A should be available for review. For studies done at the request of a referring
                                                and              Hospital-swing For
All studies must have an interpretation on file A should be available for review. beds studies done at the request of a referring
                                                and              SNF-inpatient, For studies done at the request of a referring
All studies must have an interpretation on file A should be available for review.Part A
                                                and              SNF-inpatient or home health visits the request
All studies must have an interpretation on file A should be available for review. For studies done at (Part B only)of a referring
                                                and              SNF-outpatient For studies done at the request of a referring
All studies must have an interpretation on file A should be available for review. (HHA-A also)
                                                and              Clinic-rural health
All studies must have an interpretation on file A should be available for review. For studies done at the request of a referring
                                                and              Clinic-independent studies done at the request of a
All studies must have an interpretation on file A should be available for review. Forprovider based FQHC (eff 10/91) referring
                                                and              Special facility For studies done at the request of a referring
All studies must have an interpretation on file A should be available for review.or ASC surgery-rural primary care hospital (eff
                                                A                Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                A                Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                A                SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                A                SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                A                Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                A                Clinic-CMHC in the patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained (eff 4/97)
                                                A                Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                A                Hospital-outpatient (HHA-A also) (under This 13X must be u
1.There must be medical documentation to support the condition for which HBO therapy is being provided.OPPSdocumentation
                                                A                Special facility therapy is being provided. This documentation
1.There must be medical documentation to support the condition for which HBO or ASC surgery-rural primary care hospital (eff
                                                A                Hospital-inpatient or home health visits (Part and must
Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, B only) be ma
                                                A                Hospital-outpatient patient's medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient's medical record, and must be ma
                                                A                SNF-inpatient, Part patient's medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                A                SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be ma
                                                A                SNF-outpatient the patient's
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also)medical record, and must be ma
                                                A                Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be ma
                                                A                Clinic-independent patient's medical record, 10/91)
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (effand must be ma
                                                A                Special facility or ASC surgery-rural primary and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient's medical record,care hospital (eff
                                                A                Hospital-inpatient (including Part A)
 Diagnostic Ultrasound & Echocardiography Certification and Accreditation (CPT Codes 76506-76999 & 93303-93350) All proc
                                                A                Hospital-inpatient or home health visits (Part B only)
 Diagnostic Ultrasound & Echocardiography Certification and Accreditation (CPT Codes 76506-76999 & 93303-93350) All proc
                                                A                Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
 Diagnostic Ultrasound & Echocardiography Certification and Accreditation (CPT Codes 76506-76999 & 93303-93350) All proc
                                                A                Non-Patient Laboratory Specimens
 Diagnostic Ultrasound & Echocardiography Certification and Accreditation (CPT Codes 76506-76999 & 93303-93350) All proc
                                                A                Hospital-swing Codes
 Diagnostic Ultrasound & Echocardiography Certification and Accreditation (CPT beds 76506-76999 & 93303-93350) All proc
                                                A                SNF-inpatient, Codes
 Diagnostic Ultrasound & Echocardiography Certification and Accreditation (CPT Part A 76506-76999 & 93303-93350) All proc
                                                A                SNF-inpatient or home health visits & 93303-93350) All proc
 Diagnostic Ultrasound & Echocardiography Certification and Accreditation (CPT Codes 76506-76999(Part B only)
                                                A                SNF-outpatient (HHA-A also)
 Diagnostic Ultrasound & Echocardiography Certification and Accreditation (CPT Codes 76506-76999 & 93303-93350) All proc
                                                A                Clinic-rural health
 Diagnostic Ultrasound & Echocardiography Certification and Accreditation (CPT Codes 76506-76999 & 93303-93350) All proc
                                                A                Clinic-hospital Codes 76506-76999 renal dialysis facility
 Diagnostic Ultrasound & Echocardiography Certification and Accreditation (CPTbased or independent & 93303-93350) All proc
                                                A                Special facility Codes 76506-76999 & 93303-93350) All (eff
 Diagnostic Ultrasound & Echocardiography Certification and Accreditation (CPTor ASC surgery-rural primary care hospital proc
                                                A                Hospital-inpatient or home health visits (Part and must
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record B only) be ma
                                                A                Hospital-outpatient patient?s medical record and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                Special facility or ASC surgery-rural primary and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical recordcare hospital (eff
                                                A                 Hospital-inpatient in the patient's visits (Part B only)
1. Evidence of symptomology, other than ICD-9 CM coding, should be documented or home health medical record. 2. Docum
                                                A                 Hospital-outpatient (HHA-A also) medical record. must be
1. Evidence of symptomology, other than ICD-9 CM coding, should be documented in the patient's (under OPPS 13X2. Documu
                                                A                 Hospital-swing beds
1. Evidence of symptomology, other than ICD-9 CM coding, should be documented in the patient's medical record. 2. Docum
                                                A                 SNF-inpatient, Part the
1. Evidence of symptomology, other than ICD-9 CM coding, should be documented inA patient's medical record. 2. Docum
                                                A                 SNF-inpatient or home health visits (Part record.
1. Evidence of symptomology, other than ICD-9 CM coding, should be documented in the patient's medicalB only) 2. Docum
                                                A                 SNF-outpatient (HHA-A patient's medical record. 2. Docum
1. Evidence of symptomology, other than ICD-9 CM coding, should be documented in the also)
                                                A                 Clinic-rural health
1. Evidence of symptomology, other than ICD-9 CM coding, should be documented in the patient's medical record. 2. Docum
                                                A                 Clinic-independent provider based FQHC record. 2.
1. Evidence of symptomology, other than ICD-9 CM coding, should be documented in the patient's medical (eff 10/91) Docum
                                                A                 Special facility or in the patient's medical record. 2. Docum
1. Evidence of symptomology, other than ICD-9 CM coding, should be documentedASC surgery-rural primary care hospital (eff
                                                and               Hospital-inpatient or home done visits request of a
All studies must have an interpretation on file A should be available for review. For studies healthat the (Part B only) referring
                                                and               Hospital-outpatient studies also) (under OPPS of a must be
All studies must have an interpretation on file A should be available for review. For (HHA-A done at the request 13X referring u
                                                and               Clinic-rural health
All studies must have an interpretation on file A should be available for review. For studies done at the request of a referring
                                                and               Clinic-independent studies based the request of a
All studies must have an interpretation on file A should be available for review. For providerdone atFQHC (eff 10/91)referring
                                                and               Special facility For studies done at primary care a referring
All studies must have an interpretation on file A should be available for review.or ASC surgery-rural the request ofhospital (eff
                                                A                 Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                A                 Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                 Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                 Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                A                 SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                A                 SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                 SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                A                 Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                 Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                A                 Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                A                 Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                A                 Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                 Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                 Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                A                 SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                A                 SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                 SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                A                 Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                 Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                A                 Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                A                 Hospital-inpatient or found in CMS Manual System,
Coverage criteria for outpatient therapy services and documentation requirements are home health visits (Part B only) Pub 100-
                                                A                 Hospital-outpatient (HHA-A also) (under OPPS 13X Pub be u
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, must100-
                                                A                 Hospital-swing beds
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                A                 SNF-inpatient, Part A
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                A                 SNF-inpatient or are found in visits (Part B only)
Coverage criteria for outpatient therapy services and documentation requirements home health CMS Manual System, Pub 100-
                                                A                 SNF-outpatient (HHA-A also)
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                A                 Clinic-rural health
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                A                 Clinic-independent provider based Manual System,
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS FQHC (eff 10/91)Pub 100-
                                                A                 Clinic-ORF only are found in CMS Manual (10/91 - 3/97)
Coverage criteria for outpatient therapy services and documentation requirements(eff 4/97); ORF and CMHC System, Pub 100-
                                                A                 Clinic-CORF
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                A                 Special facility or ASC surgery-rural primary care hospital (eff
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                A                 Hospital-outpatient (HHA-A also) made OPPS 13X the natur
 Initial Psychiatric Evaluation Upon admission, an evaluation by the physician (M.D./D.O.) must be (underto ascertain must be u
                                                A                 Special facility or ASC surgery-rural primary care hospital (eff
 Initial Psychiatric Evaluation Upon admission, an evaluation by the physician (M.D./D.O.) must be made to ascertain the natur
                                                A                 Hospital-outpatient (HHA-A also) (under OPPS 13X for the
Documentation in the patient's medical record must include: 1. The attending physician's order including "clock time"must beou
                                                A                 Special facility or ASC surgery-rural primary care hospital (eff
Documentation in the patient's medical record must include: 1. The attending physician's order including "clock time" for the o
                                                A                 Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                A                 Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                 Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                               A                 SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                               A                 SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                 SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                               A                 Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                 Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                               A                 Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                               A                 Hospital-inpatient or found in CMS Manual System,
Coverage criteria for outpatient therapy services and documentation requirements are home health visits (Part B only) Pub 100-
                                               A                 Hospital-outpatient (HHA-A also) (under OPPS 13X Pub be u
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, must100-
                                               A                 Hospital-swing beds
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                               A                 SNF-inpatient, Part A
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                               A                 SNF-inpatient or are found in visits (Part B only)
Coverage criteria for outpatient therapy services and documentation requirements home health CMS Manual System, Pub 100-
                                               A                 SNF-outpatient (HHA-A also)
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                               A                 Clinic-rural health
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                               A                 Clinic-independent provider based Manual System,
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS FQHC (eff 10/91)Pub 100-
                                               A                 Clinic-ORF only are found in CMS Manual (10/91 - 3/97)
Coverage criteria for outpatient therapy services and documentation requirements(eff 4/97); ORF and CMHC System, Pub 100-
                                               A                 Clinic-CORF
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                               A                 Special facility or ASC surgery-rural primary care hospital (eff
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                               A                 Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                               A                 Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                               A                 Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                               A                 SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                               A                 SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                 SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                               A                 Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                 Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                               A                 Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                               A                 Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                               A                 Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                               A                 Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                 Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                               A                 SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                               A                 SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                 SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                               A                 Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                 Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                               A                 Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                               A                 Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                               A                 Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                               A                 Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                               A                 Hospital-inpatient the patient?s medical record, and
1.Documentation supporting the medical necessity should be legible, maintained in or home health visits (Part B only) must be m
                                               A                 Hospital-outpatient (HHA-A also) (under OPPS and
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, 13X must be u    m
                                               A                 Non-Patient Laboratory Specimens
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                               A                 Hospital-swing in the
1.Documentation supporting the medical necessity should be legible, maintained beds patient?s medical record, and must be m
                                               A                 SNF-inpatient, in the
1.Documentation supporting the medical necessity should be legible, maintainedPart A patient?s medical record, and must be m
                                               A                 SNF-inpatient or the patient?s medical record, and must be m
1.Documentation supporting the medical necessity should be legible, maintained inhome health visits (Part B only)
                                               A                 SNF-outpatient (HHA-A also)
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                               A                 Clinic-rural health
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                               A                 Clinic-hospital in the patient?s medical record, and must
1.Documentation supporting the medical necessity should be legible, maintainedbased or independent renal dialysis facility be m
                                               A                 Clinic-independent provider based FQHC (eff 10/91)
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                               A                 Special facility in the surgery-rural primary care hospital be
1.Documentation supporting the medical necessity should be legible, maintainedor ASCpatient?s medical record, and must (effm
                                               A                 Hospital-outpatient (HHA-A also) (under OPPS 13X for the u
Documentation in the patient's medical record must include: 1. The attending physician's order including ?clock time?must beo
                                               A                 Special facility or ASC surgery-rural primary care hospital (eff
Documentation in the patient's medical record must include: 1. The attending physician's order including ?clock time? for the o
                                                 ordering /referring physician, that provider musthealth visits (Part B only) of the tes
If the provider of the service is other than the A                    Hospital-inpatient or home maintain documentation
                                                 ordering /referring physician, that provider must also) (under OPPS 13X must be u
If the provider of the service is other than the A                    Hospital-outpatient (HHA-A maintain documentation of the tes
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    Non-Patient Laboratory Specimens
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    Hospital-swing beds
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    SNF-inpatient, Part A
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    SNF-inpatient or home health visits (Part B only)
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    SNF-outpatient (HHA-A also)
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    Clinic-rural health
                                                 ordering /referring physician, that provideror independent renal dialysis facility tes
If the provider of the service is other than the A                    Clinic-hospital based must maintain documentation of the
                                                 ordering /referring physician, that provider must based FQHC (eff 10/91) of the tes
If the provider of the service is other than the A                    Clinic-independent provider maintain documentation
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    Special facility or ASC surgery-rural primary care hospital (eff
                                                 A                    Hospital-inpatient or found in CMS Manual System,
Coverage criteria for outpatient therapy services and documentation requirements are home health visits (Part B only) Pub 100-
                                                 A                    Hospital-outpatient (HHA-A also) (under OPPS 13X Pub be u
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, must100-
                                                 A                    Hospital-swing beds
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    SNF-inpatient, Part A
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    SNF-inpatient or are found in visits (Part B only)
Coverage criteria for outpatient therapy services and documentation requirements home health CMS Manual System, Pub 100-
                                                 A                    SNF-outpatient (HHA-A also)
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    HHA-other (Part are
Coverage criteria for outpatient therapy services and documentation requirements B) found in CMS Manual System, Pub 100-
                                                 A                    Clinic-rural health
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    Clinic-independent provider based Manual System,
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS FQHC (eff 10/91)Pub 100-
                                                 A                    Clinic-ORF only are found in CMS Manual (10/91 - 3/97)
Coverage criteria for outpatient therapy services and documentation requirements(eff 4/97); ORF and CMHC System, Pub 100-
                                                 A                    Clinic-CORF
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    Special facility or ASC surgery-rural primary care hospital (eff
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                 A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                 A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                 A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-hospital based or independent renal dialysis facility
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                 A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 A                    Hospital-inpatient or found in CMS Manual System,
Coverage criteria for outpatient therapy services and documentation requirements are home health visits (Part B only) Pub 100-
                                                 A                    Hospital-outpatient (HHA-A also) (under OPPS 13X Pub be u
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, must100-
                                                 A                    Hospital-swing beds
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    SNF-inpatient, Part A
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    SNF-inpatient or are found in visits (Part B only)
Coverage criteria for outpatient therapy services and documentation requirements home health CMS Manual System, Pub 100-
                                                 A                    SNF-outpatient (HHA-A also)
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    Clinic-rural health
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    Clinic-independent provider based Manual System,
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS FQHC (eff 10/91)Pub 100-
                                                 A                    Clinic-ORF only are found in CMS Manual (10/91 - 3/97)
Coverage criteria for outpatient therapy services and documentation requirements(eff 4/97); ORF and CMHC System, Pub 100-
                                                 A                    Clinic-CORF
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    Special facility or ASC surgery-rural primary care hospital (eff
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    Hospital-inpatient the patient?s medical record, and
1. Documentation supporting the medical necessity should be legible, maintained inor home health visits (Part B only) must be
                                                 A                    Hospital-outpatient (HHA-A also) (under record, and must be
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical OPPS 13X must be u
                                                 A                    Non-Patient Laboratory Specimens
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                                 A                    Hospital-swing in the
1. Documentation supporting the medical necessity should be legible, maintainedbeds patient?s medical record, and must be
                                                 A                    SNF-inpatient, Part A
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                                 A                    SNF-inpatient or home health visits (Part B only)
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                                 A                    SNF-outpatient in the patient?s
1. Documentation supporting the medical necessity should be legible, maintained (HHA-A also) medical record, and must be
                                             A                    Clinic-rural health
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                             A                    Clinic-independent provider based FQHC (eff 10/91)
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                             A                    Special facility or ASC surgery-rural primary care hospital be
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must(eff
                                             A                     the specific screening test performed. All studies must have
The attending/consulting physician must supply a written order forHospital-inpatient or home health visits (Part B only)
                                             A                     the specific screening test also) (under OPPS 13X must be u
The attending/consulting physician must supply a written order forHospital-outpatient (HHA-A performed. All studies must have
                                             A                     the specific screening Specimens
The attending/consulting physician must supply a written order forNon-Patient Laboratorytest performed. All studies must have
                                             A                     the specific screening health visits (Part B only)
The attending/consulting physician must supply a written order forSNF-inpatient or home test performed. All studies must have
                                             A                     the specific screening also)
The attending/consulting physician must supply a written order forSNF-outpatient (HHA-Atest performed. All studies must have
                                             A                     the specific screening test performed. All studies must have
The attending/consulting physician must supply a written order forClinic-rural health
                                             A                     the specific screening test based FQHC (eff 10/91)
The attending/consulting physician must supply a written order forClinic-independent provider performed. All studies must have
                                             A                     the specific screening test performed. All studies must have
The attending/consulting physician must supply a written order forSpecial facility or ASC surgery-rural primary care hospital (eff
                                             A                    Hospital-inpatient or necessity of this test. 2. only)
1. The patient?s medical record should include symptomatology indicating the medicalhome health visits (Part BThe ICD-9-CM
                                             A                    Hospital-outpatient (HHA-A also) this test. 2. The ICD-9-CM
1. The patient?s medical record should include symptomatology indicating the medical necessity of(under OPPS 13X must be u
                                             A                    Clinic-rural health
1. The patient?s medical record should include symptomatology indicating the medical necessity of this test. 2. The ICD-9-CM
                                             A                    Clinic-independent provider based FQHC (eff The ICD-9-CM
1. The patient?s medical record should include symptomatology indicating the medical necessity of this test. 2. 10/91)
                                             A                    Special facility or ASC surgery-rural primary care hospital (eff
1. The patient?s medical record should include symptomatology indicating the medical necessity of this test. 2. The ICD-9-CM
                                             A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                             A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                             A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                             A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                             A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                             A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                             A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                             A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                             A                    Clinic-hospital based or independent renal dialysis facility
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                             A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                             A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                             A                    Hospital-inpatient the patient?s medical record, and
1. Documentation supporting the medical necessity should be legible, maintained inor home health visits (Part B only) must be
                                             A                    Hospital-outpatient (HHA-A also) (under record, and must be
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical OPPS 13X must be u
                                             A                    SNF-inpatient or home health visits (Part B only)
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                             A                    SNF-outpatient in the patient?s
1. Documentation supporting the medical necessity should be legible, maintained (HHA-A also) medical record, and must be
                                             A                    Clinic-rural health
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                             A                    Clinic-independent provider based FQHC (eff 10/91)
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                             A                    Special facility or ASC surgery-rural primary care hospital be
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must(eff
                                             A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                             A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                             A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                             A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                             A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                             A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                             A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                             A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                             A                    Clinic-hospital based or independent renal dialysis facility
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                             A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                             A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                             A                    Hospital-inpatient or home health visits (Part B only)
Claims submitted for indications which are generally not covered must include documentation that supports the medical necess
                                             A                    Hospital-outpatient (HHA-A that (under OPPS 13X must be u
Claims submitted for indications which are generally not covered must include documentationalso) supports the medical necess
                                             A                    Non-Patient documentation that supports the medical necess
Claims submitted for indications which are generally not covered must includeLaboratory Specimens
                                             A                    Hospital-swing beds
Claims submitted for indications which are generally not covered must include documentation that supports the medical necess
                                             A                    SNF-inpatient, Part A
Claims submitted for indications which are generally not covered must include documentation that supports the medical necess
                                             A                    SNF-inpatient or home health visits (Part the medical necess
Claims submitted for indications which are generally not covered must include documentation that supportsB only)
                                             A                    SNF-outpatient (HHA-A also)
Claims submitted for indications which are generally not covered must include documentation that supports the medical necess
                                                 A                    Clinic-rural health
Claims submitted for indications which are generally not covered must include documentation that supports the medical necess
                                                 A                    Clinic-independent provider that supports the medical
Claims submitted for indications which are generally not covered must include documentationbased FQHC (eff 10/91) necess
                                                 A                    Special facility or ASC surgery-rural primary care hospital (eff
Claims submitted for indications which are generally not covered must include documentation that supports the medical necess
                                                 A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                 A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                 A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                 A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                 A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                 A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                 A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                 A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-hospital based or independent renal dialysis facility
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                 A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 A                     ordering/referring physician must clearly indicate the
1. The patient?s medical record documentation maintained by theHospital-inpatient or home health visits (Part B only) medica
                                                 A                     ordering/referring (HHA-A also) (under OPPS 13X must be
1. The patient?s medical record documentation maintained by theHospital-outpatient physician must clearly indicate the medicau
                                                 A                     ordering/referring
1. The patient?s medical record documentation maintained by theClinic-rural health physician must clearly indicate the medica
                                                 A                     ordering/referring provider must FQHC (eff 10/91)
1. The patient?s medical record documentation maintained by theClinic-independent physicianbased clearly indicate the medica
                                                 A                     ordering/referring physician must clearly indicate the medica
1. The patient?s medical record documentation maintained by theSpecial facility or ASC surgery-rural primary care hospital (eff
                                                 A                    Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
Initial Assessment/Evaluation: It may be reasonable and necessary for multiple clinicians to address a patient?s particular need
                                                 A                    Clinic-CORF
Initial Assessment/Evaluation: It may be reasonable and necessary for multiple clinicians to address a patient?s particular need
                                                 A                    Special facility or ASC surgery-rural patient?s particular need
Initial Assessment/Evaluation: It may be reasonable and necessary for multiple clinicians to address aprimary care hospital (eff
                                                 A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                 A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                 A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                 A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                 A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 A                    physician, that provider must maintain (Part B only)
1. If the provider of the service is other than the ordering/referringHospital-inpatient or home health visits hard copy documentat
                                                 A                    physician, that provider must maintain hard copy documentat
1. If the provider of the service is other than the ordering/referringHospital-outpatient (HHA-A also) (under OPPS 13X must be u
                                                 A                    physician, that provider must maintain hard copy documentat
1. If the provider of the service is other than the ordering/referringHospital-swing beds
                                                 A                    physician, that provider
1. If the provider of the service is other than the ordering/referringSNF-inpatient, Part A must maintain hard copy documentat
                                                 A                    physician, that provider must visits (Part B copy
1. If the provider of the service is other than the ordering/referringSNF-inpatient or home health maintain hardonly) documentat
                                                 A                    physician, that (HHA-A must
1. If the provider of the service is other than the ordering/referringSNF-outpatient provider also) maintain hard copy documentat
                                                 A                    physician, health
1. If the provider of the service is other than the ordering/referringClinic-rural that provider must maintain hard copy documentat
                                                 A                    physician, that provider must maintain hard copy facility
1. If the provider of the service is other than the ordering/referringClinic-hospital based or independent renal dialysisdocumentat
                                                 A                    physician, that provider must maintain hard copy documentat
1. If the provider of the service is other than the ordering/referringClinic-independent provider based FQHC (eff 10/91)
                                                 A                    physician, that
1. If the provider of the service is other than the ordering/referringClinic-CORF provider must maintain hard copy documentat
                                                 A                    physician, that provider must maintain hard care documentat
1. If the provider of the service is other than the ordering/referringSpecial facility or ASC surgery-rural primary copy hospital (eff
                                                A                   Hospital-outpatient (HHA-A also) (under OPPS to the partial
Certification Upon admission, a certification by the physician (M.D./D.O.) must be made that the patient admitted13X must be u
                                                A                   Clinic-CMHC be 4/97)
Certification Upon admission, a certification by the physician (M.D./D.O.) must (effmade that the patient admitted to the partial
                                                A                   Special must or ASC that the patient admitted to the partial
Certification Upon admission, a certification by the physician (M.D./D.O.) facilitybe madesurgery-rural primary care hospital (eff
                                                A                   Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                A                   Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                   Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                A                   SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                A                   SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                A                   Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   Clinic-hospital based or independent renal dialysis facility
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                A                   Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                A                   Hospital-inpatient or home health visits (Part B only)
1. Evidence of symptomatology, other than ICD-9-CM coding, should be documented in the patient?s medical record. 2. Docum
                                                A                   Hospital-outpatient in the patient?s medical record. 2. Docum
1. Evidence of symptomatology, other than ICD-9-CM coding, should be documented(HHA-A also) (under OPPS 13X must be u
                                                A                   Hospital-swing beds
1. Evidence of symptomatology, other than ICD-9-CM coding, should be documented in the patient?s medical record. 2. Docum
                                                A                   SNF-inpatient, Part in
1. Evidence of symptomatology, other than ICD-9-CM coding, should be documentedA the patient?s medical record. 2. Docum
                                                A                   SNF-inpatient or home health visits medical record. 2. Docum
1. Evidence of symptomatology, other than ICD-9-CM coding, should be documented in the patient?s (Part B only)
                                                A                   SNF-outpatient (HHA-A also)
1. Evidence of symptomatology, other than ICD-9-CM coding, should be documented in the patient?s medical record. 2. Docum
                                                A                   Clinic-rural health
1. Evidence of symptomatology, other than ICD-9-CM coding, should be documented in the patient?s medical record. 2. Docum
                                                A                   Clinic-independent provider based FQHC (eff 10/91)
1. Evidence of symptomatology, other than ICD-9-CM coding, should be documented in the patient?s medical record. 2. Docum
                                                A                   Special facility or ASC the patient?s medical record. 2. Docum
1. Evidence of symptomatology, other than ICD-9-CM coding, should be documented in surgery-rural primary care hospital (eff
                                                A                   Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
1.There must be medical documentation to support the condition for which HBO therapy is being given. This medical document
                                                A                   Special facility therapy is being given. This medical document
1.There must be medical documentation to support the condition for which HBO or ASC surgery-rural primary care hospital (eff
                                                 and                Hospital-inpatient or home health at the request of a
All studies must have an interpretation on file A should be available for review. For studies done visits (Part B only) referring
                                                 and                Hospital-outpatient studies done at the OPPS of a referring
All studies must have an interpretation on file A should be available for review. For(HHA-A also) (under request13X must be u
                                                 and                Non-Patient Laboratory Specimens
All studies must have an interpretation on file A should be available for review. For studies done at the request of a referring
                                                 and                Hospital-swing For
All studies must have an interpretation on file A should be available for review. beds studies done at the request of a referring
                                                 and                SNF-inpatient, For studies done at the request of a referring
All studies must have an interpretation on file A should be available for review.Part A
                                                 and                SNF-inpatient or home health visits the request
All studies must have an interpretation on file A should be available for review. For studies done at (Part B only)of a referring
                                                 and                SNF-outpatient For studies done at the request of a referring
All studies must have an interpretation on file A should be available for review. (HHA-A also)
                                                 and                Clinic-rural health
All studies must have an interpretation on file A should be available for review. For studies done at the request of a referring
                                                 and                Clinic-independent studies done at the request of a
All studies must have an interpretation on file A should be available for review. Forprovider based FQHC (eff 10/91) referring
                                                 and                Special facility For studies done at the request of a referring
All studies must have an interpretation on file A should be available for review.or ASC surgery-rural primary care hospital (eff
                                                A                   Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                A                   Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                   Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                A                   SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                A                   SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                A                   Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                A                   Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                A                   Hospital-inpatient For studies done at (Part B only)
1. All studies must have an interpretation on file and should be available for review. or home health visitsthe request of a referri
                                                A                   Hospital-outpatient (HHA-A also) (under OPPS 13X must be
1. All studies must have an interpretation on file and should be available for review. For studies done at the request of a referriu
                                                A                   Clinic-rural health
1. All studies must have an interpretation on file and should be available for review. For studies done at the request of a referri
                                                A                   Clinic-independent provider based FQHC request of
1. All studies must have an interpretation on file and should be available for review. For studies done at the(eff 10/91) a referri
                                                A                   Special facility or For studies done at the request of a referri
1. All studies must have an interpretation on file and should be available for review.ASC surgery-rural primary care hospital (eff
                                                A                   Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
 Psychiatric Evaluation The initial psychiatric evaluation with medical history and physical examination must be performed and p
                                                A                   Clinic-CMHC (eff 4/97)
 Psychiatric Evaluation The initial psychiatric evaluation with medical history and physical examination must be performed and p
                                                  A                   Special facility physical examination must be performed and
Psychiatric Evaluation The initial psychiatric evaluation with medical history and or ASC surgery-rural primary care hospital (effp
The medical necessity for and nature of eachA                         SNF-inpatient or documented by a (Part B only)
                                                   service or procedure must be clearlyhome health visits physician, and this physic
The medical necessity for and nature of eachA                         SNF-outpatient (HHA-A also)
                                                   service or procedure must be clearly documented by a physician, and this physic
                                                  A                    patient's medical (including Part A)
The ordering physician's documentation should be retained in theHospital-inpatient record. This documentation must appropria
                                                  A                    patient's medical or home health visits (Part B only)
The ordering physician's documentation should be retained in theHospital-inpatient record. This documentation must appropria
                                                  A                    patient's medical record. This documentation 13X appropria
The ordering physician's documentation should be retained in theHospital-outpatient (HHA-A also) (under OPPSmust must be u
                                                  A                    patient's medical record. This documentation must appropria
The ordering physician's documentation should be retained in theNon-Patient Laboratory Specimens
                                                  A                    patient's medical record. This documentation must appropria
The ordering physician's documentation should be retained in theHospital-swing beds
                                                  A                    patient's medical record. This documentation must appropria
The ordering physician's documentation should be retained in theSNF-inpatient, Part A
                                                  A                    patient's medical record. This documentation must appropria
The ordering physician's documentation should be retained in theSNF-inpatient or home health visits (Part B only)
                                                  A                    patient's medical record. This
The ordering physician's documentation should be retained in theSNF-outpatient (HHA-A also) documentation must appropria
                                                  A                    patient's medical
The ordering physician's documentation should be retained in theClinic-rural health record. This documentation must appropria
                                                  A                    patient's medical record. This documentation must appropria
The ordering physician's documentation should be retained in theSpecial facility or ASC surgery-rural primary care hospital (eff
                                                  A                   Hospital-inpatient (including Part A)
Documentation, such as ICD-9 diagnosis codes or comparable narrative, supporting the medical necessity of these tests must
                                                  A                   Hospital-outpatient (HHA-A also) (under OPPS 13X must be
Documentation, such as ICD-9 diagnosis codes or comparable narrative, supporting the medical necessity of these tests must u
                                                  A                   Hospital-swing beds
Documentation, such as ICD-9 diagnosis codes or comparable narrative, supporting the medical necessity of these tests must
                                                  A                   Hospital-inpatient (including examination. The patient's med
Hospital, outpatient, nursing facility or office records should clearly document the reason(s) forPart A)
                                                  A                   Hospital-inpatient or home health visits (Part B patient's med
Hospital, outpatient, nursing facility or office records should clearly document the reason(s) for examination. Theonly)
                                                  A                   Hospital-outpatient (HHA-A also) (under OPPS patient's be u
Hospital, outpatient, nursing facility or office records should clearly document the reason(s) for examination. The 13X mustmed
                                                  A                   Non-Patient Laboratory Specimens
Hospital, outpatient, nursing facility or office records should clearly document the reason(s) for examination. The patient's med
                                                  A                   Hospital-swing reason(s) for examination. The patient's med
Hospital, outpatient, nursing facility or office records should clearly document thebeds
                                                  A                   SNF-inpatient, reason(s) for examination. The patient's med
Hospital, outpatient, nursing facility or office records should clearly document thePart A
                                                  A                   SNF-inpatient or home health visits (Part B The
Hospital, outpatient, nursing facility or office records should clearly document the reason(s) for examination. only)patient's med
                                                  A                   SNF-outpatient reason(s) for
Hospital, outpatient, nursing facility or office records should clearly document the (HHA-A also) examination. The patient's med
                                                  A                   Clinic-rural the reason(s) for examination. The patient's med
Hospital, outpatient, nursing facility or office records should clearly documenthealth
                                                  A                   Special facility reason(s) for examination. care hospital (eff
Hospital, outpatient, nursing facility or office records should clearly document theor ASC surgery-rural primaryThe patient's med
                                                  A                   Hospital-outpatient (HHA-A also) for each non-coronary be u
The patient?s medical record must contain documentation that fully supports the medical necessity(under OPPS 13X mustvasc
                                                  A                   Non-Patient Laboratory necessity for
The patient?s medical record must contain documentation that fully supports the medical Specimens each non-coronary vasc
                                                  A                   Special facility medical necessity for each non-coronary (eff
The patient?s medical record must contain documentation that fully supports theor ASC surgery-rural primary care hospitalvasc
                                                  A                   Hospital-inpatient (including Part record and made available
All coverage criteria listed in Indications of Coverage must be documented in the patient?s medicalA)
                                                  A                   Hospital-outpatient (HHA-A also) record and made must be
All coverage criteria listed in Indications of Coverage must be documented in the patient?s medical(under OPPS 13X available u
                                                  A                   Hospital-swing patient?s medical record and made available
All coverage criteria listed in Indications of Coverage must be documented in the beds
                                                  A                   Special facility patient?s medical record and made available
All coverage criteria listed in Indications of Coverage must be documented in theor ASC surgery-rural primary care hospital (eff
                                                  A                   Hospital-outpatient not necessary for claims submission, be u
Patient?s clinical records must contain answers to the following questions. They are (HHA-A also) (under OPPS 13X must how
                                                  A                    test including the test results. Documentation such as history
The medical records must document the medical necessity of theHospital-inpatient (including Part A)
                                                  A                    test including the test results. Documentation only)
The medical records must document the medical necessity of theHospital-inpatient or home health visits (Part Bsuch as history
                                                  A                    test including the test results. Documentation such must be u
The medical records must document the medical necessity of theHospital-outpatient (HHA-A also) (under OPPS 13X as history
                                                  A                    test including the test results. Documentation such as history
The medical records must document the medical necessity of theNon-Patient Laboratory Specimens
                                                  A                    test including beds
The medical records must document the medical necessity of theHospital-swingthe test results. Documentation such as history
                                                  A                    test including Part A
The medical records must document the medical necessity of theSNF-inpatient,the test results. Documentation such as history
                                                  A                    test including the test health Documentation such as history
The medical records must document the medical necessity of theSNF-inpatient or homeresults. visits (Part B only)
                                                  A                    test including the test results.
The medical records must document the medical necessity of theSNF-outpatient (HHA-A also) Documentation such as history
                                                  A                    test including the
The medical records must document the medical necessity of theClinic-rural health test results. Documentation such as history
                                                  A                    test including or test surgery-rural primary care hospital (eff
The medical records must document the medical necessity of theSpecial facility theASC results. Documentation such as history
                                                  A                   Hospital-inpatient (including Part A)
The medical necessity for this test and the applicable results must be clearly documented in the patient?s record. The results o
                                                  A                   Hospital-inpatient or home health visits (Part B only)
The medical necessity for this test and the applicable results must be clearly documented in the patient?s record. The results o
                                                  A                   Hospital-outpatient (HHA-A also) (under OPPS The results u
The medical necessity for this test and the applicable results must be clearly documented in the patient?s record.13X must beo
                                                  A                   Non-Patient Laboratory in the patient?s record. The results o
The medical necessity for this test and the applicable results must be clearly documentedSpecimens
                                                  A                   Hospital-swing beds
The medical necessity for this test and the applicable results must be clearly documented in the patient?s record. The results o
                                                  A                   SNF-inpatient, Part A
The medical necessity for this test and the applicable results must be clearly documented in the patient?s record. The results o
                                                  A                   SNF-inpatient or home health patient?s B only)
The medical necessity for this test and the applicable results must be clearly documented in thevisits (Partrecord. The results o
                                                  A                   SNF-outpatient (HHA-A in the
The medical necessity for this test and the applicable results must be clearly documented also) patient?s record. The results o
                                                 A                   Clinic-rural documented in the patient?s record. The results o
The medical necessity for this test and the applicable results must be clearly health
                                                 A                   Special facility or ASC surgery-rural primary care hospital (eff
The medical necessity for this test and the applicable results must be clearly documented in the patient?s record. The results o
                                                 A                   Hospital-outpatient (HHA-A also) (under OPPS 13X must Any
Documentation to support medical necessity must include the following: 1. Documentation of the patient?s ocular history - be u
                                                 A                   for the medical necessity of Part A)
Documentation should include the following elements: * support Hospital-inpatient (including the Botulinum Toxin Type A injec
                                                 A                   for the medical necessity of the Botulinum Toxin Type
Documentation should include the following elements: * support Hospital-inpatient or home health visits (Part B only) A injec
                                                 A                   for the medical necessity of the Botulinum Toxin Type A injec
Documentation should include the following elements: * support Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
                                                 A                   for the medical necessity of the Botulinum Toxin Type A injec
Documentation should include the following elements: * support Non-Patient Laboratory Specimens
                                                 A                   for the medical necessity of the Botulinum Toxin Type A injec
Documentation should include the following elements: * support Hospital-swing beds
                                                 A                   for the medical necessity of the Botulinum Toxin Type A injec
Documentation should include the following elements: * support SNF-inpatient, Part A
                                                 A                   for the medical necessity of the Botulinum only)
Documentation should include the following elements: * support SNF-inpatient or home health visits (Part BToxin Type A injec
                                                 A                   for the medical (HHA-A also)
Documentation should include the following elements: * support SNF-outpatient necessity of the Botulinum Toxin Type A injec
                                                 A                   for the medical necessity of the Botulinum Toxin Type A injec
Documentation should include the following elements: * support Clinic-rural health
                                                 A                   for the medical necessity of the Botulinum dialysis facility
Documentation should include the following elements: * support Clinic-hospital based or independent renal Toxin Type A injec
                                                 A                   for the medical (eff 4/97); ORF and CMHC (10/91 - 3/97)
Documentation should include the following elements: * support Clinic-ORF onlynecessity of the Botulinum Toxin Type A injec
                                                 A                   for the medical
Documentation should include the following elements: * support Clinic-CORF necessity of the Botulinum Toxin Type A injec
                                                 A                   Hospital-outpatient (HHA-A also) for the cardiac catheterizati
The patient?s medical record must contain documentation that fully supports the medical necessity(under OPPS 13X must be u
                                                 A                   Non-Patient Laboratory necessity for
The patient?s medical record must contain documentation that fully supports the medical Specimens the cardiac catheterizati
                                                 A                   Special facility medical necessity for the cardiac hospital (eff
The patient?s medical record must contain documentation that fully supports theor ASC surgery-rural primary care catheterizati
                                                 A                   Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                   Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                   Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                 A                   SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                 A                   SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                   SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                 A                   Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                   Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                 A                   Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 the                 Hospital-inpatient indicate health visits (Part B only)
Medical record documentation maintained by A performing physician must clearly or home the medical necessity of the servic
                                                 the                 Hospital-outpatient (HHA-A also) (under OPPS 13X must be
Medical record documentation maintained by A performing physician must clearly indicate the medical necessity of the servicu
                                                 the                 Clinic-rural health
Medical record documentation maintained by A performing physician must clearly indicate the medical necessity of the servic
                                                 the                 Clinic-independent provider based FQHC (eff 10/91)
Medical record documentation maintained by A performing physician must clearly indicate the medical necessity of the servic
                                                 the                 Special facility or indicate the medical necessity hospital (eff
Medical record documentation maintained by A performing physician must clearlyASC surgery-rural primary care of the servic
                                                 A                   Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                   Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                   Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                   Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                 A                   Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 A                   Hospital-outpatient (HHA-A also) (under OPPS 13X must be t
The patient's medical record must contain documentation that fully supports the medical necessity for services included within u
                                                 A                   Clinic-CMHC (eff 4/97)
The patient's medical record must contain documentation that fully supports the medical necessity for services included within t
                                                 A                   Special facility or ASC necessity for services included within
The patient's medical record must contain documentation that fully supports the medical surgery-rural primary care hospital (efft
                                                 A                   Hospital-inpatient accurate Part A)
As always, it is the responsibility of the ambulance supplier to furnish complete and (includingdocumentation of the beneficiary's
                                                 A                   SNF-inpatient or home health visits (Part B only)
As always, it is the responsibility of the ambulance supplier to furnish complete and accurate documentation of the beneficiary's
                                                 A                   SNF-outpatient (HHA-A also)
As always, it is the responsibility of the ambulance supplier to furnish complete and accurate documentation of the beneficiary's
                                                 A                   Special facility or accurate documentation of the hospital (eff
As always, it is the responsibility of the ambulance supplier to furnish complete andASC surgery-rural primary care beneficiary's
                                                 A                   Hospital-inpatient or home health visits (Part B A.
I. Following is a list of the information that should be maintained and made available to Medicare upon request: only)Documen
                                                 A                   Hospital-outpatient to Medicare upon request: A. must be u
I. Following is a list of the information that should be maintained and made available (HHA-A also) (under OPPS 13X Documen
                                                 A                   Non-Patient Laboratory Specimens
I. Following is a list of the information that should be maintained and made available to Medicare upon request: A. Documen
                                                 A                   SNF-inpatient, Part A
I. Following is a list of the information that should be maintained and made available to Medicare upon request: A. Documen
                                                 A                   SNF-inpatient or home health visits (Part B only)
I. Following is a list of the information that should be maintained and made available to Medicare upon request: A. Documen
                                                 A                   SNF-outpatient (HHA-A also)
I. Following is a list of the information that should be maintained and made available to Medicare upon request: A. Documen
                                                 A                   Clinic-ORF only (eff 4/97); ORF upon request: A. 3/97)
I. Following is a list of the information that should be maintained and made available to Medicare and CMHC (10/91 - Documen
                                                 A                   Clinic-CORF
I. Following is a list of the information that should be maintained and made available to Medicare upon request: A. Documen
                                                 A                    Special facility or ASC surgery-rural primary care hospital (eff
I. Following is a list of the information that should be maintained and made available to Medicare upon request: A. Documen
                                                 A                    that direct skin
1.Medical records must be available upon request and document Not Applicable testing is impossible due to extensive dermatit
                                                 A                    Hospital-outpatient (HHA-A also) If so, then each clinician mu
It may be reasonable and necessary for multiple clinicians to address a patient?s particular needs. (under OPPS 13X must be u
                                                 A                    Clinic-CORF
It may be reasonable and necessary for multiple clinicians to address a patient?s particular needs. If so, then each clinician mu
                                                 A                    Special facility or ASC surgery-rural primary care clinician mu
It may be reasonable and necessary for multiple clinicians to address a patient?s particular needs. If so, then each hospital (eff
                                                 A                    Hospital-inpatient or home health visits (Part B only)
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for surgery in the inpatient ho
                                                 A                    Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for surgery in the inpatient ho
                                                 A                    Hospital-swing beds
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for surgery in the inpatient ho
                                                 A                    SNF-inpatient, Part A
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for surgery in the inpatient ho
                                                 A                    SNF-inpatient or home health visits surgery in the
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for (Part B only) inpatient ho
                                                 A                    SNF-outpatient (HHA-A also)
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for surgery in the inpatient ho
                                                 A                    Clinic-rural health
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for surgery in the inpatient ho
                                                 A                    Clinic-independent provider based surgery in the inpatient ho
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need forFQHC (eff 10/91)
                                                 A                    Special facility or ASC the need for primary care inpatient ho
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including surgery-rural surgery in thehospital (eff
                                                 A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                 A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                 A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                 A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                 A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 A                    Special facility in the surgery-hospice record, and based)
1.Documentation supporting the medical necessity should be legible, maintainedor ASCpatient?s medical(non-hospitalmust be m
                                                 A                    Special facility in the surgery-hospice record, based)
1.Documentation supporting the medical necessity should be legible, maintainedor ASCpatient?s medical(hospitaland must be m
                                                 A                    HHA-inpatient or home health medical record, and
1. Documentation supporting the medical necessity should be legible, maintainied inthe patient'svisits (Part B only) must be m
                                                 A                    HHA-outpatient inthe patient's
1. Documentation supporting the medical necessity should be legible, maintainied(HHA-A also) medical record, and must be m
                                                 A                    Not ICD-9 codes, must be submitted with each claim. Claims
Documentation supporting the medical necessity of this item, such as Applicable
                                                 A                    Not Applicable
The medical record must document signs and symptoms to support reasonable and necessary indications for performing a slee
                                                 A                    the Applicable
. Each claim must be submitted with ICD-9-CM codes that reflect Not condition of the patient, and indicate the reason(s) for whi
                                                 A                    Hospital-outpatient to respond adequately to conservative no
1. Documentation supporting the medical necessity of this item should include failure (HHA-A also) (under OPPS 13X must be u
                                                 A                    Hospital-swing beds
1. Documentation supporting the medical necessity of this item should include failure to respond adequately to conservative no
                                                 A                    SNF-inpatient, Part to
1. Documentation supporting the medical necessity of this item should include failure A respond adequately to conservative no
                                                 A                    SNF-inpatient or home health visits (Part B only)
1. Documentation supporting the medical necessity of this item should include failure to respond adequately to conservative no
                                                 A                    SNF-outpatient (HHA-A also)
1. Documentation supporting the medical necessity of this item should include failure to respond adequately to conservative no
                                                 A                    Clinic-rural health
1. Documentation supporting the medical necessity of this item should include failure to respond adequately to conservative no
                                                 A                    Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97)
1. Documentation supporting the medical necessity of this item should include failure to respond adequately to conservative no
                                                 A                    Clinic-CORF
1. Documentation supporting the medical necessity of this item should include failure to respond adequately to conservative no
                                                 A                    Special facility or ASC surgery-rural primary conservative no
1. Documentation supporting the medical necessity of this item should include failure to respond adequately tocare hospital (eff
                                                 A                    Hospital-inpatient or for the procedure (Part of the
1.The medical record must include the following documentation: a.That the indication home health visitsis one B only)following:
                                                 A                    Hospital-outpatient (HHA-A procedure is one of the must be
1.The medical record must include the following documentation: a.That the indication for the also) (under OPPS 13X following:u
                                                 A                    Hospital-swing beds
1.The medical record must include the following documentation: a.That the indication for the procedure is one of the following:
                                                 A                    SNF-inpatient, Part A
1.The medical record must include the following documentation: a.That the indication for the procedure is one of the following:
                                                 A                    SNF-inpatient or home the procedure is B only)
1.The medical record must include the following documentation: a.That the indication forhealth visits (Part one of the following:
                                                 A                    SNF-outpatient (HHA-A also)
1.The medical record must include the following documentation: a.That the indication for the procedure is one of the following:
                                                 A                    Special facility or ASC surgery-rural primary care hospital (eff
1.The medical record must include the following documentation: a.That the indication for the procedure is one of the following:
                                                  the                 Not Applicable
The patient?s medical record must documentA method of destruction or removal. Such documentation must, at a minimum,
                                                 A                    Not Applicable
The medical record must be made available to Medicare upon request. The HCPCS/CPT code(s) may be subject to Correct C
                                                  the                 Not Applicable
The patient?s medical record must documentA method of destruction or removal. Such documentation must, at a minimum,
                                                 A                    Not Applicable
The medical record must be made available to Medicare upon request. The HCPCS/CPT code(s) may be subject to Correct C
                                                 ordering /referring physician, that provider musthealth visits (Part B only) of the tes
If the provider of the service is other than the A                    Hospital-inpatient or home maintain documentation
                                                 ordering /referring physician, that provider must also) (under OPPS 13X must be u
If the provider of the service is other than the A                    Hospital-outpatient (HHA-A maintain documentation of the tes
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    Non-Patient Laboratory Specimens
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    Hospital-swing beds
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    SNF-inpatient, Part A
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    SNF-inpatient or home health visits (Part B only)
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    SNF-outpatient (HHA-A also)
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    Clinic-rural health
                                                 ordering /referring physician, that provideror independent renal dialysis facility tes
If the provider of the service is other than the A                    Clinic-hospital based must maintain documentation of the
                                                 ordering /referring physician, that provider must based FQHC (eff 10/91) of the tes
If the provider of the service is other than the A                    Clinic-independent provider maintain documentation
                                                 ordering /referring physician, that provider must maintain documentation of the tes
If the provider of the service is other than the A                    Special facility or ASC surgery-rural primary care hospital (eff
                                                 A                    Hospital-inpatient or found in CMS Manual System,
Coverage criteria for outpatient therapy services and documentation requirements are home health visits (Part B only) Pub 100-
                                                 A                    Hospital-outpatient (HHA-A also) (under OPPS 13X Pub be u
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, must100-
                                                 A                    Hospital-swing beds
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    SNF-inpatient, Part A
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    SNF-inpatient or are found in visits (Part B only)
Coverage criteria for outpatient therapy services and documentation requirements home health CMS Manual System, Pub 100-
                                                 A                    SNF-outpatient (HHA-A also)
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    HHA-other (Part are
Coverage criteria for outpatient therapy services and documentation requirements B) found in CMS Manual System, Pub 100-
                                                 A                    Clinic-rural health
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    Clinic-independent provider based Manual System,
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS FQHC (eff 10/91)Pub 100-
                                                 A                    Clinic-ORF only are found in CMS Manual (10/91 - 3/97)
Coverage criteria for outpatient therapy services and documentation requirements(eff 4/97); ORF and CMHC System, Pub 100-
                                                 A                    Clinic-CORF
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    Special facility or ASC surgery-rural primary care hospital (eff
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                 A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                 A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                 A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                 A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-hospital based or independent renal dialysis facility
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                 A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 A                    Not ICD-9 codes, must be submitted with each claim. Claims
Documentation supporting the medical necessity of this item, such as Applicable
                                                 A                    Not ICD-9 codes, must be submitted with each claim. Claims
Documentation supporting the medical necessity of this item, such as Applicable
                                                 A                    Not Applicable
The medical record must document signs and symptoms to support reasonable and necessary indications for performing a slee
                                                 A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                 A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                 A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                 A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                 A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                 A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                 A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                 A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                 A                    Hospital-inpatient or home health visits (Part B only)
1. History and Physical Exam 2. Physician progress notes (or operative report) which document consistency with the patient's s
                                                 A                    Hospital-outpatient (HHA-A also) (under OPPS the must be s
1. History and Physical Exam 2. Physician progress notes (or operative report) which document consistency with13X patient's u
                                                 A                    Special facility or ASC surgery-rural primary care hospital (eff
1. History and Physical Exam 2. Physician progress notes (or operative report) which document consistency with the patient's s
                                                 A
An ICD-9 code describing the patient's medical condition must beTBD    submitted with each claim. The medical record must docume
                                                 A                    Hospital-inpatient or found in CMS Manual System,
Coverage criteria for outpatient therapy services and documentation requirements are home health visits (Part B only) Pub 100-
                                                 A                    Hospital-outpatient (HHA-A also) (under OPPS 13X Pub be u
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, must100-
                                                 A                    Hospital-swing beds
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                A                   SNF-inpatient, Part A
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                A                   SNF-inpatient or are found in visits (Part B only)
Coverage criteria for outpatient therapy services and documentation requirements home health CMS Manual System, Pub 100-
                                                A                   SNF-outpatient (HHA-A also)
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                A                   HHA-other (Part are
Coverage criteria for outpatient therapy services and documentation requirements B) found in CMS Manual System, Pub 100-
                                                A                   Clinic-rural health
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                A                   Clinic-independent provider based Manual System,
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS FQHC (eff 10/91)Pub 100-
                                                A                   Clinic-ORF only are found in CMS Manual (10/91 - 3/97)
Coverage criteria for outpatient therapy services and documentation requirements(eff 4/97); ORF and CMHC System, Pub 100-
                                                A                   Clinic-CORF
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                A                   Special facility or ASC surgery-rural primary care hospital (eff
Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Manual System, Pub 100-
                                                A                   HHA-inpatient or must health visits (Part B only)
1.The plan of care must be written by and approved by the certifying physician and home be included in the patient's medical rec
                                                A                   HHA-outpatient (HHA-A also)
1.The plan of care must be written by and approved by the certifying physician and must be included in the patient's medical rec
                                                A                   Hospital-inpatient or home health visits (Part B only)
Documentation supporting the medical reasonableness and necessity of this test, such as ICD-9-CM code(s), must be submitte
                                                A                   Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
Documentation supporting the medical reasonableness and necessity of this test, such as ICD-9-CM code(s), must be submitte
                                                A                   Non-Patient Laboratory Specimens
Documentation supporting the medical reasonableness and necessity of this test, such as ICD-9-CM code(s), must be submitte
                                                A                   SNF-inpatient or home health visits code(s), must
Documentation supporting the medical reasonableness and necessity of this test, such as ICD-9-CM (Part B only) be submitte
                                                A                   SNF-outpatient such as ICD-9-CM code(s), must be submitte
Documentation supporting the medical reasonableness and necessity of this test,(HHA-A also)
                                                A                   Special facility or ASC surgery-rural primary must be submitte
Documentation supporting the medical reasonableness and necessity of this test, such as ICD-9-CM code(s), care hospital (eff
                                                A                   Hospital-inpatient or home health the beneficiary's condition t
It is the responsibility of the ambulance supplier to furnish complete and accurate documentation of visits (Part B only)
                                                A                   Hospital-outpatient (HHA-A also) the beneficiary's must be u
It is the responsibility of the ambulance supplier to furnish complete and accurate documentation of(under OPPS 13Xcondition t
                                                A                   SNF-inpatient or home health visits (Part B only)
It is the responsibility of the ambulance supplier to furnish complete and accurate documentation of the beneficiary's condition t
                                                A                   SNF-outpatient documentation
It is the responsibility of the ambulance supplier to furnish complete and accurate (HHA-A also) of the beneficiary's condition t
                                                A                   Special facility or ASC surgery-rural primary care hospital (eff
It is the responsibility of the ambulance supplier to furnish complete and accurate documentation of the beneficiary's condition t
                                                A                   Hospital-inpatient or home health visits surgery in an
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for the (Part B only) inpatien
                                                A                   Hospital-outpatient (HHA-A also) (under OPPS in an inpatien
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for the surgery 13X must be u
                                                A                   Hospital-swing beds
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for the surgery in an inpatien
                                                A                   SNF-inpatient, Part A
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for the surgery in an inpatien
                                                A                   SNF-inpatient or home health visits the surgery in
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for (Part B only) an inpatien
                                                A                   SNF-outpatient (HHA-A also)
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for the surgery in an inpatien
                                                A                   Clinic-rural health
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need for the surgery in an inpatien
                                                A                   Clinic-independent provider based the surgery in an
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including the need forFQHC (eff 10/91) inpatien
                                                A                   Special facility or ASC the need for primary care an inpatien
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, including surgery-rural the surgery inhospital (eff
N/A                                             A                   Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
                                                A                   Not ICD-9 codes, must be submitted with each claim. Claims
Documentation supporting the medical necessity of this item, such as Applicable
                                                A                   Not is used, the
  Zoledronic Acid for Osteoporosis When intravenous zoledronic acid Applicable medical record must clearly reflect that the p
                                                A                   must remain on file home health visits provider. Ambulance
1.Documentation of the need and circumstances for the services Hospital-inpatient orwith the ambulance (Part B only)
                                                A                   must remain on file with the ambulance OPPS 13X must be
1.Documentation of the need and circumstances for the services Hospital-outpatient (HHA-A also) (underprovider. Ambulance u
                                                A                   must remain on file with
1.Documentation of the need and circumstances for the services SNF-inpatient, Part A the ambulance provider. Ambulance
                                                A                   must remain on home the ambulance provider.
1.Documentation of the need and circumstances for the services SNF-inpatient orfile withhealth visits (Part B only) Ambulance
                                                A                   must remain on file with the ambulance provider. Ambulance
1.Documentation of the need and circumstances for the services SNF-outpatient (HHA-A also)
                                                A                   must remain on file with the ambulance provider. hospital (eff
1.Documentation of the need and circumstances for the services Special facility or ASC surgery-rural primary care Ambulance
                                                A                   Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                A                   Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                   Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                A                   Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                A                   Hospital-inpatient or home health status The only)
The patient's record must include the following: The patient's own assessment of his/her functionalvisits (Part Bresults of the a
                                                A                   Hospital-outpatient (HHA-A also) status The results of the
The patient's record must include the following: The patient's own assessment of his/her functional(under OPPS 13X must beau
                                                A                   Special facility or ASC surgery-rural primary care hospital (eff
The patient's record must include the following: The patient's own assessment of his/her functional status The results of the a
                                                A                   Hospital-inpatient his/her functional status The results
The patient?s record must include the following: The patient?s own assessment of or home health visits (Part B only) of the
                                                A                   Hospital-outpatient (HHA-A also) (under OPPS results of be
The patient?s record must include the following: The patient?s own assessment of his/her functional status The 13X must theu
                                                A                   Special facility of his/her functional primary care hospital (eff
The patient?s record must include the following: The patient?s own assessmentor ASC surgery-rural status The results of the
                                                A                   Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                A                   Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                   Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                A                   Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                A                   Hospital-inpatient operative reports, etc. which would
Physician?s order Medical record documentation (i.e., office notes, progress notes,or home health visits (Part B only) indicate
                                                A                   Hospital-outpatient (HHA-A reports, etc. which would indicate
Physician?s order Medical record documentation (i.e., office notes, progress notes, operativealso) (under OPPS 13X must be u
                                                A                   Non-Patient Laboratory Specimens
Physician?s order Medical record documentation (i.e., office notes, progress notes, operative reports, etc. which would indicate
                                                A                   SNF-inpatient, Part A
Physician?s order Medical record documentation (i.e., office notes, progress notes, operative reports, etc. which would indicate
                                                A                   SNF-inpatient or home health visits (Part which
Physician?s order Medical record documentation (i.e., office notes, progress notes, operative reports, etc. B only)would indicate
                                                A                   SNF-outpatient (HHA-A also)
Physician?s order Medical record documentation (i.e., office notes, progress notes, operative reports, etc. which would indicate
                                                A                   Clinic-rural notes,
Physician?s order Medical record documentation (i.e., office notes, progresshealth operative reports, etc. which would indicate
                                                A                   Clinic-hospital based or independent etc. which would indicate
Physician?s order Medical record documentation (i.e., office notes, progress notes, operative reports, renal dialysis facility
                                                A                   Clinic-CORF
Physician?s order Medical record documentation (i.e., office notes, progress notes, operative reports, etc. which would indicate
                                                A                   Special facility or ASC surgery-rural etc. which would indicate
Physician?s order Medical record documentation (i.e., office notes, progress notes, operative reports,primary care hospital (eff
                                                A                   Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                A                   Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                   Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                A                   SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                A                   SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                A                   Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                A                   Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                A                   Hospital-inpatient or home health and (Part B only)
The patient?s medical record must contain documentation that fully supports the medical necessity visitsfrequency for psychiatr
                                                A                   Hospital-outpatient (HHA-A also) and frequency for psychiatr
The patient?s medical record must contain documentation that fully supports the medical necessity(under OPPS 13X must be u
                                                A                   Clinic-rural the medical necessity and frequency for psychiatr
The patient?s medical record must contain documentation that fully supports health
                                                A                   Clinic-independent provider based FQHC (eff 10/91)
The patient?s medical record must contain documentation that fully supports the medical necessity and frequency for psychiatr
                                                A                   Clinic-CORF
The patient?s medical record must contain documentation that fully supports the medical necessity and frequency for psychiatr
                                                A                   Clinic-CMHC (eff 4/97)
The patient?s medical record must contain documentation that fully supports the medical necessity and frequency for psychiatr
                                                A                   Special facility medical necessity and frequency hospital (eff
The patient?s medical record must contain documentation that fully supports theor ASC surgery-rural primary care for psychiatr
                                                A                   Not Applicable
The medical record must document signs and symptoms to support reasonable and necessary indications for performing a slee
The surgeon's documentation in the patient's A                      Not Applicable
                                                medical record should be legible and support the medical necessity of this proced
The surgeon's documentation in the patient's A                      Not Applicable
                                                medical record should be legible and support the medical necessity of this proced
                                                P                   Not Applicable
Documentation Requirements: The medical record must clearly show that the criteria listed in ?Indications and Limitation of Co
                                                P                   Not Applicable
Documentation Requirements: The medical record must clearly show that the criteria listed in ?Indications and Limitation of Co
                                                A                   Hospital-inpatient the patient?s medical record. The
A physician order for all respiratory therapy intervention/service must be recorded inor home health visits (Part B only) order m
                                                A                   Hospital-outpatient (HHA-A also) (under record. The order m
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical OPPS 13X must be u
                                                A                   Hospital-swing beds
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical record. The order m
                                                A                   SNF-inpatient, Part A
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical record. The order m
                                                A                   SNF-inpatient or home health visits (Part B only)
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical record. The order m
                                                A                   SNF-outpatient in the patient?s medical record. The order m
A physician order for all respiratory therapy intervention/service must be recorded(HHA-A also)
                                                A                   Clinic-rural health
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical record. The order m
                                                A                   Clinic-independent provider based FQHC (eff 10/91)
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical record. The order m
                                                A                   Clinic-ORF only in the patient?s medical record. The order
A physician order for all respiratory therapy intervention/service must be recorded (eff 4/97); ORF and CMHC (10/91 - 3/97) m
                                                A                   Clinic-CORF
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical record. The order m
                                                A                   Special facility or ASC patient?s medical record. hospital (eff
A physician order for all respiratory therapy intervention/service must be recorded in the surgery-rural primary careThe order m
                                                A                   Special facility or ASC surgery-hospice (non-hospital based)
Documentation certifying terminal status must contain enough information to confirm terminal status upon review. Documentati
                                                A                   Special facility or ASC surgery-hospice (hospital based)
Documentation certifying terminal status must contain enough information to confirm terminal status upon review. Documentati
                                                A                   Hospital-inpatient the patient?s medical record. The
A physician order for all respiratory therapy intervention/service must be recorded inor home health visits (Part B only) order m
                                                A                   Hospital-outpatient (HHA-A also) (under record. The order m
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical OPPS 13X must be u
                                                A                   Hospital-swing beds
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical record. The order m
                                                A                   SNF-inpatient, Part A
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical record. The order m
                                                A                   SNF-inpatient or home health visits (Part B only)
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical record. The order m
                                                A                   SNF-outpatient in the patient?s medical record. The order m
A physician order for all respiratory therapy intervention/service must be recorded(HHA-A also)
                                                A                   Clinic-rural health
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical record. The order m
                                                A                   Clinic-independent provider based FQHC (eff 10/91)
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical record. The order m
                                                A                   Clinic-ORF only in the patient?s medical record. The order
A physician order for all respiratory therapy intervention/service must be recorded (eff 4/97); ORF and CMHC (10/91 - 3/97) m
                                                A                   Clinic-CORF
A physician order for all respiratory therapy intervention/service must be recorded in the patient?s medical record. The order m
                                                A                   Special facility or ASC patient?s medical record. hospital (eff
A physician order for all respiratory therapy intervention/service must be recorded in the surgery-rural primary careThe order m
                                                A                   Hospital-inpatient may result in denial (Part B only)
Documentation must be made available to Medicare upon request. Failure to do so,or home health visits of claims. Documenta
                                                A                   Hospital-outpatient (HHA-A also) (under claims. Documenta
Documentation must be made available to Medicare upon request. Failure to do so, may result in denial ofOPPS 13X must be u
                                                A                   Non-Patient Laboratory Specimens
Documentation must be made available to Medicare upon request. Failure to do so, may result in denial of claims. Documenta
                                                A                   SNF-inpatient so, may result visits (Part claims.
Documentation must be made available to Medicare upon request. Failure to door home health in denial of B only) Documenta
                                                A                   SNF-outpatient (HHA-A also)
Documentation must be made available to Medicare upon request. Failure to do so, may result in denial of claims. Documenta
                                                A                   Special facility so, may result in denial of claims. Documenta
Documentation must be made available to Medicare upon request. Failure to do or ASC surgery-rural primary care hospital (eff
                                                A                   describe the wound, describe the immunization status of the p
Documentation in the progress notes must identify the exposure, Not Applicable
                                                A                   describe the wound, describe the immunization status of the p
Documentation in the progress notes must identify the exposure, Not Applicable
                                                A                   describe the wound, describe the immunization status of the p
Documentation in the progress notes must identify the exposure, Not Applicable
                                                A                   describe the wound, describe the immunization status of the p
Documentation in the progress notes must identify the exposure, Not Applicable
                                                A                   Hospital-inpatient (including Part A)
The provider of the service must clearly document in the patient?s medical record that all requirements have been met and sup
                                                A                   Hospital-inpatient or all requirements have been met
The provider of the service must clearly document in the patient?s medical record thathome health visits (Part B only) and sup
                                                A                   Hospital-outpatient (HHA-A also) (under OPPS 13X must sup
The provider of the service must clearly document in the patient?s medical record that all requirements have been met and be u
                                                A                   Non-Patient Laboratory requirements
The provider of the service must clearly document in the patient?s medical record that all Specimens have been met and sup
                                                A                   Hospital-swing beds
The provider of the service must clearly document in the patient?s medical record that all requirements have been met and sup
                                                A                   SNF-inpatient, Part A
The provider of the service must clearly document in the patient?s medical record that all requirements have been met and sup
                                                A                   SNF-inpatient or home requirements have been
The provider of the service must clearly document in the patient?s medical record that allhealth visits (Part B only) met and sup
                                                A                   SNF-outpatient that all also)
The provider of the service must clearly document in the patient?s medical record(HHA-A requirements have been met and sup
                                                A                   Clinic-rural health
The provider of the service must clearly document in the patient?s medical record that all requirements have been met and sup
                                                A                   Clinic-hospital based or requirements have been met and
The provider of the service must clearly document in the patient?s medical record that all independent renal dialysis facility sup
                                                A                   Special facility or ASC surgery-rural primary care hospital sup
The provider of the service must clearly document in the patient?s medical record that all requirements have been met and (eff
                                                A                   Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                A                   Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                   Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                                A                   SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                                A                   SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                                A                   Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                A                   Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                A                   Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                                A                   Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                                A                   Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                                A                   Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                                A                   Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                                A                   Hospital-inpatient or home health the highest level of
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to visits (Part B only) specifici
                                                A                   Hospital-outpatient (HHA-A also) the highest level of specifici
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to(under OPPS 13X must be u
                                                A                   Non-Patient Laboratory coded to the
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM codesSpecimens highest level of specifici
                                                A                   Special facility or codes coded to the highest level of specifici
1. Documentation supporting the medical necessity of this item, such as ICD-9-CM ASC surgery-rural primary care hospital (eff
                                                A                   Hospital-inpatient or home health visits (Part B only)
The patient's medical record must contain documentation that fully supports the medical necessity and frequency for psychiatry
                                                A                   Hospital-outpatient (HHA-A also) (under OPPS for must be u
The patient's medical record must contain documentation that fully supports the medical necessity and frequency13Xpsychiatry
                                                A                   Clinic-rural health
The patient's medical record must contain documentation that fully supports the medical necessity and frequency for psychiatry
                                                A                   Clinic-independent provider based FQHC (eff 10/91)
The patient's medical record must contain documentation that fully supports the medical necessity and frequency for psychiatry
                                             A                   Clinic-CORF
The patient's medical record must contain documentation that fully supports the medical necessity and frequency for psychiatry
                                             A                   Clinic-CMHC (eff 4/97)
The patient's medical record must contain documentation that fully supports the medical necessity and frequency for psychiatry
                                             A                   Special facility or ASC necessity and frequency for psychiatry
The patient's medical record must contain documentation that fully supports the medical surgery-rural primary care hospital (eff
                                             A                   Hospital-inpatient or home submitted (Part B only)
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must behealth visitswith each claim. Claims
                                             A                   Hospital-outpatient (HHA-A submitted with each claim. Claims
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be also) (under OPPS 13X must be u
                                             A                   SNF-inpatient or home health visits (Part B only)
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                             A                   SNF-outpatient (HHA-A be submitted with each claim. Claims
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must also)
                                             A                   Clinic-rural codes,
 Documentation supporting the medical necessity of this item, such as ICD-9 health must be submitted with each claim. Claims
                                             A                   Clinic-hospital based or be submitted with each claim. Claims
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, mustindependent renal dialysis facility
                                             A                   Clinic-independent provider based FQHC each claim.
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with(eff 10/91) Claims
                                             A                   Special facility or ASC surgery-rural primary care hospital (eff
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                             A                   Hospital-inpatient or home submitted (Part B only)
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must behealth visitswith each claim. Claims
                                             A                   Hospital-outpatient (HHA-A submitted with each claim. Claims
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be also) (under OPPS 13X must be u
                                             A                   SNF-inpatient or home health visits (Part B only)
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                             A                   SNF-outpatient (HHA-A be submitted with each claim. Claims
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must also)
                                             A                   Clinic-rural codes,
 Documentation supporting the medical necessity of this item, such as ICD-9 health must be submitted with each claim. Claims
                                             A                   Clinic-hospital based or be submitted with each claim. Claims
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, mustindependent renal dialysis facility
                                             A                   Clinic-independent provider based FQHC each claim.
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with(eff 10/91) Claims
                                             A                   Special facility or ASC surgery-rural primary care hospital (eff
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                             A                   Hospital-inpatient or home submitted (Part B only)
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must behealth visitswith each claim. Claims
                                             A                   Hospital-outpatient (HHA-A submitted with each claim. Claims
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be also) (under OPPS 13X must be u
                                             A                   SNF-inpatient or home health visits (Part B only)
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                             A                   SNF-outpatient (HHA-A be submitted with each claim. Claims
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must also)
                                             A                   Clinic-rural codes,
 Documentation supporting the medical necessity of this item, such as ICD-9 health must be submitted with each claim. Claims
                                             A                   Clinic-hospital based or be submitted with each claim. Claims
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, mustindependent renal dialysis facility
                                             A                   Clinic-independent provider based FQHC each claim.
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with(eff 10/91) Claims
                                             A                   Special facility or ASC surgery-rural primary care hospital (eff
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                             A                   Hospital-inpatient or home submitted (Part B only)
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must behealth visitswith each claim. Claims
                                             A                   Hospital-outpatient (HHA-A submitted with each claim. Claims
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be also) (under OPPS 13X must be u
                                             A                   SNF-inpatient or home health visits (Part B only)
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                             A                   SNF-outpatient (HHA-A be submitted with each claim. Claims
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must also)
                                             A                   Clinic-rural codes,
 Documentation supporting the medical necessity of this item, such as ICD-9 health must be submitted with each claim. Claims
                                             A                   Clinic-hospital based or be submitted with each claim. Claims
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, mustindependent renal dialysis facility
                                             A                   Clinic-independent provider based FQHC each claim.
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with(eff 10/91) Claims
                                             A                   Special facility or ASC surgery-rural primary care hospital (eff
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                             A                     a. That the indication for health visits (Part B of the
1. The medical record must include the following documentation: Hospital-inpatient or homethe procedure is one only) followin
                                             A                     a. That the indication for the procedure is one 13X must be
1. The medical record must include the following documentation: Hospital-outpatient (HHA-A also) (under OPPS of the followinu
                                             A                     a. That the indication
1. The medical record must include the following documentation: Hospital-swing beds for the procedure is one of the followin
                                             A                     a. That the indication
1. The medical record must include the following documentation: SNF-inpatient, Part A for the procedure is one of the followin
                                             A                     a. That the indication health visits (Part B only)
1. The medical record must include the following documentation: SNF-inpatient or homefor the procedure is one of the followin
                                             A                     a. That the indication for the
1. The medical record must include the following documentation: SNF-outpatient (HHA-A also) procedure is one of the followin
                                             A                     a. That the indication for the procedure is one of the followin
1. The medical record must include the following documentation: Special facility or ASC surgery-rural primary care hospital (eff
                                             A                   Hospital-inpatient necessity of this test. The ICD-9-CM 784.0
The patient's medical record should include symptomatology indicating the medical or home health visits (Part B only)
                                             A                   Hospital-outpatient (HHA-A of this test. OPPS 13X must be u
The patient's medical record should include symptomatology indicating the medical necessity also) (under The ICD-9-CM 784.0
                                             A                   Clinic-rural health
The patient's medical record should include symptomatology indicating the medical necessity of this test. The ICD-9-CM 784.0
                                             A                   Clinic-independent provider of this test. The 10/91)
The patient's medical record should include symptomatology indicating the medical necessity based FQHC (effICD-9-CM 784.0
                                             A                   Special facility or necessity of this test. The ICD-9-CM 784.0
The patient's medical record should include symptomatology indicating the medicalASC surgery-rural primary care hospital (eff
                                             A                    listed as "covered" must provide written medical necessity do
1.Submissions of claims with an ICD-9-CM code other than thoseHospital-inpatient (including Part A)
                                             A                    listed as "covered" home health visits (Part B only)
1.Submissions of claims with an ICD-9-CM code other than thoseHospital-inpatient ormust provide written medical necessity do
                                             A                    listed as "covered" must provide written medical necessity do
1.Submissions of claims with an ICD-9-CM code other than thoseHospital-outpatient (HHA-A also) (under OPPS 13X must be u
                                             A                    listed as "covered" must provide written medical necessity do
1.Submissions of claims with an ICD-9-CM code other than thoseNon-Patient Laboratory Specimens
                                             A                    listed as "covered"
1.Submissions of claims with an ICD-9-CM code other than thoseHospital-swing bedsmust provide written medical necessity do
                                                  A                    listed as "covered" must provide written medical necessity do
1.Submissions of claims with an ICD-9-CM code other than thoseSNF-inpatient, Part A
                                                  A                    listed as "covered" must provide written B only)
1.Submissions of claims with an ICD-9-CM code other than thoseSNF-inpatient or home health visits (Part medical necessity do
                                                  A                    listed as "covered" must provide written medical necessity do
1.Submissions of claims with an ICD-9-CM code other than thoseSNF-outpatient (HHA-A also)
                                                  A                    listed as "covered"
1.Submissions of claims with an ICD-9-CM code other than thoseSNF-swing beds must provide written medical necessity do
                                                  A                    listed as "covered"
1.Submissions of claims with an ICD-9-CM code other than thoseClinic-rural health must provide written medical necessity do
                                                  A                    listed as "covered" must provide written medical necessity
1.Submissions of claims with an ICD-9-CM code other than thoseClinic-hospital based or independent renal dialysis facility do
                                                  A                    listed as "covered" 4/97); ORF and CMHC (10/91 - 3/97)
1.Submissions of claims with an ICD-9-CM code other than thoseClinic-ORF only (eff must provide written medical necessity do
                                                  A                    listed as "covered" must provide written medical necessity do
1.Submissions of claims with an ICD-9-CM code other than thoseClinic-CORF
                                                  A                    listed as "covered" must provide written medical necessity do
1.Submissions of claims with an ICD-9-CM code other than thoseSpecial facility or ASC surgery-ambulatory surgical center (Di
                                                  A                    listed as "covered" must provide written medical hospital (eff
1.Submissions of claims with an ICD-9-CM code other than thoseSpecial facility or ASC surgery-rural primary care necessity do
                                                  A                   Not ICD-9 codes, must be submitted with each claim. Claims
Documentation supporting the medical necessity of this item, such as Applicable
                                                  A                   Not ICD-9 codes, must be submitted with each claim. Claims
Documentation supporting the medical necessity of this item, such as Applicable
                                                  A                   Not ICD-9 codes, must be submitted with each claim. Claims
Documentation supporting the medical necessity of this item, such as Applicable
                                                  A                   Not ICD-9 codes, must be submitted with each claim. Claims
Documentation supporting the medical necessity of this item, such as Applicable
                                                  A                   Not Applicable
* Each claim must be submitted with an ICD-9 code(s) that reflects the condition of the patient and indicates the reason(s) for w
                                                  A                   Not Applicable
* Each claim must be submitted with an ICD-9 code(s) that reflects the condition of the patient and indicates the reason(s) for w
                                                  A                   Not Applicable
* Each claim must be submitted with an ICD-9 code(s) that reflects the condition of the patient and indicates the reason(s) for w
                                                  A                   Not Applicable
* Each claim must be submitted with an ICD-9 code(s) that reflects the condition of the patient and indicates the reason(s) for w
                                                  P                   Not Applicable
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                                  P                   Not Applicable
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                                  P                   Not Applicable
 Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                                  A                   Hospital-outpatient (HHA-A also) level of specificity,
1.Documentation supporting the medical necessity, such as ICD-9-CM codes coded to the highest (under OPPS 13X must be u                s
                                                  A                   Special facility or ASC surgery-rural primary care hospital be
1.Documentation supporting the medical necessity, such as ICD-9-CM codes coded to the highest level of specificity, must (effs
                                                  A                   Hospital-inpatient reason for the test(s) and the results. 2. T
1. Hospital, outpatient, nursing facility or office records should clearly document the(including Part A)
                                                  A                   Hospital-inpatient reason health visits (Part B only)
1. Hospital, outpatient, nursing facility or office records should clearly document theor home for the test(s) and the results. 2. T
                                                  A                   Hospital-outpatient (HHA-A also) test(s) OPPS 13X must be u
1. Hospital, outpatient, nursing facility or office records should clearly document the reason for the (under and the results. 2. T
                                                  A                   Non-Patient Laboratory Specimens
1. Hospital, outpatient, nursing facility or office records should clearly document the reason for the test(s) and the results. 2. T
                                                  A                   Hospital-swing beds
1. Hospital, outpatient, nursing facility or office records should clearly document the reason for the test(s) and the results. 2. T
                                                  A                   SNF-inpatient, the A
1. Hospital, outpatient, nursing facility or office records should clearly document Partreason for the test(s) and the results. 2. T
                                                  A                   SNF-inpatient the reason for visits (Part B only)
1. Hospital, outpatient, nursing facility or office records should clearly documentor home health the test(s) and the results. 2. T
                                                  A                   SNF-outpatient (HHA-A also)
1. Hospital, outpatient, nursing facility or office records should clearly document the reason for the test(s) and the results. 2. T
                                                  A                   SNF-swing beds
1. Hospital, outpatient, nursing facility or office records should clearly document the reason for the test(s) and the results. 2. T
                                                  A                   Clinic-rural health
1. Hospital, outpatient, nursing facility or office records should clearly document the reason for the test(s) and the results. 2. T
                                                  A                   Clinic-hospital the reason for the test(s) and the results.
1. Hospital, outpatient, nursing facility or office records should clearly document based or independent renal dialysis facility 2. T
                                                  A                   Clinic-independent provider based FQHC (eff 10/91)
1. Hospital, outpatient, nursing facility or office records should clearly document the reason for the test(s) and the results. 2. T
                                                  A                   Clinic-CORF
1. Hospital, outpatient, nursing facility or office records should clearly document the reason for the test(s) and the results. 2. T
                                                  A                   Special facility the reason for the test(s) and the results. (Di
1. Hospital, outpatient, nursing facility or office records should clearly document or ASC surgery-ambulatory surgical center2. T
                                                  A                   Special facility the reason for the test(s) and the hospital (eff
1. Hospital, outpatient, nursing facility or office records should clearly document or ASC surgery-rural primary careresults. 2. T
                                                  A                   Hospital-inpatient (including Part A)
1. Medical record documentation maintained by the treating physician must clearly document the medical necessity to initiate IV
                                                  A                   Hospital-outpatient (HHA-A the medical OPPS 13X initiate u
1. Medical record documentation maintained by the treating physician must clearly document also) (under necessity tomust beIV
                                                  A                   HHA-other (Part document the medical necessity to initiate IV
1. Medical record documentation maintained by the treating physician must clearlyB)
                                                  A                   the service was performed Part A)
1. Hospital, office or mobile unit records should clearly document Hospital-inpatient (includingby or under direct physician super
                                                  A                   the service was performed by or visits (Part physician super
1. Hospital, office or mobile unit records should clearly document Hospital-inpatient or home healthunder direct B only)
                                                  A                   the service was performed also) (under OPPS 13X must be
1. Hospital, office or mobile unit records should clearly document Hospital-outpatient (HHA-A by or under direct physician superu
                                                  A                   the service Laboratory Specimens
1. Hospital, office or mobile unit records should clearly document Non-Patientwas performed by or under direct physician super
                                                  A                   the service was performed by or under direct physician super
1. Hospital, office or mobile unit records should clearly document Clinic-rural health
                                                  A                   the service was performed based FQHC (eff 10/91)
1. Hospital, office or mobile unit records should clearly document Clinic-independent providerby or under direct physician super
                                                  A                   the service was performed by or under direct physician super
1. Hospital, office or mobile unit records should clearly document Special facility or ASC surgery-rural primary care hospital (eff
                                                  A                    approved stent was placed. 2.Documentation must reflect an
1.The medical record must contain information stating which FDAHospital-inpatient (including Part A)
                                                  A                    approved stent was placed. 2.Documentation only)
1.The medical record must contain information stating which FDAHospital-inpatient or home health visits (Part B must reflect an
                                                  A                    approved stent was placed. 2.Documentation 13X reflect an
1.The medical record must contain information stating which FDAHospital-outpatient (HHA-A also) (under OPPSmust must be u
                                                  A                    approved stent was placed. 2.Documentation must reflect an
1.The medical record must contain information stating which FDANon-Patient Laboratory Specimens
                                              A                      approved stent was
1.The medical record must contain information stating which FDAHospital-swing beds placed. 2.Documentation must reflect an
                                              A                      approved stent was
1.The medical record must contain information stating which FDASNF-inpatient, Part Aplaced. 2.Documentation must reflect an
                                              A                      approved stent home health visits (Part B only)
1.The medical record must contain information stating which FDASNF-inpatient orwas placed. 2.Documentation must reflect an
                                              A                      approved stent was placed.
1.The medical record must contain information stating which FDASNF-outpatient (HHA-A also)2.Documentation must reflect an
                                              A                      approved beds
1.The medical record must contain information stating which FDASNF-swingstent was placed. 2.Documentation must reflect an
                                              A                      approved health
1.The medical record must contain information stating which FDAClinic-rural stent was placed. 2.Documentation must reflect an
                                              A                      approved stent was or independent renal dialysis facility
1.The medical record must contain information stating which FDAClinic-hospital based placed. 2.Documentation must reflect an
                                              A                      approved stent was placed. 2.Documentation must
1.The medical record must contain information stating which FDAClinic-independent provider based FQHC (eff 10/91)reflect an
                                              A                      approved stent was placed. 2.Documentation must reflect an
1.The medical record must contain information stating which FDAClinic-CORF
                                              A                      approved stent ASC surgery-ambulatory surgical reflect an
1.The medical record must contain information stating which FDASpecial facility orwas placed. 2.Documentation mustcenter (Di
                                              A                      approved stent ASC surgery-rural primary care hospital (eff
1.The medical record must contain information stating which FDASpecial facility orwas placed. 2.Documentation must reflect an
1. Hospital, outpatient or independent cardiacA                    Hospital-inpatient (including Part A)
                                               catheterization laboratory records should support rationale for the performance o
1. Hospital, outpatient or independent cardiacA                    Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
                                               catheterization laboratory records should support rationale for the performance o
                                              A                    Hospital-inpatient (including Part A)
1.Documentation in the progress notes must reflect the medical necessity for the MRI. 2.In order for an MRI to be covered for a
                                              A                    Hospital-outpatient (HHA-A also) (under OPPS covered be u
1.Documentation in the progress notes must reflect the medical necessity for the MRI. 2.In order for an MRI to be13X must for a
                                              A                    Special for the MRI. 2.In order for an MRI to be covered (Di
1.Documentation in the progress notes must reflect the medical necessityfacility or ASC surgery-ambulatory surgical centerfor a
                                              A                    Special for the MRI. 2.In order for an MRI to be hospital (eff
1.Documentation in the progress notes must reflect the medical necessityfacility or ASC surgery-rural primary carecovered for a
                                              A                     the general medical care. Submit the
1. The medical record must identify the physician responsbile for Hospital-inpatient (including Part A) date the patient was la
                                              A                     the general medical care. Submit the (Part B patient
1. The medical record must identify the physician responsbile for Hospital-inpatient or home health visitsdate the only) was la
                                              A                     the general medical care. also) (under OPPS 13X must be
1. The medical record must identify the physician responsbile for Hospital-outpatient (HHA-ASubmit the date the patient was lau
                                              A                     the general Laboratory Specimens
1. The medical record must identify the physician responsbile for Non-Patient medical care. Submit the date the patient was la
                                              A                     the general medical
1. The medical record must identify the physician responsbile for Hospital-swing beds care. Submit the date the patient was la
                                              A                     the general medical care. Submit the date the patient was la
1. The medical record must identify the physician responsbile for SNF-inpatient, Part A
                                              A                     the general medical care. Submit (Part B the patient was la
1. The medical record must identify the physician responsbile for SNF-inpatient or home health visitsthe date only)
                                              A                     the general medical care. Submit the date the patient was la
1. The medical record must identify the physician responsbile for SNF-outpatient (HHA-A also)
                                              A                     the general medical care. Submit the date the patient was la
1. The medical record must identify the physician responsbile for SNF-swing beds
                                              A                     the general medical care. Submit the date only)
1. The medical record must identify the physician responsbile for HHA-inpatient or home health visits (Part B the patient was la
                                              A                     the general medical care. Submit the date the patient was la
1. The medical record must identify the physician responsbile for HHA-outpatient (HHA-A also)
                                              A                     the general medical
1. The medical record must identify the physician responsbile for HHA-other (Part B) care. Submit the date the patient was la
                                              A                     the general medical
1. The medical record must identify the physician responsbile for Clinic-rural health care. Submit the date the patient was la
                                              A                     the general medical care. based FQHC (eff 10/91)
1. The medical record must identify the physician responsbile for Clinic-independent providerSubmit the date the patient was la
                                              A                     the general medical care. Submit the date (10/91 - 3/97)
1. The medical record must identify the physician responsbile for Clinic-ORF only (eff 4/97); ORF and CMHC the patient was la
                                              A                     the general
1. The medical record must identify the physician responsbile for Clinic-CORFmedical care. Submit the date the patient was la
                                              A                     the general medical care. Submit the date the patient was la
1. The medical record must identify the physician responsbile for Clinic-CMHC (eff 4/97)
                                              A                     the general medical care. Submit the date the patient was la
1. The medical record must identify the physician responsbile for Special facility or ASC surgery-ambulatory surgical center (Di
                                              A                     the general medical care. Submit the date care hospital (eff
1. The medical record must identify the physician responsbile for Special facility or ASC surgery-rural primarythe patient was la
                                              A                    Hospital-inpatient (including Part A)
1. Hospital, outpatient, or independent cardiac catheterization laboratory records should clearly document the reason for the pro
                                              A                    Hospital-inpatient or home health visits the B only)
1. Hospital, outpatient, or independent cardiac catheterization laboratory records should clearly document(Partreason for the pro
                                              A                    Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
1. Hospital, outpatient, or independent cardiac catheterization laboratory records should clearly document the reason for the pro
                                              A                    Non-Patient Laboratory Specimens
1. Hospital, outpatient, or independent cardiac catheterization laboratory records should clearly document the reason for the pro
                                              A                    Hospital-swing should
1. Hospital, outpatient, or independent cardiac catheterization laboratory records beds clearly document the reason for the pro
                                              A                    SNF-inpatient, should
1. Hospital, outpatient, or independent cardiac catheterization laboratory records Part A clearly document the reason for the pro
                                              A                    SNF-inpatient should health visits (Part B reason for the pro
1. Hospital, outpatient, or independent cardiac catheterization laboratory recordsor homeclearly document theonly)
                                              A                    SNF-outpatient (HHA-A also)
1. Hospital, outpatient, or independent cardiac catheterization laboratory records should clearly document the reason for the pro
                                              A                    SNF-swing beds
1. Hospital, outpatient, or independent cardiac catheterization laboratory records should clearly document the reason for the pro
                                              A                    Clinic-rural health
1. Hospital, outpatient, or independent cardiac catheterization laboratory records should clearly document the reason for the pro
                                              A                    Clinic-hospital should clearly document the reason for the
1. Hospital, outpatient, or independent cardiac catheterization laboratory recordsbased or independent renal dialysis facility pro
                                              A                    Clinic-ORF only (eff 4/97); ORF and CMHC reason 3/97)
1. Hospital, outpatient, or independent cardiac catheterization laboratory records should clearly document the (10/91 -for the pro
                                              A                    Clinic-CORF
1. Hospital, outpatient, or independent cardiac catheterization laboratory records should clearly document the reason for the pro
                                              A                    Special facility should clearly document the reason for the pro
1. Hospital, outpatient, or independent cardiac catheterization laboratory recordsor ASC surgery-ambulatory surgical center (Di
                                              A                    Special facility should clearly document the care hospital (eff
1. Hospital, outpatient, or independent cardiac catheterization laboratory recordsor ASC surgery-rural primary reason for the pro
                                              A                    Hospital-inpatient (including Part A)
1. The patient?s medical record should document the medical necessity of the procedure. 2. Documentation supporting the me
                                              A                    Hospital-inpatient or home Documentation B only)
1. The patient?s medical record should document the medical necessity of the procedure. 2.health visits (Partsupporting the me
                                              A                    Hospital-outpatient (HHA-A Documentation supporting the me
1. The patient?s medical record should document the medical necessity of the procedure. 2. also) (under OPPS 13X must be u
                                              A                    Non-Patient procedure. 2. Documentation supporting the me
1. The patient?s medical record should document the medical necessity of theLaboratory Specimens
                                              A                    Hospital-swing beds
1. The patient?s medical record should document the medical necessity of the procedure. 2. Documentation supporting the me
                                              A                    SNF-inpatient, Part A
1. The patient?s medical record should document the medical necessity of the procedure. 2. Documentation supporting the me
                                              A                    SNF-inpatient or home health visits (Part B supporting the me
1. The patient?s medical record should document the medical necessity of the procedure. 2. Documentation only)
                                              A                    SNF-outpatient (HHA-A 2. Documentation supporting the me
1. The patient?s medical record should document the medical necessity of the procedure.also)
                                              A                    SNF-swing beds
1. The patient?s medical record should document the medical necessity of the procedure. 2. Documentation supporting the me
                                              A                    Clinic-rural health
1. The patient?s medical record should document the medical necessity of the procedure. 2. Documentation supporting the me
                                              A                    Clinic-hospital based or 2. Documentation supporting the
1. The patient?s medical record should document the medical necessity of the procedure.independent renal dialysis facility me
                                              A                    Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97)
1. The patient?s medical record should document the medical necessity of the procedure. 2. Documentation supporting the me
                                              A                    Clinic-CORF
1. The patient?s medical record should document the medical necessity of the procedure. 2. Documentation supporting the me
                                              A                    Special facility or ASC surgery-ambulatory surgical center me
1. The patient?s medical record should document the medical necessity of the procedure. 2. Documentation supporting the(Di
                                              A                    Special facility or ASC surgery-rural primary care hospital (eff
1. The patient?s medical record should document the medical necessity of the procedure. 2. Documentation supporting the me
                                              A                    Hospital-inpatient (including Part A)
1.Since you cannot accurately code the conditions listed under "Indications and Limitations," their presence must be thoroughly
                                              A                    Hospital-outpatient (HHA-A also) (under OPPS be thoroughly
1.Since you cannot accurately code the conditions listed under "Indications and Limitations," their presence must 13X must be u
                                              A                    Special facility or ASC surgery-rural primary care hospital (eff
1.Since you cannot accurately code the conditions listed under "Indications and Limitations," their presence must be thoroughly
                                              A                    should clearly document the pertinent
1.Hospital, outpatient, ASC or office records or procedure reports Hospital-inpatient (including Part A) history and physical ex
                                              A                    should clearly document the pertinent history and physical ex
1.Hospital, outpatient, ASC or office records or procedure reports Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
                                              A                    should clearly document the visits (Part B only)
1.Hospital, outpatient, ASC or office records or procedure reports SNF-inpatient or home healthpertinent history and physical ex
                                              A                    should clearly (HHA-A also)
1.Hospital, outpatient, ASC or office records or procedure reports SNF-outpatientdocument the pertinent history and physical ex
                                              A                    should clearly
1.Hospital, outpatient, ASC or office records or procedure reports Clinic-CORF document the pertinent history and physical ex
                                              A                    should facility document the pertinent history and center ex
1.Hospital, outpatient, ASC or office records or procedure reports Special clearly or ASC surgery-ambulatory surgicalphysical(Di
                                              A                    should facility document the pertinent history and physical ex
1.Hospital, outpatient, ASC or office records or procedure reports Special clearly or ASC surgery-rural primary care hospital (eff
                                              A                    trigger point. 2. Identification of A)
1. Documentation of proper evaluation leading to diagnosis of the Hospital-inpatient (including Part the affected muscle(s). 3. D
                                              A                    trigger point. 2. Identification of the affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the Hospital-inpatient or home health visits (Part B only)
                                              A                    trigger point. 2. Identification of (under OPPS 13X must be u
1. Documentation of proper evaluation leading to diagnosis of the Hospital-outpatient (HHA-A also)the affected muscle(s). 3. D
                                              A                    trigger point. 2. Identification of the
1. Documentation of proper evaluation leading to diagnosis of the Non-Patient Laboratory Specimens affected muscle(s). 3. D
                                              A                    trigger point. 2. Identification of I
1. Documentation of proper evaluation leading to diagnosis of the Hospital-intermediate care - levelthe affected muscle(s). 3. D
                                              A                    trigger point. 2. Identification of II
1. Documentation of proper evaluation leading to diagnosis of the Hospital-intermediate care - levelthe affected muscle(s). 3. D
                                              A                    trigger point. 2. Identification of III
1. Documentation of proper evaluation leading to diagnosis of the Hospital-intermediate care - levelthe affected muscle(s). 3. D
                                              A                    trigger point. beds
1. Documentation of proper evaluation leading to diagnosis of the Hospital-swing2. Identification of the affected muscle(s). 3. D
                                              A                    trigger point. 2. Identification of the affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the Hospital-reserved for national assignment
                                              A                    trigger point. or home health of the affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the SNF-inpatient 2. Identification visits (Part B only)
                                              A                    trigger point. 2. Identification
1. Documentation of proper evaluation leading to diagnosis of the SNF-outpatient (HHA-A also) of the affected muscle(s). 3. D
                                              A                    trigger point. 2. Identification of the affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the SNF-other (Part B)
                                              A                    trigger point. 2. Identification of
1. Documentation of proper evaluation leading to diagnosis of the SNF-intermediate care - level I the affected muscle(s). 3. D
                                              A                    trigger point. 2. Identification of
1. Documentation of proper evaluation leading to diagnosis of the SNF-intermediate care - level II the affected muscle(s). 3. D
                                              A                    trigger point. 2. Identification of
1. Documentation of proper evaluation leading to diagnosis of the SNF-intermediate care - level III the affected muscle(s). 3. D
                                              A                    trigger point. 2.
1. Documentation of proper evaluation leading to diagnosis of the SNF-swing beds Identification of the affected muscle(s). 3. D
                                              A                    trigger point. for national assignment
1. Documentation of proper evaluation leading to diagnosis of the SNF-reserved 2. Identification of the affected muscle(s). 3. D
                                              A                    trigger point. (including Part of
1. Documentation of proper evaluation leading to diagnosis of the HHA-inpatient 2. Identification A) the affected muscle(s). 3. D
                                              A                    trigger point. or home health visits affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the HHA-inpatient 2. Identification of the (Part B only)
                                              A                    trigger point. 2. Identification
1. Documentation of proper evaluation leading to diagnosis of the HHA-outpatient (HHA-A also) of the affected muscle(s). 3. D
                                              A                    trigger point. 2. Identification of the affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the HHA-other (Part B)
                                              A                    trigger point. 2. Identification I
1. Documentation of proper evaluation leading to diagnosis of the HHA-intermediate care - level of the affected muscle(s). 3. D
                                              A                    trigger point. 2. Identification II
1. Documentation of proper evaluation leading to diagnosis of the HHA-intermediate care - level of the affected muscle(s). 3. D
                                              A                    trigger point. 2. Identification III
1. Documentation of proper evaluation leading to diagnosis of the HHA-intermediate care - level of the affected muscle(s). 3. D
                                              A                    trigger point. 2.
1. Documentation of proper evaluation leading to diagnosis of the HHA-swing bedsIdentification of the affected muscle(s). 3. D
                                              A                    trigger point. for national assignment
1. Documentation of proper evaluation leading to diagnosis of the HHA-reserved2. Identification of the affected muscle(s). 3. D
                                              A                    trigger point. 2. Identification of the affected (RNHCI) hospita
1. Documentation of proper evaluation leading to diagnosis of the Religious Nonmedical Health Care Institution muscle(s). 3. D
                                              A                    trigger hospital-inpatient or home health visits (Part B only)
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger hospital-outpatient (HHA-A also)
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger hospital-other (Part B)
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger hospital-intermediate of the affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identificationcare - level I
                                            A                      trigger hospital-intermediate of the affected
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identificationcare - level II muscle(s). 3. D
                                            A                      trigger hospital-intermediate of the affected
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identificationcare - level III muscle(s). 3. D
                                            A                      trigger hospital-swing beds
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger hospital-reserved for national assignment
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger point. 2. Identification of the affected OBSOLETE eff
1. Documentation of proper evaluation leading to diagnosis of the CS extended care-inpatient (including Part A)muscle(s). 3. D
                                            A                      trigger extended care-inpatient the affected muscle(s). 3.
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identification ofor home health visits (Part BD
                                            A                      trigger extended care-outpatient (HHA-A also) (eff. 7/00); prio
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger extended care-other (Part B)(eff. 7/00); prior to 7/00 re
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger extended care-intermediate affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identification of the care - level I (eff. 7/00) pr
                                            A                      trigger extended care-intermediate affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identification of the care - level II (eff. 7/00) p
                                            A                      trigger extended care-intermediate affected muscle(s). 3. p
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identification of the care - level III (eff. 7/00) D
                                            A                      trigger extended care-swing of the affected muscle(s). refe
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identificationbeds (eff. 7/00) prior to 7/00 3. D
                                            A                      trigger extended care-reserved the affected muscle(s). 3. 7
1. Documentation of proper evaluation leading to diagnosis of the RNHCI point. 2. Identification of for national assignment (eff.D
                                            A                      trigger point. 2. Identification of the affected
1. Documentation of proper evaluation leading to diagnosis of the Intermediate care-inpatient (including Part A) muscle(s). 3. D
                                            A                      trigger point. 2. Identification home health visits (Part B 3. D
1. Documentation of proper evaluation leading to diagnosis of the Intermediate care-inpatient or of the affected muscle(s). only)
                                            A                      trigger point. 2. Identification of the also)
1. Documentation of proper evaluation leading to diagnosis of the Intermediate care-outpatient (HHA-Aaffected muscle(s). 3. D
                                            A                      trigger point. 2. Identification of
1. Documentation of proper evaluation leading to diagnosis of the Intermediate care-other (Part B) the affected muscle(s). 3. D
                                            A                      trigger point. 2. Identification of the - level I
1. Documentation of proper evaluation leading to diagnosis of the Intermediate care-intermediate care affected muscle(s). 3. D
                                            A                      trigger point. 2. Identification of the - level II
1. Documentation of proper evaluation leading to diagnosis of the Intermediate care-intermediate care affected muscle(s). 3. D
                                            A                      trigger point. 2. Identification of the - level III
1. Documentation of proper evaluation leading to diagnosis of the Intermediate care-intermediate care affected muscle(s). 3. D
                                            A                      trigger point. 2. Identification
1. Documentation of proper evaluation leading to diagnosis of the Intermediate care-swing beds of the affected muscle(s). 3. D
                                            A                      trigger point. 2. Identification national assignment
1. Documentation of proper evaluation leading to diagnosis of the Intermediate care-reserved forof the affected muscle(s). 3. D
                                            A                      trigger point. 2. Identification of the affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the Clinic-rural health
                                            A                      trigger point. based or independent renal dialysis facility
1. Documentation of proper evaluation leading to diagnosis of the Clinic-hospital 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger point. 2. Identification of the affected 10/91)
1. Documentation of proper evaluation leading to diagnosis of the Clinic-independent provider based FQHC (effmuscle(s). 3. D
                                            A                      trigger point. 2. Identification of the CMHC (10/91 - 3/97)
1. Documentation of proper evaluation leading to diagnosis of the Clinic-ORF only (eff 4/97); ORF and affected muscle(s). 3. D
                                            A                      trigger point.
1. Documentation of proper evaluation leading to diagnosis of the Clinic-CORF 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger point. 2. 4/97)
1. Documentation of proper evaluation leading to diagnosis of the Clinic-CMHC (effIdentification of the affected muscle(s). 3. D
                                            A                      trigger point. 2. Identification of the affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the Clinic-reserved for national assignment
                                            A                      trigger point. 2. Identification of the affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the Clinic-reserved for national assignment
                                            A                      trigger point.
1. Documentation of proper evaluation leading to diagnosis of the Clinic-other 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger facility or ASC surgery-hospice (non-hospital based)
1. Documentation of proper evaluation leading to diagnosis of the Special point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger facility or ASC surgery-hospice (hospital based)
1. Documentation of proper evaluation leading to diagnosis of the Special point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger facility or ASC surgery-ambulatory surgical center (Di
1. Documentation of proper evaluation leading to diagnosis of the Special point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger facility or ASC surgery-freestanding muscle(s). 3.
1. Documentation of proper evaluation leading to diagnosis of the Special point. 2. Identification of the affectedbirthing center D
                                            A                      trigger facility or ASC surgery-rural affected muscle(s). (eff
1. Documentation of proper evaluation leading to diagnosis of the Special point. 2. Identification of the primary care hospital 3. D
                                            A                      trigger facility or ASC surgery-reserved for national use
1. Documentation of proper evaluation leading to diagnosis of the Special point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger facility or ASC surgery-reserved for national use
1. Documentation of proper evaluation leading to diagnosis of the Special point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger facility or ASC surgery-reserved for national use
1. Documentation of proper evaluation leading to diagnosis of the Special point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger facility or ASC surgery-other
1. Documentation of proper evaluation leading to diagnosis of the Special point. 2. Identification of the affected muscle(s). 3. D
                                            A                      trigger point. 2. Identification of the
1. Documentation of proper evaluation leading to diagnosis of the Reserved-inpatient (including Part A)affected muscle(s). 3. D
                                            A                      trigger point. 2. Identification of the affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the Reserved-inpatient or home health visits (Part B only)
                                            A                      trigger point. 2. Identification of the
1. Documentation of proper evaluation leading to diagnosis of the Reserved-outpatient (HHA-A also) affected muscle(s). 3. D
                                            A                      trigger point. 2. Identification of the affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the Reserved-other (Part B)
                                            A                      trigger point. 2. Identification of the
1. Documentation of proper evaluation leading to diagnosis of the Reserved-intermediate care - level I affected muscle(s). 3. D
                                            A                      trigger point. 2. Identification of the
1. Documentation of proper evaluation leading to diagnosis of the Reserved-intermediate care - level IIaffected muscle(s). 3. D
                                            A                      trigger point. 2. Identification of the affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the Reserved-intermediate care - level III
                                            A                      trigger point. 2. Identification of the affected muscle(s). 3. D
1. Documentation of proper evaluation leading to diagnosis of the Reserved-swing beds
                                            A                      trigger point. 2. Identification of the affected
1. Documentation of proper evaluation leading to diagnosis of the Reserved-reserved for national assignment muscle(s). 3. D
                                              A                    Hospital-inpatient (including Part A)
1. The following documentation should be present for reimbursement: * History and Physical;* Operative Report;* Visual Fie
                                              A                    Hospital-outpatient Physical;* Operative Report;* must Fie
1. The following documentation should be present for reimbursement: * History and(HHA-A also) (under OPPS 13XVisual be u
                                              A                    Special History and Physical;* Operative Report;* Visual Fie
1. The following documentation should be present for reimbursement: * facility or ASC surgery-rural primary care hospital (eff
                                              P                    Not Applicable
1. Documentation supporting the medical necessity, such as ICD-9-CM codes, must be submitted with each claim. Claims sub
                                              A                    Hospital-inpatient (including Part A)
1. The operating physician should retain in the patient?s medical record the history and physical examination and notes docum
                                              A                    Hospital-outpatient (HHA-A also) (under OPPS notes docum
1. The operating physician should retain in the patient?s medical record the history and physical examination and13X must be u
                                              A                     such as ICD-9-CM codes, Part be
1.Documentation supporting the medical necessity of this service,Hospital-inpatient (includingmust A) submitted with each claim
                                              A                     such as ICD-9-CM home must visits (Part B only)
1.Documentation supporting the medical necessity of this service,Hospital-inpatient or codes, healthbe submitted with each claim
                                              A                     such as ICD-9-CM codes, also) (under OPPS 13X must be u
1.Documentation supporting the medical necessity of this service,Hospital-outpatient (HHA-A must be submitted with each claim
                                              A                     such as ICD-9-CM codes, must be
1.Documentation supporting the medical necessity of this service,Non-Patient Laboratory Specimens submitted with each claim
                                              A                     such as ICD-9-CM
1.Documentation supporting the medical necessity of this service,Hospital-swing bedscodes, must be submitted with each claim
                                              A                     such as ICD-9-CM codes, must be submitted with each claim
1.Documentation supporting the medical necessity of this service,SNF-inpatient, Part A
                                              A                     such as ICD-9-CM codes, must be submitted with
1.Documentation supporting the medical necessity of this service,SNF-inpatient or home health visits (Part B only) each claim
                                              A                     such as ICD-9-CM codes, must be submitted with each claim
1.Documentation supporting the medical necessity of this service,SNF-outpatient (HHA-A also)
                                              A                     such as ICD-9-CM codes, must be submitted with each claim
1.Documentation supporting the medical necessity of this service,SNF-swing beds
                                              A                     such as ICD-9-CM
1.Documentation supporting the medical necessity of this service,Clinic-rural health codes, must be submitted with each claim
                                              A                     such as ICD-9-CM codes, must be renal dialysis each
1.Documentation supporting the medical necessity of this service,Clinic-hospital based or independentsubmitted withfacilityclaim
                                              A                     such as ICD-9-CM 4/97); must be CMHC (10/91 3/97)
1.Documentation supporting the medical necessity of this service,Clinic-ORF only (eff codes,ORF and submitted with -each claim
                                              A                     such as ICD-9-CM codes, must be submitted with each claim
1.Documentation supporting the medical necessity of this service,Clinic-CORF
                                              A                     such as ICD-9-CM codes, must be submitted with each claim
1.Documentation supporting the medical necessity of this service,Special facility or ASC surgery-ambulatory surgical center (Di
                                              A                     such as ICD-9-CM codes, must be submitted with each (eff
1.Documentation supporting the medical necessity of this service,Special facility or ASC surgery-rural primary care hospitalclaim
                                              A                    Hospital-inpatient (including Part be
1. The medical necessity for the tests must be established in the patient's record. 2. The test mustA) ordered by the patient's
                                              A                    Hospital-outpatient The test must be ordered by the patient's
1. The medical necessity for the tests must be established in the patient's record. 2. (HHA-A also) (under OPPS 13X must be u
                                              A                    Hospital-swing 2. The test must be ordered by the patient's
1. The medical necessity for the tests must be established in the patient's record.beds
                                              A                    Clinic-CORF
1. The medical necessity for the tests must be established in the patient's record. 2. The test must be ordered by the patient's
                                              A                    Special record. ASC surgery-ambulatory surgical patient's
1. The medical necessity for the tests must be established in the patient'sfacility or2. The test must be ordered by thecenter (Di
                                              A                    Special record. ASC surgery-rural ordered by hospital (eff
1. The medical necessity for the tests must be established in the patient'sfacility or2. The test must beprimary carethe patient's
1. The need for pharmacologic testing versusA                      Hospital-inpatient in the patient?s medical record. 2. Separa
                                               exercise testing must be documented(including Part A)
1. The need for pharmacologic testing versusA                      Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
                                               exercise testing must be documented in the patient?s medical record. 2. Separa
1. The need for pharmacologic testing versusA                      Special facility or ASC surgery-rural primary care hospital (eff
                                               exercise testing must be documented in the patient?s medical record. 2. Separa
                                              A                    Hospital-inpatient (including reasonableness of the service. 2
1. The patient's medical record must be legible and clearly indicate the medical necessity and Part A)
                                              A                    Hospital-inpatient or home health visits (Part of the
1. The patient's medical record must be legible and clearly indicate the medical necessity and reasonableness B only)service. 2
                                              A                    Hospital-outpatient (HHA-A reasonableness of the must be u
1. The patient's medical record must be legible and clearly indicate the medical necessity andalso) (under OPPS 13Xservice. 2
                                              A                    Non-Patient Laboratory and reasonableness of the service. 2
1. The patient's medical record must be legible and clearly indicate the medical necessity Specimens
                                              A                    Hospital-swing beds
1. The patient's medical record must be legible and clearly indicate the medical necessity and reasonableness of the service. 2
                                              A                    SNF-inpatient, Part A
1. The patient's medical record must be legible and clearly indicate the medical necessity and reasonableness of the service. 2
                                              A                    SNF-inpatient or home and reasonableness of the
1. The patient's medical record must be legible and clearly indicate the medical necessityhealth visits (Part B only) service. 2
                                              A                    SNF-outpatient (HHA-A also)
1. The patient's medical record must be legible and clearly indicate the medical necessity and reasonableness of the service. 2
                                              A                    SNF-swing beds
1. The patient's medical record must be legible and clearly indicate the medical necessity and reasonableness of the service. 2
                                              A                    Clinic-rural health
1. The patient's medical record must be legible and clearly indicate the medical necessity and reasonableness of the service. 2
                                              A                    Clinic-hospital based or and reasonableness of the service. 2
1. The patient's medical record must be legible and clearly indicate the medical necessity independent renal dialysis facility
                                              A                    Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 3/97)
1. The patient's medical record must be legible and clearly indicate the medical necessity and reasonableness of the -service. 2
                                              A                    Clinic-CORF
1. The patient's medical record must be legible and clearly indicate the medical necessity and reasonableness of the service. 2
                                              A                    Special facility or ASC surgery-ambulatory surgical service. 2
1. The patient's medical record must be legible and clearly indicate the medical necessity and reasonableness of the center (Di
                                              A                    Special facility or ASC surgery-rural primary of the service. 2
1. The patient's medical record must be legible and clearly indicate the medical necessity and reasonablenesscare hospital (eff
                                               be                  Hospital-inpatient (including Part A)
1.Documentation of all coverage criteria mustA present in the patient's medical record and must clearly indicate that the patie
                                               be                  Hospital-inpatient or home must visits indicate that
1.Documentation of all coverage criteria mustA present in the patient's medical record and healthclearly (Part B only) the patie
                                               be                  Hospital-outpatient (HHA-A also) (under OPPS that the patie
1.Documentation of all coverage criteria mustA present in the patient's medical record and must clearly indicate13X must be u
                                               be                  Non-Patient Laboratory Specimens
1.Documentation of all coverage criteria mustA present in the patient's medical record and must clearly indicate that the patie
                                               be                  Hospital-swing record
1.Documentation of all coverage criteria mustA present in the patient's medical beds and must clearly indicate that the patie
                                               be                  SNF-inpatient, record
1.Documentation of all coverage criteria mustA present in the patient's medicalPart A and must clearly indicate that the patie
                                               be                  SNF-inpatient or home health visits (Part B only)
1.Documentation of all coverage criteria mustA present in the patient's medical record and must clearly indicate that the patie
                                               be                 SNF-outpatient (HHA-A also)
1.Documentation of all coverage criteria mustA present in the patient's medical record and must clearly indicate that the patie
                                               be                 SNF-swing beds
1.Documentation of all coverage criteria mustA present in the patient's medical record and must clearly indicate that the patie
                                               be                 Clinic-rural health
1.Documentation of all coverage criteria mustA present in the patient's medical record and must clearly indicate that the patie
                                               be                 Special facility record surgery-ambulatory surgical center (Di
1.Documentation of all coverage criteria mustA present in the patient's medicalor ASC and must clearly indicate that the patie
                                               be                 Special facility record surgery-rural primary care hospital (eff
1.Documentation of all coverage criteria mustA present in the patient's medicalor ASC and must clearly indicate that the patie
                                             A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                             A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                             A                    Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                             A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                             A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                             A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                             A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                             A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                             A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                             A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                              the                 Hospital-inpatient indicate health visits (Part B only)
Medical record documentation maintained by A performing physician must clearly or home the medical necessity of the servic
                                              the                 Hospital-outpatient (HHA-A also) (under OPPS 13X must be
Medical record documentation maintained by A performing physician must clearly indicate the medical necessity of the servicu
                                              the                 Clinic-rural health
Medical record documentation maintained by A performing physician must clearly indicate the medical necessity of the servic
                                              the                 Clinic-independent provider based FQHC (eff 10/91)
Medical record documentation maintained by A performing physician must clearly indicate the medical necessity of the servic
                                              the                 Special facility or indicate the medical necessity hospital (eff
Medical record documentation maintained by A performing physician must clearlyASC surgery-rural primary care of the servic
                                             A                    Hospital-inpatient or home health visits statement that
Support for the medical necessity of the Botulinum Toxin injections include: 1. A covered diagnosis; 2. A (Part B only) traditio
                                             A                    Non-Patient A covered diagnosis;
Support for the medical necessity of the Botulinum Toxin injections include: 1.Laboratory Specimens2. A statement that traditio
                                             A                    SNF-inpatient, covered
Support for the medical necessity of the Botulinum Toxin injections include: 1. APart A diagnosis; 2. A statement that traditio
                                             A                    of the procedure
Claims for co-surgery will require an accompanying written report Not Applicable and justifications for co-surgery. Laser-ass
                                             A                    of the procedure
Claims for co-surgery will require an accompanying written report Not Applicable and justifications for co-surgery. Laser-ass
                                             A                    of the procedure
Claims for co-surgery will require an accompanying written report Not Applicable and justifications for co-surgery. Laser-ass
                                             A                    Hospital-inpatient (including in the
1. The treating provider must document the medical necessity of the chosen treatment/testing Part A)patient's medical record. S
                                             A                    Hospital-outpatient (HHA-A in the patient's medical record. u
1. The treating provider must document the medical necessity of the chosen treatment/testingalso) (under OPPS 13X must be S
                                             A                    Non-Patient Laboratory Specimens
1. The treating provider must document the medical necessity of the chosen treatment/testing in the patient's medical record. S
                                             A                    Hospital-swing beds
1. The treating provider must document the medical necessity of the chosen treatment/testing in the patient's medical record. S
                                             A                    SNF-inpatient, Part A
1. The treating provider must document the medical necessity of the chosen treatment/testing in the patient's medical record. S
                                             A                    SNF-outpatient (HHA-A also)
1. The treating provider must document the medical necessity of the chosen treatment/testing in the patient's medical record. S
                                             A                    Clinic-rural health
1. The treating provider must document the medical necessity of the chosen treatment/testing in the patient's medical record. S
                                             A                    Clinic-independent provider in the patient's medical
1. The treating provider must document the medical necessity of the chosen treatment/testingbased FQHC (eff 10/91) record. S
                                             A                    Clinic-ORF only (eff 4/97); ORF and CMHC medical record.
1. The treating provider must document the medical necessity of the chosen treatment/testing in the patient's (10/91 - 3/97) S
                                             A                    Clinic-CORF
1. The treating provider must document the medical necessity of the chosen treatment/testing in the patient's medical record. S
                                             A                    Clinic-CMHC (eff 4/97)
1. The treating provider must document the medical necessity of the chosen treatment/testing in the patient's medical record. S
                                             A                    Special facility or ASC surgery-ambulatory surgical center (Di
1. The treating provider must document the medical necessity of the chosen treatment/testing in the patient's medical record. S
                                             A                    Special facility or ASC surgery-rural primary care hospital (eff
1. The treating provider must document the medical necessity of the chosen treatment/testing in the patient's medical record. S
                                             A                    Hospital-inpatient (including Part must be maintained in the p
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report A)
                                             A                    Hospital-inpatient or home health visits (Part B only)
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must be maintained in the p
                                             A                    Hospital-outpatient (HHA-A also) (under OPPS 13X must be
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must be maintained in the pu
                                             A                    Non-Patient Laboratory Specimens
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must be maintained in the p
                                             A                    Hospital-swing beds
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must be maintained in the p
                                             A                    SNF-inpatient, Part A
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must be maintained in the p
                                             A                    SNF-inpatient or home health visits (Part maintained in the p
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must beB only)
                                             A                    SNF-outpatient (HHA-A also)
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must be maintained in the p
                                             A                    SNF-swing beds
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must be maintained in the p
                                             A                    Clinic-rural health
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must be maintained in the p
                                             A                    Clinic-hospital based or independent renal dialysis facility
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must be maintained in the p
                                             A                    Clinic-independent provider based FQHC maintained
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must be (eff 10/91) in the p
                                             A                    Clinic-CORF
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must be maintained in the p
                                             A                   Special facility or ASC surgery-ambulatory surgical center (Di
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must be maintained in the p
                                             A                   Special facility or ASC surgery-rural primary care hospital (eff
1.Submissions without a covered ICD-9-CM code will be denied. 2.The operative/procedure report must be maintained in the p
                                             A                   Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                             A                   Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                             A                   Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                             A                   Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                             A                   Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                             P                    has been diagnosed with acutely decompensated heart failur
The patient?s medical record should document: ? that the patient Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
                                             A                   HHA-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                             A                   HHA-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                             A                   Hospital-outpatient (HHA-A also) for rheumatoid arthritis be u
1.The medical record must contain duration, dosage, and response to methotrexate administration (under OPPS 13X mustpatie
                                             A                   Non-Patient Laboratory Specimens
1.The medical record must contain duration, dosage, and response to methotrexate administration for rheumatoid arthritis patie
                                             A                   SNF-inpatient, Part A
1.The medical record must contain duration, dosage, and response to methotrexate administration for rheumatoid arthritis patie
                                             A                   SNF-inpatient or home health visits (Part B only)
1.The medical record must contain duration, dosage, and response to methotrexate administration for rheumatoid arthritis patie
                                             A                   SNF-outpatient (HHA-A also)
1.The medical record must contain duration, dosage, and response to methotrexate administration for rheumatoid arthritis patie
                                             A                   Clinic-rural health
1.The medical record must contain duration, dosage, and response to methotrexate administration for rheumatoid arthritis patie
                                             A                   Special facility or ASC surgery-ambulatory surgical center (Di
1.The medical record must contain duration, dosage, and response to methotrexate administration for rheumatoid arthritis patie
                                             A                   Special facility or ASC surgery-rural rheumatoid hospital (eff
1.The medical record must contain duration, dosage, and response to methotrexate administration forprimary care arthritis patie
                                             A                   Hospital-inpatient test. It is not necessary to B only)
The patient?s medical records must clearly document the medical necessity for the or home health visits (Part include documen
                                             A                   Hospital-outpatient (HHA-A also) (under OPPS 13X documen
The patient?s medical records must clearly document the medical necessity for the test. It is not necessary to include must be u
                                             A                   Non-Patient Laboratory Specimens
The patient?s medical records must clearly document the medical necessity for the test. It is not necessary to include documen
                                             A                   SNF-inpatient, Part A
The patient?s medical records must clearly document the medical necessity for the test. It is not necessary to include documen
                                             A                   SNF-inpatient the test. health necessary to include documen
The patient?s medical records must clearly document the medical necessity for or home It is notvisits (Part B only)
                                             A                   SNF-outpatient (HHA-A is not
The patient?s medical records must clearly document the medical necessity for the test. Italso) necessary to include documen
                                             A                   Clinic-rural health
The patient?s medical records must clearly document the medical necessity for the test. It is not necessary to include documen
                                             A                   Clinic-hospital based or is not necessary dialysis facility
The patient?s medical records must clearly document the medical necessity for the test. Itindependent renalto include documen
                                             A                   Clinic-independent provider based FQHC to include
The patient?s medical records must clearly document the medical necessity for the test. It is not necessary (eff 10/91)documen
                                             A                   Clinic-ORF only (eff 4/97); not and CMHC include 3/97)
The patient?s medical records must clearly document the medical necessity for the test. It isORFnecessary to(10/91 - documen
                                             A                   Clinic-CORF
The patient?s medical records must clearly document the medical necessity for the test. It is not necessary to include documen
                                             A                   Special facility or test. It is not necessary to include documen
The patient?s medical records must clearly document the medical necessity for theASC surgery-rural primary care hospital (eff
Reasons for Denial When the documentationA                       Hospital-inpatient or rendered or the documentation
                                              does not meet the criteria for the servicehome health visits (Part B only) does no
Reasons for Denial When the documentationA                       Hospital-outpatient (HHA-A also) the documentation does no
                                              does not meet the criteria for the service rendered or (under OPPS 13X must be u
Reasons for Denial When the documentationA                       SNF-inpatient or home health visits (Part B only)
                                              does not meet the criteria for the service rendered or the documentation does no
Reasons for Denial When the documentationA                       SNF-outpatient (HHA-A also)
                                              does not meet the criteria for the service rendered or the documentation does no
Reasons for Denial When the documentationA                       Special facility or ASC surgery-rural primary care hospital no
                                              does not meet the criteria for the service rendered or the documentation does(eff
                                             A                   Hospital-inpatient (including Part A)
 General Documentation Requirements Documentation in the clinical record must be descriptive, clearly related to functionality
                                             A                   TBD
Medical records must include the indications to support using IVIG. For those indications stating routine use is not indicated, the
                                             A                   Hospital-inpatient (including Part A)
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation supporting the medical necessity of this item, s
                                             A                   Hospital-inpatient or home health visits (Part B only)
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation supporting the medical necessity of this item, s
                                             A                   Hospital-outpatient (HHA-A also) (under OPPS 13X must be s
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation supporting the medical necessity of this item, u
                                             A                   Non-Patient Laboratory Specimens
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation supporting the medical necessity of this item, s
                                             A                   SNF-inpatient, supporting the medical necessity of this item, s
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation Part A
                                             A                   SNF-inpatient supporting the medical necessity
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentationor home health visits (Part B only) of this item, s
                                             A                   SNF-outpatient (HHA-A also)
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation supporting the medical necessity of this item, s
                                             A                   HHA-other (Part B)
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation supporting the medical necessity of this item, s
                                             A                   Clinic-rural health
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation supporting the medical necessity of this item, s
                                             A                   Clinic-hospital supporting the medical necessity of this item, s
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentationbased or independent renal dialysis facility
                                             A                   Clinic-independent provider based FQHC (eff 10/91)
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation supporting the medical necessity of this item, s
                                             A                   Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 this item, s
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation supporting the medical necessity of - 3/97)
                                             A                   Clinic-CORF
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation supporting the medical necessity of this item, s
                                             A                   Special facility supporting the medical (hospital of this
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation or ASC surgery-hospicenecessity based)item, s
                                             A                   Special facility supporting the medical necessity of this item,
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation or ASC surgery-ambulatory surgical center (Dis
                                            A                    Special facility supporting the medical necessity hospital (eff
1. Chemotherapy agent which caused the febrile neutropenia. 2. Documentation or ASC surgery-rural primary careof this item, s
                                            A                    Hospital-inpatient or home health visits (Part B only)
Documentation supporting the medical reasonableness and necessity of this test, such as ICD-9-CM code(s), must be submitte
                                            A                    Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
Documentation supporting the medical reasonableness and necessity of this test, such as ICD-9-CM code(s), must be submitte
                                            A                    Non-Patient Laboratory Specimens
Documentation supporting the medical reasonableness and necessity of this test, such as ICD-9-CM code(s), must be submitte
                                            A                    SNF-inpatient or home health visits code(s), must
Documentation supporting the medical reasonableness and necessity of this test, such as ICD-9-CM (Part B only) be submitte
                                            A                    SNF-outpatient such as ICD-9-CM code(s), must be submitte
Documentation supporting the medical reasonableness and necessity of this test,(HHA-A also)
                                            A                    Special facility or ASC surgery-rural primary must be submitte
Documentation supporting the medical reasonableness and necessity of this test, such as ICD-9-CM code(s), care hospital (eff
Reasons for Denial When the documentationA                       Hospital-inpatient or rendered or the documentation
                                             does not meet the criteria for the servicehome health visits (Part B only) does no
Reasons for Denial When the documentationA                       Hospital-outpatient (HHA-A also) the documentation does no
                                             does not meet the criteria for the service rendered or (under OPPS 13X must be u
Reasons for Denial When the documentationA                       SNF-inpatient or home health visits (Part B only)
                                             does not meet the criteria for the service rendered or the documentation does no
Reasons for Denial When the documentationA                       SNF-outpatient (HHA-A also)
                                             does not meet the criteria for the service rendered or the documentation does no
Reasons for Denial When the documentationA                       Special facility or ASC surgery-rural primary care hospital no
                                             does not meet the criteria for the service rendered or the documentation does(eff
                                            A                    Hospital-inpatient (including Part anemia 285.3 or 285.9 (as s
1.Documentation of the following items must be provided with each claim: a.A primary diagnosis ofA)
                                            A                    Hospital-inpatient or diagnosis of anemia 285.3 or 285.9 (as s
1.Documentation of the following items must be provided with each claim: a.A primary home health visits (Part B only)
                                            A                    Hospital-outpatient (HHA-A also) anemia 285.3 or 285.9 be s
1.Documentation of the following items must be provided with each claim: a.A primary diagnosis of (under OPPS 13X must(as u
                                            A                    Non-Patient primary diagnosis of anemia 285.3 or 285.9 (as s
1.Documentation of the following items must be provided with each claim: a.A Laboratory Specimens
                                            A                    SNF-inpatient, Part A
1.Documentation of the following items must be provided with each claim: a.A primary diagnosis of anemia 285.3 or 285.9 (as s
                                            A                    SNF-inpatient or home health visits (Part 285.3
1.Documentation of the following items must be provided with each claim: a.A primary diagnosis of anemia B only)or 285.9 (as s
                                            A                    SNF-outpatient (HHA-A also)
1.Documentation of the following items must be provided with each claim: a.A primary diagnosis of anemia 285.3 or 285.9 (as s
                                            A                    HHA-other (Part B)
1.Documentation of the following items must be provided with each claim: a.A primary diagnosis of anemia 285.3 or 285.9 (as s
                                            A                    Clinic-rural health
1.Documentation of the following items must be provided with each claim: a.A primary diagnosis of anemia 285.3 or 285.9 (as s
                                            A                    Clinic-hospital based or independent renal dialysis 285.9
1.Documentation of the following items must be provided with each claim: a.A primary diagnosis of anemia 285.3 or facility(as s
                                            A                    Clinic-independent provider based FQHC (eff 10/91)
1.Documentation of the following items must be provided with each claim: a.A primary diagnosis of anemia 285.3 or 285.9 (as s
                                            A                    Clinic-ORF only (eff diagnosis and CMHC (10/91 - 3/97)
1.Documentation of the following items must be provided with each claim: a.A primary4/97); ORFof anemia 285.3 or 285.9 (as s
                                            A                    Clinic-CORF
1.Documentation of the following items must be provided with each claim: a.A primary diagnosis of anemia 285.3 or 285.9 (as s
                                            A                    Special a.A primary diagnosis of anemia 285.3 based)
1.Documentation of the following items must be provided with each claim:facility or ASC surgery-hospice (hospital or 285.9 (as s
                                            A                    Special a.A primary diagnosis of anemia surgical center (Di
1.Documentation of the following items must be provided with each claim:facility or ASC surgery-ambulatory285.3 or 285.9 (as s
                                            A                    Special a.A primary diagnosis of anemia 285.3 or 285.9 (eff
1.Documentation of the following items must be provided with each claim:facility or ASC surgery-rural primary care hospital(as s
                                            A                    Hospital-inpatient (including Part A)
1.Medical record documentation should clearly document the reason for the use of the drug. This information should be availab
                                            A                    Hospital-inpatient or drug. This visits (Part B only)
1.Medical record documentation should clearly document the reason for the use of thehome healthinformation should be availab
                                            A                    Hospital-outpatient (HHA-A This (under OPPS 13X must be u
1.Medical record documentation should clearly document the reason for the use of the drug. also)information should be availab
                                            A                    Non-Patient Laboratory Specimens
1.Medical record documentation should clearly document the reason for the use of the drug. This information should be availab
                                            A                    SNF-inpatient, of the
1.Medical record documentation should clearly document the reason for the use Part A drug. This information should be availab
                                            A                    SNF-inpatient of the drug. This information should be availab
1.Medical record documentation should clearly document the reason for the useor home health visits (Part B only)
                                            A                    SNF-outpatient (HHA-A also)
1.Medical record documentation should clearly document the reason for the use of the drug. This information should be availab
                                            A                    HHA-other (Part the
1.Medical record documentation should clearly document the reason for the use ofB) drug. This information should be availab
                                            A                    Clinic-rural health
1.Medical record documentation should clearly document the reason for the use of the drug. This information should be availab
                                            A                    Clinic-hospital of the drug. This information should be availab
1.Medical record documentation should clearly document the reason for the use based or independent renal dialysis facility
                                            A                    Clinic-independent provider based FQHC (eff 10/91)
1.Medical record documentation should clearly document the reason for the use of the drug. This information should be availab
                                            A                    Clinic-ORF only (eff 4/97); This information should 3/97)
1.Medical record documentation should clearly document the reason for the use of the drug. ORF and CMHC (10/91 - be availab
                                            A                    Clinic-CORF
1.Medical record documentation should clearly document the reason for the use of the drug. This information should be availab
                                            A                    Special facility of the drug. This information should be
1.Medical record documentation should clearly document the reason for the use or ASC surgery-hospice (hospital based)availab
                                            A                    Special facility of the drug. This information should be availab
1.Medical record documentation should clearly document the reason for the use or ASC surgery-ambulatory surgical center (Di
                                            A                    Special facility of the drug. This information should be availab
1.Medical record documentation should clearly document the reason for the use or ASC surgery-rural primary care hospital (eff
                                            A                    Hospital-inpatient (including Part A)
1.Document the reason for the use of the drug, the type of the underlying disease and the type of anemia in the patient chart. T
                                            A                    Hospital-inpatient or the type of anemia in the only)
1.Document the reason for the use of the drug, the type of the underlying disease and home health visits (Part Bpatient chart. T
                                            A                    Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
1.Document the reason for the use of the drug, the type of the underlying disease and the type of anemia in the patient chart. T
                                            A                    Non-Patient Laboratory type of anemia in the patient chart. T
1.Document the reason for the use of the drug, the type of the underlying disease and theSpecimens
                                            A                    SNF-inpatient, Part A
1.Document the reason for the use of the drug, the type of the underlying disease and the type of anemia in the patient chart. T
                                            A                    SNF-inpatient or home health visits (Part B only)
1.Document the reason for the use of the drug, the type of the underlying disease and the type of anemia in the patient chart. T
                                            A                    SNF-outpatient and the type
1.Document the reason for the use of the drug, the type of the underlying disease(HHA-A also) of anemia in the patient chart. T
                                            A                    HHA-other (Part B)
1.Document the reason for the use of the drug, the type of the underlying disease and the type of anemia in the patient chart. T
                                               A                   Clinic-rural health
1.Document the reason for the use of the drug, the type of the underlying disease and the type of anemia in the patient chart. T
                                               A                   Clinic-hospital based or type of anemia in dialysis facility
1.Document the reason for the use of the drug, the type of the underlying disease and theindependent renal the patient chart. T
                                               A                   Clinic-independent provider based FQHC the patient
1.Document the reason for the use of the drug, the type of the underlying disease and the type of anemia in(eff 10/91) chart. T
                                               A                   Clinic-ORF only and the type of and CMHC (10/91 - 3/97)
1.Document the reason for the use of the drug, the type of the underlying disease (eff 4/97); ORF anemia in the patient chart. T
                                               A                   Clinic-CORF
1.Document the reason for the use of the drug, the type of the underlying disease and the type of anemia in the patient chart. T
                                               A                   Special disease ASC surgery-hospice in the patient chart. T
1.Document the reason for the use of the drug, the type of the underlying facility orand the type of anemia(hospital based)
                                               A                   Special disease ASC surgery-ambulatory surgical center (Di
1.Document the reason for the use of the drug, the type of the underlying facility orand the type of anemia in the patient chart. T
                                               A                   Special disease ASC surgery-rural primary care hospital (eff
1.Document the reason for the use of the drug, the type of the underlying facility orand the type of anemia in the patient chart. T
                                               A                   should include a (including Part A)
1.Medical record documentation to support any claim information Hospital-inpatientplan of care, reasons for use, and laboratory
                                               A                   should include a or home health visits (Part B and
1.Medical record documentation to support any claim information Hospital-inpatientplan of care, reasons for use, only)laboratory
                                               A                   should include a plan of care, reasons for use, 13X must be u
1.Medical record documentation to support any claim information Hospital-outpatient (HHA-A also) (under OPPS and laboratory
                                               A                   should include a plan of care, reasons for use, and laboratory
1.Medical record documentation to support any claim information Non-Patient Laboratory Specimens
                                               A                   should include a plan
1.Medical record documentation to support any claim information SNF-inpatient, Part A of care, reasons for use, and laboratory
                                               A                   should include a plan of care, reasons for use, and
1.Medical record documentation to support any claim information SNF-inpatient or home health visits (Part B only) laboratory
                                               A                   should include (HHA-A care,
1.Medical record documentation to support any claim information SNF-outpatient a plan of also) reasons for use, and laboratory
                                               A                   should include a plan
1.Medical record documentation to support any claim information HHA-other (Part B) of care, reasons for use, and laboratory
                                               A                   should include a
1.Medical record documentation to support any claim information Clinic-rural healthplan of care, reasons for use, and laboratory
                                               A                   should include a plan of care, reasons for dialysis laboratory
1.Medical record documentation to support any claim information Clinic-hospital based or independent renal use, andfacility
                                               A                   should include a plan of care, reasons for use, and laboratory
1.Medical record documentation to support any claim information Clinic-independent provider based FQHC (eff 10/91)
                                               A                   should include a plan of care, reasons for use, and 3/97)
1.Medical record documentation to support any claim information Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 -laboratory
                                               A                   should include
1.Medical record documentation to support any claim information Clinic-CORF a plan of care, reasons for use, and laboratory
                                               A                   should facility a ASC surgery-hospice (hospital based)
1.Medical record documentation to support any claim information Special include or plan of care, reasons for use, and laboratory
                                               A                   should facility a ASC surgery-ambulatory surgical laboratory
1.Medical record documentation to support any claim information Special include or plan of care, reasons for use, and center (Di
                                               A                   should facility a ASC surgery-rural primary care hospital (eff
1.Medical record documentation to support any claim information Special include or plan of care, reasons for use, and laboratory
NULL                                           P                   Hospital-inpatient or home health visits (Part B only)
NULL                                           P                   Hospital-outpatient (HHA-A also) (under OPPS 13X must be u
NULL                                           P                   Hospital-other (Part B)
NULL                                           P                   Hospital-swing beds
NULL                                           P                   SNF-inpatient (including Part A)
NULL                                           P                   SNF-inpatient or home health visits (Part B only)
NULL                                           P                   SNF-outpatient (HHA-A also)
NULL                                           P                   Clinic-rural health
NULL                                           P                   Special facility or ASC surgery-rural primary care hospital (eff
                                               or                  Not meet established criteria, demonstrated by documentatio
Initial pump implantation for control of spasm P intractable pain must Applicable
                                               the                 Hospital-inpatient or home health visits (Part B to initiate IGIV
Medical record documentation maintained by A treating physician must clearly document the medical necessityonly)
                                               the                 Hospital-outpatient (HHA-A also) (under OPPS to initiate be u
Medical record documentation maintained by A treating physician must clearly document the medical necessity 13X must IGIV
                                               the                 SNF-inpatient document the visits (Part B only)
Medical record documentation maintained by A treating physician must clearly or home healthmedical necessity to initiate IGIV
                                               the                 SNF-outpatient (HHA-A also)
Medical record documentation maintained by A treating physician must clearly document the medical necessity to initiate IGIV
                                               the                 Special facility document the medical necessity to initiate (eff
Medical record documentation maintained by A treating physician must clearly or ASC surgery-rural primary care hospital IGIV
                                               the                 Hospital-inpatient or home health visits (Part B to initiate IGIV
Medical record documentation maintained by A treating physician must clearly document the medical necessityonly)
                                               the                 Hospital-outpatient (HHA-A also) (under OPPS to initiate be u
Medical record documentation maintained by A treating physician must clearly document the medical necessity 13X must IGIV
                                               the                 SNF-inpatient document the visits (Part B only)
Medical record documentation maintained by A treating physician must clearly or home healthmedical necessity to initiate IGIV
                                               the                 SNF-outpatient (HHA-A also)
Medical record documentation maintained by A treating physician must clearly document the medical necessity to initiate IGIV
                                               the                 Special facility document the medical necessity to initiate (eff
Medical record documentation maintained by A treating physician must clearly or ASC surgery-rural primary care hospital IGIV
                                               P                   Not Applicable
1. Each claim must be submitted with ICD-9-CM codes that reflect the condition of the patient, and indicate the reason(s) for wh
                                               A                   Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                               A                   Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                               A                   Non-Patient Laboratory Specimens
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                   Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                               A                   SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                               A                   SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                   SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                            A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                            A                    Clinic-hospital based or independent renal dialysis facility
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                            A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                            A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                            A                    Hospital-outpatient to respond adequately to conservative no
1. Documentation supporting the medical necessity of this item should include failure (HHA-A also) (under OPPS 13X must be u
                                            A                    Hospital-swing beds
1. Documentation supporting the medical necessity of this item should include failure to respond adequately to conservative no
                                            A                    SNF-inpatient, Part to
1. Documentation supporting the medical necessity of this item should include failure A respond adequately to conservative no
                                            A                    SNF-inpatient or home health visits (Part B only)
1. Documentation supporting the medical necessity of this item should include failure to respond adequately to conservative no
                                            A                    SNF-outpatient (HHA-A also)
1. Documentation supporting the medical necessity of this item should include failure to respond adequately to conservative no
                                            A                    Clinic-rural health
1. Documentation supporting the medical necessity of this item should include failure to respond adequately to conservative no
                                            A                    Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97)
1. Documentation supporting the medical necessity of this item should include failure to respond adequately to conservative no
                                            A                    Clinic-CORF
1. Documentation supporting the medical necessity of this item should include failure to respond adequately to conservative no
                                            A                    Special facility or ASC surgery-rural primary conservative no
1. Documentation supporting the medical necessity of this item should include failure to respond adequately tocare hospital (eff
                                            A                    Hospital-inpatient or home health visits either: Oral
When using intravenous infusion of zoledronic acid, the medical record must contain documentation that (Part B only) bisphosp
                                            A                    Hospital-outpatient documentation that OPPS 13X must be
When using intravenous infusion of zoledronic acid, the medical record must contain (HHA-A also) (undereither: Oral bisphospu
                                            A                    Hospital-swing beds
When using intravenous infusion of zoledronic acid, the medical record must contain documentation that either: Oral bisphosp
                                            A                    SNF-inpatient, Part A
When using intravenous infusion of zoledronic acid, the medical record must contain documentation that either: Oral bisphosp
                                            A                    SNF-inpatient or home health visits (Part B only)
When using intravenous infusion of zoledronic acid, the medical record must contain documentation that either: Oral bisphosp
                                            A                    SNF-outpatient (HHA-A also)
When using intravenous infusion of zoledronic acid, the medical record must contain documentation that either: Oral bisphosp
                                            A                    Clinic-rural contain
When using intravenous infusion of zoledronic acid, the medical record must health documentation that either: Oral bisphosp
                                            A                    Clinic-independent documentation that either: Oral
When using intravenous infusion of zoledronic acid, the medical record must contain provider based FQHC (eff 10/91)bisphosp
                                            A                    Special facility or ASC surgery-rural primary care hospital (eff
When using intravenous infusion of zoledronic acid, the medical record must contain documentation that either: Oral bisphosp
                                            A                    Hospital-inpatient anemia secondary
1.The medical record must document the presence of gastrointestinal bleeding and (including Part A) to blood loss. 2.Docum
                                            A                    Hospital-inpatient anemia health visits blood only)
1.The medical record must document the presence of gastrointestinal bleeding and or home secondary to(Part Bloss. 2.Docum
                                            A                    Hospital-outpatient (HHA-A also) (under OPPS 13X must be
1.The medical record must document the presence of gastrointestinal bleeding and anemia secondary to blood loss. 2.Documu
                                            A                    Non-Patient Laboratory Specimens
1.The medical record must document the presence of gastrointestinal bleeding and anemia secondary to blood loss. 2.Docum
                                            A                    Hospital-swing beds
1.The medical record must document the presence of gastrointestinal bleeding and anemia secondary to blood loss. 2.Docum
                                            A                    SNF-inpatient, Part A
1.The medical record must document the presence of gastrointestinal bleeding and anemia secondary to blood loss. 2.Docum
                                            A                    SNF-inpatient or home health visits (Part B only)
1.The medical record must document the presence of gastrointestinal bleeding and anemia secondary to blood loss. 2.Docum
                                            A                    SNF-outpatient (HHA-A also)
1.The medical record must document the presence of gastrointestinal bleeding and anemia secondary to blood loss. 2.Docum
                                            A                    SNF-swing beds
1.The medical record must document the presence of gastrointestinal bleeding and anemia secondary to blood loss. 2.Docum
                                            A                    Clinic-rural health
1.The medical record must document the presence of gastrointestinal bleeding and anemia secondary to blood loss. 2.Docum
                                            A                    Clinic-independent provider based FQHC (eff loss.
1.The medical record must document the presence of gastrointestinal bleeding and anemia secondary to blood 10/91)2.Docum
                                            A                    Clinic-ORF only (eff 4/97); ORF and to blood loss. 3/97)
1.The medical record must document the presence of gastrointestinal bleeding and anemia secondaryCMHC (10/91 - 2.Docum
                                            A                    Clinic-CORF
1.The medical record must document the presence of gastrointestinal bleeding and anemia secondary to blood loss. 2.Docum
                                            A                    Special facility or anemia secondary to blood loss. 2.Docum
1.The medical record must document the presence of gastrointestinal bleeding andASC surgery-ambulatory surgical center (Di
                                            A                    Special facility or anemia secondary to blood loss. 2.Docum
1.The medical record must document the presence of gastrointestinal bleeding andASC surgery-rural primary care hospital (eff
                                            A                    that the patient has one of also) (under and/or indications u
1. Documentation in the patient's medical record must indicate Hospital-outpatient (HHA-Athe conditionsOPPS 13X must belis
                                            A                    that the patient has one of the conditions and/or hospital (eff
1. Documentation in the patient's medical record must indicate Special facility or ASC surgery-rural primary careindications lis
                                            A                    Hospital-inpatient (including Part the
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to A) highest specificity, must
                                            A                    Hospital-inpatient or home health visits (Part specificity, must
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to the highest B only)
                                            A                    Hospital-outpatient (HHA-A also) (under OPPS 13X must be
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to the highest specificity, mustu
                                            A                    Non-Patient Laboratory coded to the
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM codes Specimens highest specificity, must
                                            A                    SNF-inpatient, Part A
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to the highest specificity, must
                                            A                    SNF-inpatient or codes coded to the highest specificity, must
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM home health visits (Part B only)
                                            A                    SNF-outpatient (HHA-A also)
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to the highest specificity, must
                                            A                    HHA-other (Part codes coded to the highest specificity, must
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM B)
                                            A                    Clinic-rural health
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to the highest specificity, must
                                            A                    Clinic-hospital based or independent renal dialysis facility
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to the highest specificity, must
                                            A                    Clinic-independent provider based FQHC (eff 10/91)
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to the highest specificity, must
                                            A                    Clinic-ORF only codes coded to the highest specificity, must
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM(eff 4/97); ORF and CMHC (10/91 - 3/97)
                                            A                    Clinic-CORF
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to the highest specificity, must
                                              A                     Special facility or ASC surgery-hospice (hospital based)
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to the highest specificity, must
                                              A                     Special facility or ASC surgery-ambulatory surgical center (Di
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to the highest specificity, must
                                              A                     Special facility or ASC surgery-rural highest specificity, must
1.Documentation supporting the medical necessity of this item, such as ICD-9-CM codes coded to theprimary care hospital (eff
                                              A                     Hospital-inpatient (including and indicate the reason(s) for wh
1. Each claim must be submitted with ICD-9-CM codes that reflect the condition of the patient,Part A)
                                              A                     Hospital-outpatient (HHA-A also) indicate the reason(s) for wh
1. Each claim must be submitted with ICD-9-CM codes that reflect the condition of the patient, and (under OPPS 13X must be u
                                              A                     Special facility of ASC surgery-rural primary care hospital (eff
1. Each claim must be submitted with ICD-9-CM codes that reflect the condition or the patient, and indicate the reason(s) for wh
                                              A                     Hospital-inpatient (including Part A)
1. The operating physician should retain in the patient?s medical record the history and physical examination and notes docum
                                              A                     Hospital-inpatient or home health visits (Part B notes
1. The operating physician should retain in the patient?s medical record the history and physical examination andonly) docum
                                              A                     Hospital-outpatient (HHA-A also) (under OPPS notes docum
1. The operating physician should retain in the patient?s medical record the history and physical examination and13X must be u
                                              A                     Non-Patient Laboratory Specimens
1. The operating physician should retain in the patient?s medical record the history and physical examination and notes docum
                                              A                     Hospital-swing beds
1. The operating physician should retain in the patient?s medical record the history and physical examination and notes docum
                                              A                     SNF-inpatient, Part A
1. The operating physician should retain in the patient?s medical record the history and physical examination and notes docum
                                              A                     SNF-inpatient or and physical examination and
1. The operating physician should retain in the patient?s medical record the historyhome health visits (Part B only)notes docum
                                              A                     SNF-outpatient (HHA-A also)
1. The operating physician should retain in the patient?s medical record the history and physical examination and notes docum
                                              A                     SNF-swing beds
1. The operating physician should retain in the patient?s medical record the history and physical examination and notes docum
                                              A                     Clinic-rural health
1. The operating physician should retain in the patient?s medical record the history and physical examination and notes docum
                                              A                     Clinic-hospital based physical examination and notes docum
1. The operating physician should retain in the patient?s medical record the history andor independent renal dialysis facility
                                              A                     Clinic-independent provider based FQHC (eff 10/91)
1. The operating physician should retain in the patient?s medical record the history and physical examination and notes docum
                                              A                     Clinic-CORF
1. The operating physician should retain in the patient?s medical record the history and physical examination and notes docum
                                              A                     Special facility or and surgery-ambulatory and notes docum
1. The operating physician should retain in the patient?s medical record the history ASCphysical examinationsurgical center (Di
                                              A                     Special facility or and surgery-rural primary care hospital (eff
1. The operating physician should retain in the patient?s medical record the history ASCphysical examination and notes docum
                                              A                     Hospital-inpatient or home Coverage and/or B only)
The medical record must clearly show that the criteria listed in ?Indications and Limitation of health visits (Part Medical Necessit
                                              A                     Hospital-outpatient (HHA-A also) (under OPPS 13X Necessit
The medical record must clearly show that the criteria listed in ?Indications and Limitation of Coverage and/or Medicalmust be u
                                              A                     SNF-inpatient or home health visits (Part B only)
The medical record must clearly show that the criteria listed in ?Indications and Limitation of Coverage and/or Medical Necessit
                                              A                     SNF-outpatient (HHA-A of Coverage and/or Medical Necessit
The medical record must clearly show that the criteria listed in ?Indications and Limitation also)
                                              A                     Special facility or ASC surgery-rural primary Medical Necessit
The medical record must clearly show that the criteria listed in ?Indications and Limitation of Coverage and/or care hospital (eff
                                              A                     Hospital-inpatient or home Coverage and/or B only)
The medical record must clearly show that the criteria listed in ?Indications and Limitation of health visits (Part Medical Necessit
                                              A                     Hospital-outpatient (HHA-A also) (under OPPS 13X Necessit
The medical record must clearly show that the criteria listed in ?Indications and Limitation of Coverage and/or Medicalmust be u
                                              A                     SNF-inpatient or home health visits (Part B only)
The medical record must clearly show that the criteria listed in ?Indications and Limitation of Coverage and/or Medical Necessit
                                              A                     SNF-outpatient (HHA-A of Coverage and/or Medical Necessit
The medical record must clearly show that the criteria listed in ?Indications and Limitation also)
                                              A                     Special facility or ASC surgery-rural primary Medical Necessit
The medical record must clearly show that the criteria listed in ?Indications and Limitation of Coverage and/or care hospital (eff
                                              A                     Hospital-inpatient or home health visits with B only)
The evaluation leading to the block must be explicitly documented in the patient?s medical records along (Part the post-block re
                                              A                     Hospital-outpatient (HHA-A also) along OPPS post-block re
The evaluation leading to the block must be explicitly documented in the patient?s medical records (underwith the13X must be u
                                              A                     SNF-inpatient or medical records along with the
The evaluation leading to the block must be explicitly documented in the patient?s home health visits (Part B only)post-block re
                                              A                     SNF-outpatient (HHA-A also)
The evaluation leading to the block must be explicitly documented in the patient?s medical records along with the post-block re
                                              A                     Special facility or ASC surgery-rural primary the post-block re
The evaluation leading to the block must be explicitly documented in the patient?s medical records along with care hospital (eff
                                              A                     Hospital-inpatient or home health visits with B only)
The evaluation leading to the block must be explicitly documented in the patient?s medical records along (Part the post-block re
                                              A                     Hospital-outpatient (HHA-A also) along OPPS post-block re
The evaluation leading to the block must be explicitly documented in the patient?s medical records (underwith the13X must be u
                                              A                     SNF-inpatient or medical records along with the
The evaluation leading to the block must be explicitly documented in the patient?s home health visits (Part B only)post-block re
                                              A                     SNF-outpatient (HHA-A also)
The evaluation leading to the block must be explicitly documented in the patient?s medical records along with the post-block re
                                              A                     Special facility or ASC surgery-rural primary the post-block re
The evaluation leading to the block must be explicitly documented in the patient?s medical records along with care hospital (eff
                                              A                     Hospital-inpatient (including Part A)
In all cases, the monitoring must be ordered by the patient?s physician and the physician must have performed a thorough eva
                                              A                     Hospital-inpatient or home health visits (Part B thorough eva
In all cases, the monitoring must be ordered by the patient?s physician and the physician must have performed aonly)
                                              A                     Hospital-outpatient (HHA-A also) (under OPPS thorough be
In all cases, the monitoring must be ordered by the patient?s physician and the physician must have performed a13X must evau
                                              A                     Non-Patient Laboratory must have
In all cases, the monitoring must be ordered by the patient?s physician and the physician Specimensperformed a thorough eva
                                              A                     Hospital-swing beds
In all cases, the monitoring must be ordered by the patient?s physician and the physician must have performed a thorough eva
                                              A                     SNF-inpatient, Part A
In all cases, the monitoring must be ordered by the patient?s physician and the physician must have performed a thorough eva
                                              A                     SNF-inpatient or home must visits (Part B only)
In all cases, the monitoring must be ordered by the patient?s physician and the physicianhealth have performed a thorough eva
                                              A                     SNF-outpatient (HHA-A also)
In all cases, the monitoring must be ordered by the patient?s physician and the physician must have performed a thorough eva
                                              A                     SNF-swing beds
In all cases, the monitoring must be ordered by the patient?s physician and the physician must have performed a thorough eva
                                              A                     Clinic-rural health
In all cases, the monitoring must be ordered by the patient?s physician and the physician must have performed a thorough eva
                                              A                     Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97)
In all cases, the monitoring must be ordered by the patient?s physician and the physician must have performed a thorough eva
                                               A                   Clinic-CORF
In all cases, the monitoring must be ordered by the patient?s physician and the physician must have performed a thorough eva
                                               A                   Special facility or ASC surgery-ambulatory surgical center (Di
In all cases, the monitoring must be ordered by the patient?s physician and the physician must have performed a thorough eva
                                               A                   Special facility or ASC surgery-rural primary care hospital (eff
In all cases, the monitoring must be ordered by the patient?s physician and the physician must have performed a thorough eva
                                               the                 Not services performed for each submitted date of service o
The patient's medical record must document P medical necessity of Applicable
                                               A                   Hospital-inpatient (including Part A)
Documentation to support the medical necessity for major joint injections should include: patient complaints; objective physical
                                               A                   Hospital-outpatient (HHA-A also) (under OPPS 13X physical
Documentation to support the medical necessity for major joint injections should include: patient complaints; objectivemust be u
                                               A                   Clinic-CORF
Documentation to support the medical necessity for major joint injections should include: patient complaints; objective physical
                                               A                   Special facility include: patient complaints; objective physical
Documentation to support the medical necessity for major joint injections should or ASC surgery-rural primary care hospital (eff
                                               A                   Hospital-inpatient (including Part A)
1.Documentation must reflect the medical necessity of providing the service. 2.During a post-payment review, the record will be
                                               A                   Hospital-outpatient (HHA-A also) (under OPPS record will be
1.Documentation must reflect the medical necessity of providing the service. 2.During a post-payment review, the13X must be u
                                               A                   Special facility or ASC surgery-rural review, the hospital (eff
1.Documentation must reflect the medical necessity of providing the service. 2.During a post-paymentprimary carerecord will be
                                               A                   Hospital-inpatient (including the A)
The medical record should clearly document the reason and medical necessity for performing Partprocedure at the frequency re
                                               A                   Hospital-outpatient (HHA-A the (under OPPS 13X must be u
The medical record should clearly document the reason and medical necessity for performingalso)procedure at the frequency re
                                               A                   Clinic-ORF only performing the procedure (10/91 - 3/97)
The medical record should clearly document the reason and medical necessity for(eff 4/97); ORF and CMHCat the frequency re
                                               A                   Clinic-CORF
The medical record should clearly document the reason and medical necessity for performing the procedure at the frequency re
                                               A                   Special facility or ASC surgery-rural primary care frequency re
The medical record should clearly document the reason and medical necessity for performing the procedure at the hospital (eff
                                               A                   Hospital-inpatient (including Part A)
1.The medical record documentation must clearly include the indications and medical necessity and the reason for the frequenc
                                               A                   Hospital-outpatient necessity and the reason for the frequenc
1.The medical record documentation must clearly include the indications and medical(HHA-A also) (under OPPS 13X must be u
                                               A                   Clinic-ORF medical necessity and the reason for the frequenc
1.The medical record documentation must clearly include the indications and only (eff 4/97); ORF and CMHC (10/91 - 3/97)
                                               A                   Clinic-CORF
1.The medical record documentation must clearly include the indications and medical necessity and the reason for the frequenc
                                               A                   Special facility or ASC surgery-rural primary care the frequenc
1.The medical record documentation must clearly include the indications and medical necessity and the reason for hospital (eff
                                               A                   Hospital-outpatient (HHA-A also) (under OPPS 13X must Ot
1.Patient?s clinical records must contain the following information: * Test results documenting the diagnosis of epilepsy; * be u
                                               A                   Hospital-inpatient may result in denial (Part B only)
Documentation must be made available to Medicare upon request. Failure to do so,or home health visits of claims. Documenta
                                               A                   Hospital-outpatient (HHA-A also) (under claims. Documenta
Documentation must be made available to Medicare upon request. Failure to do so, may result in denial ofOPPS 13X must be u
                                               A                   Non-Patient Laboratory Specimens
Documentation must be made available to Medicare upon request. Failure to do so, may result in denial of claims. Documenta
                                               A                   SNF-inpatient so, may result visits (Part claims.
Documentation must be made available to Medicare upon request. Failure to door home health in denial of B only) Documenta
                                               A                   SNF-outpatient (HHA-A also)
Documentation must be made available to Medicare upon request. Failure to do so, may result in denial of claims. Documenta
                                               A                   Special facility so, may result in denial of claims. Documenta
Documentation must be made available to Medicare upon request. Failure to do or ASC surgery-rural primary care hospital (eff
                                               A                   Hospital-inpatient necessity Part A)
Documentation must reflect the medical necessity of providing the service. Medical (including of implanting dorsal column stimu
                                               A                   Hospital-outpatient (HHA-A of implanting dorsal column stimu
Documentation must reflect the medical necessity of providing the service. Medical necessity also) (under OPPS 13X must be u
                                               P                   necessity for the
The patient?s medical record must clearly document the medical Not Applicable service/procedure rendered. Documentation
                                               P                   Not Applicable
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record and made availa
                                               A                   the Applicable
. Each claim must be submitted with ICD-9-CM codes that reflect Not condition of the patient, and indicate the reason(s) for whi
                                               P                   substantiate the medical necessity of the testing performed. T
Documentation must be evident in the patient's medical record to Hospital-inpatient or home health visits (Part B only)
                                               P                   substantiate the medical necessity of the testing performed. u
Documentation must be evident in the patient's medical record to Hospital-outpatient (HHA-A also) (under OPPS 13X must be T
                                               P                   substantiate the medical necessity
Documentation must be evident in the patient's medical record to Non-Patient Laboratory Specimens of the testing performed. T
                                               P                   substantiate the home health visits (Part testing
Documentation must be evident in the patient's medical record to SNF-inpatient or medical necessity of the B only) performed. T
                                               P                   substantiate the medical necessity of the testing performed. T
Documentation must be evident in the patient's medical record to SNF-outpatient (HHA-A also)
                                               P                   substantiate the medical necessity of the testing performed. T
Documentation must be evident in the patient's medical record to Clinic-rural health
                                               P                   substantiate the medical necessity of the testing performed. T
Documentation must be evident in the patient's medical record to Clinic-hospital based or independent renal dialysis facility
                                               P                   substantiate the ASC surgery-rural primary care hospital (eff
Documentation must be evident in the patient's medical record to Special facility ormedical necessity of the testing performed. T
                                               A                   Hospital-inpatient or home health for bone mass measureme
The patient?s medical record must contain documentation that fully supports the medical necessity visits (Part B only)
                                               A                   Hospital-outpatient (HHA-A also) for bone mass measureme
The patient?s medical record must contain documentation that fully supports the medical necessity(under OPPS 13X must be u
                                               A                   SNF-inpatient, medical
The patient?s medical record must contain documentation that fully supports thePart A necessity for bone mass measureme
                                               A                   SNF-inpatient or home necessity for bone only)
The patient?s medical record must contain documentation that fully supports the medicalhealth visits (Part B mass measureme
                                               A                   SNF-outpatient (HHA-A also)
The patient?s medical record must contain documentation that fully supports the medical necessity for bone mass measureme
                                               A                   Clinic-rural the medical necessity for bone mass measureme
The patient?s medical record must contain documentation that fully supports health
                                               A                   Special facility medical necessity for bone mass hospital (eff
The patient?s medical record must contain documentation that fully supports theor ASC surgery-rural primary care measureme
                                               P                   TBD
1. Each claim must be submitted with ICD-9-CM codes that reflect the condition of the patient, and indicate the reason(s) for wh
                                               A                   Hospital-inpatient the patient?s medical record, and must be m
1.Documentation supporting the medical necessity should be legible, maintained in (including Part A)
                                               A                   Hospital-inpatient the patient?s medical record, and
1.Documentation supporting the medical necessity should be legible, maintained in or home health visits (Part B only) must be m
                                               A                   Hospital-outpatient (HHA-A also) (under OPPS and
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, 13X must be u       m
                                            A                    Hospital-swing in the
1.Documentation supporting the medical necessity should be legible, maintained beds patient?s medical record, and must be m
                                            A                    SNF-inpatient or the patient?s medical record, and must be m
1.Documentation supporting the medical necessity should be legible, maintained inhome health visits (Part B only)
                                            A                    SNF-outpatient (HHA-A also)
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                            A                    Clinic-rural health
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                            A                    Clinic-independent provider based FQHC (eff 10/91)
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                            A                    Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97)
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                            A                    Clinic-CORF
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                            A                    Special facility in the surgery-rural primary care hospital be
1.Documentation supporting the medical necessity should be legible, maintainedor ASCpatient?s medical record, and must (effm
                                            A                     ordering/referring physician must clearly indicate the
1. The patient?s medical record documentation maintained by theHospital-inpatient or home health visits (Part B only) medica
                                            A                     ordering/referring (HHA-A also) (under OPPS 13X must be
1. The patient?s medical record documentation maintained by theHospital-outpatient physician must clearly indicate the medicau
                                            A                     ordering/referring
1. The patient?s medical record documentation maintained by theClinic-rural health physician must clearly indicate the medica
                                            A                     ordering/referring provider must FQHC (eff 10/91)
1. The patient?s medical record documentation maintained by theClinic-independent physicianbased clearly indicate the medica
                                            A                     ordering/referring physician must clearly indicate the medica
1. The patient?s medical record documentation maintained by theSpecial facility or ASC surgery-rural primary care hospital (eff
Copies of the medical records must be made P                     Not Applicable
                                             available upon Medicare request. The HCPCS/CPT code(s) may be subject to C
                                            P                    Not Applicable
The medical record must be made available to Medicare upon request. The HCPCS/CPT code(s) may be subject to Correct C
Copies of the medical records must be made P                     Not Applicable
                                             available upon Medicare request. The HCPCS/CPT code(s) may be subject to C
                                            P                    Not Applicable
The medical record must be made available to Medicare upon request. The HCPCS/CPT code(s) may be subject to Correct C
                                            of                    ICD-9-CM codes, must be submitted with each claim.
Documentation supporting medical necessity A this item, such asHospital-inpatient or home health visits (Part B only) Claims
                                            of                    ICD-9-CM codes, (HHA-A also) (under OPPS claim. Claims
Documentation supporting medical necessity A this item, such asHospital-outpatient must be submitted with each13X must be u
                                            of                    ICD-9-CM codes, must be submitted with each claim. Claims
Documentation supporting medical necessity A this item, such asHospital-swing beds
                                            of                    ICD-9-CM codes, A
Documentation supporting medical necessity A this item, such asSNF-inpatient, Partmust be submitted with each claim. Claims
                                            of                    ICD-9-CM codes, must be submitted with only)
Documentation supporting medical necessity A this item, such asSNF-inpatient or home health visits (Part Beach claim. Claims
                                            of                    ICD-9-CM codes, must be submitted with each claim. Claims
Documentation supporting medical necessity A this item, such asSNF-outpatient (HHA-A also)
                                            of                    ICD-9-CM codes,
Documentation supporting medical necessity A this item, such asClinic-rural health must be submitted with each claim. Claims
                                            of                    ICD-9-CM codes, provider based FQHC each claim.
Documentation supporting medical necessity A this item, such asClinic-independent must be submitted with(eff 10/91) Claims
                                            of                    ICD-9-CM codes, must be submitted with each hospital (eff
Documentation supporting medical necessity A this item, such asSpecial facility or ASC surgery-rural primary careclaim. Claims
                                            A                    Hospital-inpatient or home health visits either: ?Oral
When using intravenous infusion of zoledronic acid, the medical record must contain documentation that (Part B only) bisphos
                                            A                    Hospital-outpatient documentation that OPPS 13X must be
When using intravenous infusion of zoledronic acid, the medical record must contain (HHA-A also) (undereither: ?Oral bisphosu
                                            A                    Hospital-swing beds
When using intravenous infusion of zoledronic acid, the medical record must contain documentation that either: ?Oral bisphos
                                            A                    SNF-inpatient, Part A
When using intravenous infusion of zoledronic acid, the medical record must contain documentation that either: ?Oral bisphos
                                            A                    SNF-inpatient or home health visits (Part B only)
When using intravenous infusion of zoledronic acid, the medical record must contain documentation that either: ?Oral bisphos
                                            A                    SNF-outpatient (HHA-A also)
When using intravenous infusion of zoledronic acid, the medical record must contain documentation that either: ?Oral bisphos
                                            A                    Clinic-rural contain
When using intravenous infusion of zoledronic acid, the medical record must health documentation that either: ?Oral bisphos
                                            A                    Clinic-independent documentation that either: ?Oral
When using intravenous infusion of zoledronic acid, the medical record must contain provider based FQHC (eff 10/91) bisphos
                                            A                    Special facility or ASC surgery-rural primary care hospital (eff
When using intravenous infusion of zoledronic acid, the medical record must contain documentation that either: ?Oral bisphos
                                            A                    Hospital-inpatient the patient?s medical record, and
1.Documentation supporting the medical necessity should be legible, maintained in or home health visits (Part B only) must be m
                                            A                    Hospital-outpatient (HHA-A also) (under OPPS and
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, 13X must be u    m
                                            A                    SNF-inpatient or the patient?s medical record, and must be m
1.Documentation supporting the medical necessity should be legible, maintained inhome health visits (Part B only)
                                            A                    SNF-outpatient (HHA-A also)
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                            A                    Clinic-rural health
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                            A                    Clinic-independent provider based FQHC (eff 10/91)
1.Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be m
                                            A                    Special facility in the surgery-rural primary care hospital be
1.Documentation supporting the medical necessity should be legible, maintainedor ASCpatient?s medical record, and must (effm
                                            A                    Hospital-inpatient the patient?s medical record, and
1. Documentation supporting the medical necessity should be legible, maintained inor home health visits (Part B only) must be
                                            A                    Hospital-outpatient (HHA-A also) (under record, and must be
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical OPPS 13X must be u
                                            A                    Non-Patient Laboratory Specimens
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                            A                    Hospital-swing in the
1. Documentation supporting the medical necessity should be legible, maintainedbeds patient?s medical record, and must be
                                            A                    SNF-inpatient, Part A
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                            A                    SNF-inpatient or home health visits (Part B only)
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                            A                    SNF-outpatient in the patient?s
1. Documentation supporting the medical necessity should be legible, maintained (HHA-A also) medical record, and must be
                                            A                    Clinic-rural health
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                            A                    Clinic-independent provider based FQHC (eff 10/91)
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be
                                            A                    Special facility or ASC surgery-rural primary care hospital be
1. Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must(eff
                                          A                      maintained in
* Documentation supporting medical necessity should be legible, Not Applicablethe patient?s medical record and made availab
Reasons for Denial When the documentationA                      Hospital-inpatient or rendered or the documentation
                                           does not meet the criteria for the servicehome health visits (Part B only) does no
Reasons for Denial When the documentationA                      Hospital-outpatient (HHA-A also) the documentation does no
                                           does not meet the criteria for the service rendered or (under OPPS 13X must be u
Reasons for Denial When the documentationA                      SNF-inpatient or home health visits (Part B only)
                                           does not meet the criteria for the service rendered or the documentation does no
Reasons for Denial When the documentationA                      SNF-outpatient (HHA-A also)
                                           does not meet the criteria for the service rendered or the documentation does no
Reasons for Denial When the documentationA                      Special facility or ASC surgery-rural primary care hospital no
                                           does not meet the criteria for the service rendered or the documentation does(eff
                                          A                     Hospital-inpatient must be submitted with each claim.
Documentation supporting the medical necessity of this item, such as ICD-9 codes, or home health visits (Part B only) Claims
                                          A                     Hospital-outpatient (HHA-A also) (under OPPS claim. Claims
Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each 13X must be u
                                          A                     Hospital-swing beds
Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                          A                     SNF-inpatient, Part A
Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                          A                     SNF-inpatient or home be submitted with each
Documentation supporting the medical necessity of this item, such as ICD-9 codes, musthealth visits (Part B only)claim. Claims
                                          A                     SNF-outpatient (HHA-A also)
Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims
                                          A                     Clinic-hospital based or be submitted with dialysis facility
Documentation supporting the medical necessity of this item, such as ICD-9 codes, must independent renal each claim. Claims
                                          A                     Special facility or must be submitted with each claim. Claims
Documentation supporting the medical necessity of this item, such as ICD-9 codes,ASC surgery-rural primary care hospital (eff
                                          A                     Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                          A                     Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                          A                     Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                          A                     SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                          A                     SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                          A                     SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                          A                     Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                          A                     Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                          A                     Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                          A                     Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                          A                     Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                          A                     Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                          A                     Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                          A                     Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                          A                     Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                          A                     Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                          A                     Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                          A                     SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                          A                     SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                          A                     SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                          A                     Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                          A                     Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                          A                     Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                          A                     Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                          A                     Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                          A                     Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                          A                     SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                          A                     SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                          A                     SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                          A                     Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                          A                     Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                          A                     Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                          A                     Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                          A                     Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                          A                     Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                          A                     SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                          A                     SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                          A                     SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                               A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                               A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                               A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                               A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                               A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                               A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                               A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                               A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                               A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                               A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                               A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                               A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                               A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                               A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                               A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                               A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                               A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                               A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                               A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                               A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                               A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                               A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                               A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                               A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                               A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                               A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                               A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                               A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                               A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                               A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                               A                    Not Applicable
All claims for any procedure for bariatric surgery for morbid obesity must be supported by documentation in the medical record
                                               A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                               A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                               A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                               A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                               A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                               A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                               A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                               A                    Hospital-inpatient or home health visits (Part and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record,B only)
                                               A                    Hospital-outpatient patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                               A                    Hospital-swing the
Documentation supporting the medical necessity should be legible, maintained inbedspatient?s medical record, and must be ma
                                               A                    SNF-inpatient, Part patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the A
                                               A                    SNF-inpatient or home health visits (Part B only)
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                    SNF-outpatient the patient?s
Documentation supporting the medical necessity should be legible, maintained in (HHA-A also) medical record, and must be ma
                                               A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, and must be ma
                                               A                    Clinic-independent patient?s medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (eff 10/91)
                                               A                    Special facility or ASC surgery-rural primary care must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient?s medical record, andhospital (eff
                                               A                    Hospital-inpatient or home health visits (Part and must
Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, B only) be ma
                                               A                    Hospital-outpatient patient's medical record, and must be ma
Documentation supporting the medical necessity should be legible, maintained in the (HHA-A also) (under OPPS 13X must be u
                                               A                    Clinic-rural health
Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be ma
                                               A                    Clinic-independent patient's medical record, 10/91)
Documentation supporting the medical necessity should be legible, maintained in theprovider based FQHC (effand must be ma
                                               A                    Special facility or ASC surgery-rural primary and must be ma
Documentation supporting the medical necessity should be legible, maintained in the patient's medical record,care hospital (eff
                                               A                    Not and be available for review on request, the following info
 For Mammoplasty: 1. The beneficiary's medical record must contain,Applicable
Copies of the medical records must be made A                        Not Applicable
                                                available upon Medicare request. The HCPCS/CPT code(s) may be subject to C
                                               A                    Not Applicable
The medical record must be made available to Medicare upon request. The HCPCS/CPT code(s) may be subject to Correct C
                                               A                    Not Applicable
The patient's record must support the necessity for the nerve blocks and the frequency with which they are given, and be availa
                                               A                    Not Applicable
The patient's record must support the necessity for the nerve blocks and the frequency with which they are given, and be availa
                                               A                    Not Applicable
The patient's record must support the necessity for the nerve blocks and the frequency with which they are given, and be availa
                                               A                     as Applicable
Documentation must support the medical necessity of this serviceNot outlined in the Indications and Limitations of Coverage an
                                               A                     as Applicable
Documentation must support the medical necessity of this serviceNot outlined in the Indications and Limitations of Coverage an
                                               A                     as Applicable
Documentation must support the medical necessity of this serviceNot outlined in the Indications and Limitations of Coverage an
                                               A                    treatment. Medical records should include not only the standa
The patient's record must support the necessity and frequency of Not Applicable
                                               A                    treatment. Medical records should include not only the standa
The patient's record must support the necessity and frequency of Not Applicable
                                               A                    treatment. Medical records should include not only the standa
The patient's record must support the necessity and frequency of Not Applicable
                                                be                  Not Applicable
Documentation of the prerequisite tests must A present in the medical record. The medical record need not be submitted with
                                                be                  Not Applicable
Documentation of the prerequisite tests must A present in the medical record. The medical record need not be submitted with
                                                be                  Not Applicable
Documentation of the prerequisite tests must A present in the medical record. The medical record need not be submitted with
                                               A
The medical record must be made available to Medicare upon request. Not Applicable
                                               A
The medical record must be made available to Medicare upon request. Not Applicable
                                               A
The medical record must be made available to Medicare upon request. Not Applicable
                                               A                    Not Applicable
The clinical record should include the elements leading to the diagnosis and the therapies tried before the decision to use inject
                                               A                    The reasonable
Documentation in the patient's medical records must support: 1. Not Applicable and necessary requirements as outlined und
                                               A                    The reasonable
Documentation in the patient's medical records must support: 1. Not Applicable and necessary requirements as outlined und
                                               A                    The reasonable
Documentation in the patient's medical records must support: 1. Not Applicable and necessary requirements as outlined und
                                               A                    Not Applicable
1. Each claim must be submitted with an ICD-9-CM code(s) that reflects the condition of the patient and indicates the reason(s)
                                               A                    Not Applicable
1. Each claim must be submitted with an ICD-9-CM code(s) that reflects the condition of the patient and indicates the reason(s)
                                               A                    Not Applicable
1. Each claim must be submitted with an ICD-9-CM code(s) that reflects the condition of the patient and indicates the reason(s)
                                               A                    Not Applicable
If the patient presents with a combination of nail problems, and the physician addresses them with a combination of procedures
                                               A                    Not Applicable
If the patient presents with a combination of nail problems, and the physician addresses them with a combinat