Medical Necessity Guide

Transcription

1 Medical Necessity Guide Medicare Part B 2015

2 Medical Necessity Guide Medicare requires a statement of diagnosis for each laboratory test ordered. Medicare may not consider certain tests, diagnoses, and frequency combinations to be medically necessary and will not reimburse for any test that is judged to lack a medically necessary diagnosis or does not conform to frequency guidelines. These tests, therefore, would require that the patient sign an ABN (Advance Beneficiary Notice) before laboratory testing can be performed. This document contains data derived from Center for Medicare & Medicaid Services (CMS) Policy and Wisconsin Physicians Service (WPS) and affects Medicare Part B beneficiaries. The data contained within is an informational service intended to assist healthcare providers in providing appropriate and complete documentation to the The Medical Foundation in order to facilitate the efficient and effective delivery of healthcare services to patients. It is the responsibility of every healthcare provider to bill correctly. The Medical Foundation does not intend this guide to be legal advice or a substitute for legal advice relating to reimbursement or any other issue. As a guide, it should not be considered authoritative or complete as regards the content. It is also not intended to induce any recipient to direct Medicare related lab services to the The Medical Foundation. The information within does change from time to time and all healthcare providers should remember to confirm their compliance with all appropriate guidelines on their own. CAUTION: The Medical Foundation warns against using this guide to determine a diagnosis for reimbursement purposes. It is offered only as a means to determine if a test is covered by Medicare and, therefore, would not currently require that an Advance Beneficiary Notice (ABN) be signed. The Medical Foundation Medical Necessity Guide May

3 The Medical Foundation Medical Necessity Guide May

4 The test list below has been derived from the Center for Medicare & Medicaid Services (CMS) Policy and Wisconsin Physicians Service and affects Medicare Part B beneficiaries. Tests appear in this document with their order number, CPT code(s), and estimated fees and are followed by the ICD-9 codes that Medicare considers acceptable, medically necessary diagnoses. The exception is Complete Blood Count Testing. For CBCs the listed ICD-9 codes are for those diagnoses that Medicare does not consider medically necessary. Tests with a frequency limitation always need an ABN signed by the beneficiary. Any tests that are for research purposes only or are otherwise not approved by the Food and Drug Administration (FDA) are considered investigational and will require an Advance Beneficiary Notice. Table of Contents Allergen Testing LCD Page 1 Alpha-fetoprotein NCD Page 4 CA 15-3 / CA for Tumor Antigen, by Immunoassay NCD Page 6 CA 19-9 Immunoassay for Tumor Antigen, by Immunoassay NCD Page 7 CA 125 Immunoassay for Tumor Antigen, by Immunoassay NCD Page 8 CEA (Carcinoembryonic Antigen) NCD Page 9 Circulating Tumor Marker Assays LCD Page 11 Collagen Cross Links NCD Page 12 CBC (Complete Blood Count) NCD Page 13 Cytogenetic Studies LCD Page 21 Digoxin Therapeutic Drug Assay NCD Page 27 Drug Testing LCD Page 30 Ferritin (see Iron Studies) NCD Page 72 Flow Cytometry LCD Page 33 Fructosamine (see Hemoglobin A1c) NCD Page 61 GGT (Gamma Glutamyl Transferase) NCD Page 46 Glucose Testing, Blood NCD Page 56 Hemoglobin A1c NCD Page 61 Hepatitis Panel/Acute Hepatitis Panel NCD Page 63 Human Immunodeficiency Virus(HIV) Testing (Diagnosis) NCD Page 64 Human Immunodeficiency Virus (HIV) Testing (Monitoring) NCD Page 69 hcg (Human Chorionic Gonadotropin) NCD Page 70 Iron Studies, Serum NCD Page 72 Lipid Profile / Cholesterol Testing NCD Page 82 Molecular Diagnostic Testing LCD Page 89 Occult Blood Test, Feces (FOBT) NCD Page 95 Prothrombin Time NCD Page 100 PSA (Prostate Specific Antigen) NCD Page 111 PTT (Partial Thromboplastin Time) NCD Page 113 Thyroid Function Testing NCD Page 121 Triglycerides (see Lipid Testing) NCD Page 82 Urine Culture, Bacterial NCD Page 127 Vitamin D Assay Testing LCD Page 130 LCD = Local Coverage Determination (Indiana only) NCD = National Coverage Determination The Medical Foundation Medical Necessity Guide May 2015 Table of Contents

5 TEST FREQUENCY LIMITATIONS Human Immunodeficiency Virus (HIV) Screening Screening HIV tests are covered at a frequency of once every 12 months (11 full months must elapse following the month the previous test was performed in order for the subsequent test to be covered). For beneficiaries reporting increased risk factors, claims shall contain HCPCS code G0432, G0433, or G0435 with diagnosis code V73.89 (Special screening for other specified viral disease) as primary, and V69.8 (Other problems related to lifestyle), as secondary. For beneficiaries not reporting increased risk factors, claims shall contain HCPCS code G0432, G0433, or G0435 with diagnosis code V73.89 only. Screening HIV tests (codes G0432, G0433, or G0435) are covered at a maximum of three times per term pregnancy for pregnant Medicare beneficiaries beginning with the date of the first test when ordered by the woman s clinician. For pregnant Medicare beneficiaries, claims shall contain HCPCS code G0432, G0433, or G0435 with diagnosis code V73.89 as primary, and one of the following ICD-9 diagnosis codes: V22.0 (Supervision of normal first pregnancy), V22.1 (Supervision of other normal pregnancy), or V23.9 (Supervision of unspecified high-risk pregnancy), as secondary. Pap Smear, ThinPrep Screening Screening Pap tests are covered when the beneficiary has not had a screening Pap test during the preceding 2 years. At a frequency of once every 12 months for women who qualify for coverage under the childbearing provision (at least 11 months have passed following the month in which the last Medicare-covered screening Pap test was performed). Note: The 11-month calculation starts after completion of the entire month that follows the test date. [Example: A patient is tested in the month of January. The following month is February. The earliest that the test can be performed again is February of the next year (11 months have passed following the entire month in which the last test was performed)]. PSA (Prostate Specific Antigen) Screening prostate specific antigen tests are covered at a frequency of once every 12 months for men who have attained age 50 (at least 11 months have passed following the month in which the last Medicarecovered screening prostate specific antigen test was performed). Allergy Testing (Allergen Specific IgE; Quantitative or Semiquantitative) CPT code Twelve (12) allergens per panel are used but no more than 2 panels per beneficiary over a 12-month period are allowed. The medical necessity of more test must be documented in the patient s record and be available to the contractor upon request. The Medical Foundation Medical Necessity Guide May 2015 Test Frequency Limitations

6 Non-covered ICD-9-CM Codes for All NCD Edits This section lists codes that are never covered. If a code from this section is given as the reason for the test, the test may be billed to the Medicare beneficiary without billing Medicare first because the service is not covered by statute, in most instances because it is performed for screening purposes and is not within an exception. The beneficiary, however, does have a right to have the claim submitted to Medicare, upon request Sudden death, cause unknown V15.85 Personal history of contact with and (suspected) exposure to potentially hazardous body fluids V16.1 Family history of malignant neoplasm, trachea, bronchus, and lung V16.2 Family history of malignant neoplasm, other respiratory and intrathoracic organs V16.40 Family history of malignant neoplasm, genital organs V16.50 Family history of malignant neoplasm, urinary organs V16.51 Family history of malignant neoplasm, kidney V16.52 Family history of malignant neoplasm, bladder V16.59 Family history of malignant neoplasm, other V16.6 Family history of malignant neoplasm, leukemia V16.7 Family history of malignant neoplasm, other lymphatic and hematopoietic neoplasms V16.8 Family history of malignant neoplasm, other specified malignant neoplasm V16.9 Family history of malignant neoplasm, unspecified malignant neoplasm V17.0 V17.3 Family history of certain chronic disabling diseases V17.41 Family history of sudden cardiac death (SCD) V17.49 Family history of other cardiovascular diseases V17.5 V17.98 Family history of asthma; other chronic respiratory conditions arthritis; other musculoskeletal diseases V18.0 Family history of diabetes mellitus V18.11 Family history of multiple endocrine neoplasia (MEN) syndrome V18.19 Family history of other endocrine and metabolic diseases V18.2 V18.4, V18.51, V18.59, V18.61, V18.69, V18.7 V18.9 Family history of anemia; other blood disorders; mental retardation; colonic polyps; other digestive disorders; polycystic kidney; other kidney diseases; other genitourinary diseases; infectious and parasitic diseases; genetic disease carrier V19.11 Family history of glaucoma V19.19 Family history of other specified eye disorder V19.2 V19.8 Family history of other conditions V20.0 V20.2 Health supervision of infant or child V20.31 Health supervision for newborn under 8 days old V20.32 Health supervision for newborn 8 to 28 days old V V28.9 Encounter for antenatal screening of mother V V50.9 Elective surgery for purposes other than remedying health states V53.2 Hearing aid Lack of housing; inadequate housing; lack of material resources; person living alone; V60.0-V60.6 no other household person avle to render care; holiday relief care; and person living in residential institution V60.81 Foster care (status) The Medical Foundation Medical Necessity Guide May 2015 Non-covered ICD-9-CM Codes

7 V60.89 Other specified housing or economic circumstances V60.9 Unspecified housing or economic circumstances V62.0 Unemployment V62.1 Adverse effects of work environment V65.0 Healthy persons accompanying sick persons V65.11 Pediatric pre-birth visit for expectant parent(s) V65.19 Other person consulting on behalf of another person V V68.9 Encounters for administrative purposes V V70.9 General medical examinations V73.0-V73.6 Special screening examinations for viral and chlamydia diseases V73.81 Special screening examinations for Human papillomavirus (HPV) V73.88-V73.89 V73.98-V73.99 Other specified chlamydial and viral diseases Unspecified chlamydial and viral disease V V74.9 Special screening examinations for bacterial and spirochetal diseases V V75.9 Special screening examination for other infectious diseases V76.0 Special screening for malignant neoplasms, respiratory organs V76.3 Special screening for malignant neoplasms, bladder V76.42-V76.43, V76.45-V76.47, V76.49, V76.50, V76.52, V76.81, V76.89,V76.9 Special screening for malignant neoplasms,(sites other than breast, cervix, and rectum) V77.0 Special screening for endocrine, nutrition, metabolic, and immunity disorders V77.2-V77.99 Special screening for endocrine, nutrition, metabolic, and immunity disorders V78.0-V78.9 Special screening for disorders of blood and blood-forming organs V79.0-V79.9 Special screening for mental disorders V80.01 Special screening for traumatic brain injury V80.09 Special screening for other neurological conditions V81.3-V81.6 Special screening for cardiovascular, respiratory, and genitourinary diseases V82.0-V82.6, V82.71,V82.79, V82.81, V82.89, Special screening for other conditions V82.9 The Medical Foundation Medical Necessity Guide May 2015 Non-covered ICD-9-CM Codes

8 Allergy Testing -- LCD L30471 Order # CPT Estimated Fee Total IgE Allergen Specific IgE; Quantitative or Semiquantitative Allergen Specific IgE; Qualitative, Multiallergen Screen See TMF Lab Manual for complete listing See TMF Lab Manual for complete listing See TMF Lab Manual for complete listing $ $ Specific IgE in Vitro Test (RAST) These tests detect antigen-specific IgE antibodies in the patient's serum. In-vitro testing is not as sensitive as skin testing, but is covered when skin testing is not possible or would be unreliable as indicated below. When in-vitro testing is ordered or performed, the medical record must clearly document the indication. Invitro testing is covered only as a substitute for skin testing. It is not covered when done in addition to a skin test for the same antigen, except in the case of suspected latex sensitivity, hymenoptera, or nut/peanut sensitivity where both the skin test and the in-vitro test may be performed. It is rarely necessary to test for more than 50 allergies and, if food allergy is not suspected, fewer than 30 are usually sufficient. Testing must be based on a careful history/physical examination which suggests IgEmediated disease. If testing is inconclusive, and contraindications for skin testing have been resolved, then skin testing may be done and is covered. The medical record must document this rationale. Twelve (12) allergens per panel are used but no more than 2 panels per beneficiary over a 12-month period are allowed. The medical necessity of more tests must be submitted with the claim. THE FOLLOWING ICD-9 CODES SUPPORT MEDICAL NECESSITY FOR CPT CODE 86003, HOWEVER, DUE TO FREQUENCY LIMITATIONS, AN ABN IS REQUIRED Aspergillosis Acute Atopic Conjunctivitis Other Chronic Allergic Conjunctivitis Chronic Serous Otitis Media Simple Or Unspecified Other Chronic Serous Otitis Media Other And Unspecified Chronic Nonsuppurative Otitis Media Nonsuppurative Otitis Media Not Specified As Acute Or Chronic Eustachian Salpingitis Unspecified - Chronic Eustachian Salpingitis Dysfunction Of Eustachian Tube Unspecified Otitis Media Acute Bronchitis Polyp Of Nasal Cavity Other Polyp Of Sinus Allergy Testing (LCD) Medical Necessity Guide May 2015 Page 1

9 472.0 Chronic Rhinitis Chronic Tonsillitis - Chronic Tonsillitis And Adenoiditis Hypertrophy Of Tonsil With Adenoids - Hypertrophy Of Adenoids Alone Allergic Rhinitis Due To Pollen Allergic Rhinitis Due To Food Allergic Rhinitis, Due To Animal (Cat) (Dog) Hair And Dander Allergic Rhinitis Due To Other Allergen Allergic Rhinitis Cause Unspecified Nasal Mucositis (Ulcerative) Other Disease Of Nasal Cavity And Sinuses Extrinsic Asthma Unspecified Extrinsic Asthma With Status Asthmaticus Extrinsic Asthma With (Acute) Exacerbation Intrinsic Asthma Unspecified Intrinsic Asthma With Status Asthmaticus Intrinsic Asthma With (Acute) Exacerbation Chronic Obstructive Asthma Unspecified Chronic Obstructive Asthma With Status Asthmaticus Chronic Obstructive Asthma With (Acute) Exacerbation Cough Variant Asthma Asthma Unspecified Asthma Unspecified Type With Status Asthmaticus Asthma Unspecified With (Acute) Exacerbation Allergic Bronchopulmonary Aspergilliosis Other Atopic Dermatitis And Related Conditions Contact Dermatitis And Other Eczema Unspecified Cause Dermatitis Due To Drugs And Medicines Taken Internally Dermatitis Due To Food Taken Internally Dermatitis Due To Other Specified Substances Taken Internally Dermatitis Due To Unspecified Substance Taken Internally Allergic Urticaria Dermatographic Urticaria Other Specified Urticaria Allergy Testing (LCD) Medical Necessity Guide May 2015 Page 2

10 708.9 Unspecified Urticaria Disturbances Of Sensation Of Smell And Taste Rash And Other Nonspecific Skin Eruption Wheezing Toxic Effect Of Venom Toxic Effect Of Latex Other Anaphylactic Reaction Angioneurotic Edema Not Elsewhere Classified Other Drug Allergy Allergy Unspecified Not Elsewhere Classified Anaphylactic Reaction Due To Unspecified Food - Anaphylactic Reaction Due To Other Specified Food Other Adverse Food Reactions Not Elsewhere Classified V15.09 Personal History Of Other Allergy Other Than To Medicinal Agents V67.59 Other Follow-Up Examination Total Serum IgE (82785, 83518) is covered for follow-up of bronchopulmonary aspergillosis and it may be necessary to diagnose atopy in small children. It is also covered in association with the drug Omalizumab, Xolair (The patient's pretreatment serum IgE level and body weight are used to determine doses and dosing frequency). It is not appropriate in most general allergy testing. Instead, individual IgE tests are performed against a specific antigen. FOR CPT CODES AND 86005, NO ICD-9 CODE WILL BE REIMBURSED. A SIGNED ABN IS REQUIRED. Allergy Testing (LCD) Medical Necessity Guide May 2015 Page 3

11 Alpha-fetoprotein NCD Order # CPT Estimated Fee Alpha-Fetoprotein, Tumor Marker $ Alpha-Fetoprotein, Maternal, NTD Only May also be ordered as a component of the following panels: $ Prenatal Risk Assessment, Penta Screen (45382) Prenatal Risk Assessment, Quadruple Marker (30180) Prenatal Risk Assessment, Triple Marker (30080) ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY AND DO NOT CURRENTLY REQUIRE AN ABN: Chronic viral hepatitis B with hepatic coma, with or without mention of hepatitis delta Chronic viral hepatitis B without mention of hepatic coma, with or without mention of hepatitis delta Chronic hepatitis C with hepatic coma Chronic hepatitis C without mention of hepatic coma Syphilis of liver Clonorchiasis Fascioliasis Malignant neoplasm of the liver and intrahepatic bile ducts Malignant neoplasm of the mediastinum Malignant neoplasm, ovary Malignant neoplasm of undescended testis Malignant neoplasm, other and unspecified testis Secondary malignant neoplasm of medaistinum Secondary malignant neoplasm of liver Secondary malignant neoplasm of ovary Secondary malignant neoplasm, genital organs , Malignant carcinoid tumors of other and unspecified sites Secondary neuroendocrine tumor, unspecified site Secondary neuroendocrine tumor of distant lymph nodes Secondary neuroendocrine tumor of liver Secondary neuroendocrine tumor of bone Secondary neuroendocrine tumor of peritoneum Secondary Merkel cell carcinoma Secondary neuroendocrine tumor of other sites Benign neoplasm of liver and biliary passages Neoplasm of uncertain behavior of liver and biliary passages Mixed hyperlipidemia Alpha-1-antitrypsin deficiency Alpha-fetoprotein (NCD) (cont) Medical Necessity Guide May 2015 Page 4

12 Hereditary hemochromatosis Hemochromatosis due to repeated red blood cell transfusions Other hemochromatosis Other disorders of iron metabolism Disorder of copper metabolism Cystic Fibrosis without mention of meconium ileus Cystic Fibrosis with gastrointestinal manifestations Other deficiencies of circulating enzymes Sideroblastic Anemia Neoplasm related pain (acute)(chronic) Coronary atherosclerosis due to calcified coronary lesion Saddle embolus of abdominal aorta Other arterial embolism and thrombosis of abdominal aorta Alcoholic cirrhosis of liver Chronic hepatitis, unspecified Chronic persistent hepatitis Autoimmune hepatitis Other chronic hepatitis Cirrhosis of liver without mention of alcohol Hepatopulmonary syndrome Other specified disorders of male genital organs Solitary pulmonary nodule Other nonspecific abnormal finding of lung field Non-specific abnormal findings of other intrathoracic organs Non-specific abnormal findings of biliary tract Non-specific abnormal findings of abdominal area, including retro peritoneum Other abnormal tumor markers V10.07 Personal history of malignant neoplasm, liver V10.43 Personal history of malignant neoplasm, ovary V10.47 Personal history of malignant neoplasm, testis V86.0 Estrogen receptor positive status (ER+) V86.1 Estrogen receptor negative status (ER-) Alpha-fetoprotein (NCD) (cont) Medical Necessity Guide May 2015 Page 5

13 Tumor Antigen by Immunoassay CA 15-3/CA NCD Order # CPT Estimated Fee CA 15-3, by ECLIA $ CA 27.29, by Chemiluminescence $ ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY AND DO NOT CURRENTLY REQUIRE AN ABN: Breast, primary (female) malignant neoplasm of female breast Breast, primary (male) malignant neoplasm of male breast Secondary malignant neoplasm (male breast) Secondary malignant neoplasm (female breast) Neoplasm related pain (acute)(chronic) Other abnormal tumor markers V10.3 Personal history of malignant neoplasm, breast These services are not covered for the evaluation of patients with signs or symptoms suggestive of malignancy. The service may be ordered at times necessary to assess either the presence of recurrent disease or the patient s response to treatment with subsequent treatment cycles. Tumor Antigen by Immunoassay CA 15 Medical Necessity Guide May 2015 Page 6

14 Tumor Antigen by Immunoassay CA 19-9 NCD Order # CPT Estimated Fee CA 19-9, by Chemiluminescence, Serum $ CA 19-9, by Chemiluminescence, Body Fluid $ ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY AND DO NOT CURRENTLY REQUIRE AN ABN: Malignant neoplasm, intrahepatic bile ducts Malignant neoplasm of the gallbladder Malignant neoplasm, extrahepatic bile ducts Malignant neoplasm of the Ampulla of Vater Malignant neoplasm, other specified sites of gallbladder and extrahepatic bile ducts Malignant neoplasm, unspecified part of biliary tract Malignant neoplasm, pancreas Secondary malignant neoplasm, other digestive organs and spleen Neoplasm of uncertain behavior, liver and biliary passages Neoplasm of uncertain behavior, other and unspecified digestive organs Neoplasm related pain (acute)(chronic) Other abnormal tumor markers V10.09 Other personal history of cancer These services are not covered for the evaluation of patients with signs or symptoms suggestive of malignancy. The service may be ordered at times necessary to assess either the presence of recurrent disease or the patient s response to treatment with subsequent treatment cycles. Tumor Antigen by Immunoassay CA 19-9 Medical Necessity Guide May 2015 Page 7

15 Tumor Antigen by Immunoassay CA 125 NCD Order # CPT Estimated Fee CA 125 II, by ECLIA $ CA 125, with HAMA Treatment ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY AND DO NOT CURRENTLY REQUIRE AN ABN: Malignant neoplasm, specified parts of peritoneum Malignant neoplasm, peritoneum, unspecified Malignant neoplasm, endocervix Malignant neoplasm of corpus uteri, except isthmus Malignant neoplasm, ovary Malignant neoplasm, fallopian tube Malignant neoplasm, other specified sites of uterine adnexa Malignant neoplasm, other specified sites of female genital organs Secondary malignant neoplasm, ovary Secondary malignancy of genital organs Neoplasm of uncertain behavior of female genital organs Neoplasm related pain (acute)(chronic) Abdominal or pelvic swelling, mass or lump of other specified site Elevated cancer antigen 125 [CA 125] Other abnormal tumor markers V10.41 Personal history of malignant neoplasm, cervix uteri V10.42 Personal history of malignant neoplasm, other parts of uterus V10.43 V10.44 Personal history of malignant neoplasm of female genital organs These services are not covered for the evaluation of patients with signs or symptoms suggestive of malignancy. The service may be ordered at times necessary to assess either the presence of recurrent disease or the patient s response to treatment with subsequent treatment cycles. The CA 125 is specifically not covered for aiding in the differential diagnosis of patients with a pelvic mass as the sensitivity and specificity of the test is not sufficient. In general, a single tumor marker will suffice in following a patient with one of these malignancies. CA 125 (NCD) Medical Necessity Guide May 2015 Page 8

16 Carcinoembryonic Antigen (CEA) NCD Order # CPT Estimated Fee Carcinoembryonic Antigen, Serum $ Carcinoembryonic Antigen, Body Fluid $ Carcinoembryonic Antigen, with HAMA Treatment x2 ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY AND DO NOT CURRENTLY REQUIRE AN ABN: Malignant neoplasm of esophagus Malignant neoplasm of stomach Malignant neoplasm of small intestine, including duodenum, rectum, rectosigmoid junction and anus Primary malignancy of pancreas Malignant neoplasma of intestinal tract, part unspecified Malignant neoplasm of trachea, bronchus, and lung Malignant neoplasm of female breast Malignant neoplasm of male breast Malignant neoplasm of ovary Secondary malignant neoplasm of neoplasm of lung Secondary malignant neoplasm of small intestine Secondary malignant neoplasm of large intestine and rectum , Malignant carcinoid tumors of the small intestine Malignant carcinoid tumors of the appendix, large intestine, and rectum Malignant carcinoid tumors of other and unspecified sites Secondary neuroendocrine tumor, unspecified site Secondary neuroendocrine tumor of distant lymph nodes Secondary neuroendocrine tumor of liver Secondary neuroendocrine tumor of bone Secondary neuroendocrine tumor of peritoneum Secondary Merkel cell carcinoma Secondary neuroendocrine tumor of other sites Carcinoma in situ of colon Carcinoma in situ of rectum Carcinoma in situ of other and unspecified parts of intestine Carcinoma in situ other and unspecified digestive organs Neoplasm of uncertain behavior of stomach, intestines, rectum Neoplasm related pain (acute)(chronic) Other nonspecific findings on examination of blood Elevated carcinoembryonic antigen (CEA) Other abnormal tumor markers V10.00 Personal history of malignant neoplasm of gastro-intestinal tract, unspecified CEA (NCD) Medical Necessity Guide May 2015 Page 9

17 V10.05 Personal history of malignant neoplasm, large intestine V10.06 Personal history of malignant neoplasm, rectum, rectosigmoid junction, and anus V10.11 Personal history of malignant neoplasm, bronchus and lung V10.3 Personal history of malignant neoplasm, breast V10.43 Personal history of malignant neoplasm, ovary V67.2 Follow-up examination; following chemotherapy Serum CEA determinations are generally not indicated more frequently than once per chemotherapy treatment cycle for patients with metastatic solid tumors which express CEA or every two months post-surgical treatment for patients who have had colorectal carcinoma. However, it may be proper to order the test more frequently in certain situations, for example, when there has been a significant change from prior CEA level or a significant change in patient status which could reflect disease progression or recurrence. Testing with a diagnosis of an in situ carcinoma is not reasonably done more frequently than once, unless the result is abnormal, in which case the test may be repeated once. CEA (NCD) Medical Necessity Guide May 2015 Page 10

18 Circulating Tumor Cell Marker Assays L32218 Order # CPT Estimated Fee Circulating Tumor Cell Count $ THE FOLLOWING ICD-9 CODES SUPPORT MEDICAL NECESSITY FOR CPT CODE, HOWEVER, DUE TO FREQUENCY LIMITATIONS, AN ABN IS REQUIRED Malignant neoplasm of hepatic flexure - malignant neoplasm of colon unspecified site Malignant neoplasm of rectosigmoid junction - malignant neoplasm of other sites of rectum rectosigmoid junction and anus Malignant neoplasm of nipple and areola of female breast - malignant neoplasm of breast (female) unspecified site Malignant neoplasm of nipple and areola of male breast - malignant neoplasm of other and unspecified sites of male breast 185 Malignant neoplasm of prostate WPS Medicare expects physicians to limit CTC testing to only times when the CTC information may change treatment. Documentation maintained in the patient record must support medical necessity and be available upon request. Frequency Baseline limited to once prior to initiation of tumor-type specific chemotherapy Follow-up during chemotherapy treatment - repeat every 4-6 weeks Surveillance with no chemotherapy treatments - repeat every 4-6 months Circulating Tumor Cell Marker Assays Medical Necessity Guide May 2015 Page 11

19 Collagen Cross Links NCD Order # CPT Estimated Fee Deoxypyridinoline Crosslinks $ N-Telopeptide, Cross-Linked, Serum $ N-Telopeptide, Cross-Linked, Urine $ Pyridinium Crosslinks, Total, Urine $ Pyridinoline and Deoxypyridinoline, by HPLC $ Beta-C-Terminal Telopeptide, Serum or Plasma $ Ehlers-Danlos Syndrome Type VI Screen, Urine $ ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY AND DO NOT CURRENTLY REQUIRE AN ABN: Thyrotoxicosis Chronic lymphocytic thyroiditis (only if thyrotoxic) Unspecified disorder of thyroid , Hyperparathyroidism Postablative ovarian failure Other ovarian failure Other ovarian dysfunction Unspecified ovarian dysfunction Unspecified Vitamin D deficiency Mineral deficiency, not elsewhere classified Premenopausal menorrhagia Postmenopausal bleeding Menopausal or female climacteric state States associated with artificial menopause Other specified menopausal and postmenopausal disorders Unspecified menopausal and postmenopausal disorder Osteitis deformans without mention of bone tumor (Paget s disease of bone) Osteoporosis Pathological fracture Disorder of bone and cartilage, unspecified Fracture of vertebral column without mention of spinal cord injury, unspecified, closed V58.65 Long-term (current) use of steroids V58.69 Long-term (current) use of other medications Collagen Cross Links Medical Necessity Guide May 2015 Page 12

20 CBC (Complete Blood Count) NCD Order # CPT Estimated Fee CBC with Automated Differential /G0306 $39.60 CBC without Differential $37.50 CBC with Manual Differential /85007 $63.20 Hemoglobin, Blood $19.30 Hematocrit $19.30 Hematocrit, Body Fluid $19.30 Eosinophil Count, Blood $25.70 Differential, Blood $25.70 Platelet Count $25.70 Hemoglobin and Hematocrit /85014 $38.60 IMPORTANT NOTE: ICD-9 codes as listed for CBC are an EXCEPTION TO THE RULE. THE ICD-9 CODES BELOW DO NOT SUPPORT MEDICAL NECESSITY AND WILL REQUIRE AN ABN: Viral Warts Benign neoplasm of lip, oral cavity, and pharynx Lipoma, skin and subcutaneous tissue of face Benign neoplasm of skin 217 Benign neoplasm of breast Benign neoplasm of male genital organs Benign neoplasm of eye Carcinoma in situ of lip, oral cavity and pharynx Carcinoma in situ of skin Neurotic disorders Personality disorders Sexual deviations and disorders Stammering and stuttering Tics Stereotyped repetitive movements Psychalgia Disturbance of conduct, not elsewhere classified Disturbance of emotions, specific to childhood and adolescence Hyperkinetic syndrome of childhood Central pain syndrome Acute pain due to trauma Acute post-thoracotomy pain Other acute postoperative pain CBC (NCD) Medical Necessity Guide May 2015 Page 13

21 Other acute pain Chronic pain due to trauma Chronic post-thoracotomy pain Other chronic postoperative pain Other chronic pain Chronic pain syndrome Chorioretinal scars Choroidal degeneration Hereditary choroidal dystrophies Choroidal detachment Cataract Disorders of refraction and accommodation Corneal opacity and other disorders of cornea Inflammation of eyelids Disorders of lacrimal system Endocrine exophthalmos Other exophthalmic conditions Deformity of orbit Exophthalmos Retained (old) foreign body following penetrating wound of orbit Orbital cysts; myopathy of extraocular muscles Other orbital disorders Unspecified disorder of orbit Optic atrophy Other disorders of optic disc Perforation of tympanic membrane Other specified disorders of tympanic membrane Other disorders of middle ear and mastoid Otosclerosis Degenerative and vascular disorders of ear; noise effects on inner ear; sudden hearing loss, unspecified; and tinnitus Other abnormal auditory perception Disorders of acoustic nerve , Conductive hearing loss Sensorineural hearing loss Mixed hearing loss Deaf, non-speaking, not elsewhere classifiable 389.8, Hearing loss Atherosclerosis of aorta and renal artery Peripheral vascular disease Capillary nevus, non neoplastic Postmastectomy lymphedema syndrome 470 Deviated nasal septum Nasal polyps CBC (NCD) Medical Necessity Guide May 2015 Page 14

22 478.0 Hypertrophy of nasal turbinates Nasal mucositis (ulcerative) Other disease of nasal cavity and sinuses Polyp of vocal cord or larynx Disorders of tooth development and eruption , , , , , , , , Diseases of hard tissues of teeth Dentofacial anomalies, including malocclusion 525.0, , , , 525.3, , , , Other diseases and conditions of teeth and supporting structures Osseointegration failure of dental implant Post-osseointegration biological failure of dental implant Post-osseointegration mechanic failure of dental implant Other specified disorders of the teeth and supporting structures Unspecified disorder of the teeth and supporting structures Diseases of the jaws Perforation of root canal space Endodontic overfill Endodontic underfill Other periradicular pathology associated with previous endodontic treatment Diseases of the salivary glands Cholesterolosis of gallbladder Hyperplasia of prostate Encysted hydrocele Other specified types of hydrocele Hydrocele, unspecified 605 Redundant prepuce and phimosis Infertility, male Spermatocoele Torsion of testis, unspecified Extravaginal torsion of spermatic cord Intravaginal torsion of spermatic cord Torsion of appendix testis Torsion of appemdix epididymis Atrophy of testis Benign mammary dysplasia CBC (NCD) Medical Necessity Guide May 2015 Page 15

23 Other disorders of breast Unspecified breast disorder Cyst of Bartholin s gland , , , , , , Genital proplapse Noninflammatory disorders of ovary, fallopian tube, and broad ligament Malposition or inversion of uterus Menopausal and post menopausal disorders Infertility, female Other disorders of breast associated with childbirth and disorders of lactation Atopic dermatitis and related disorders Contact dermatitis and other eczema 700 Corns and callosities Other hypertrophic and atrophic conditions of skin Other dermatoses Unspecified disease of nail Diseases of sebaceous glands Other disorders of skin and subcutaneous tissue Osteoarthrosis Other and unspecified arthropathies , , Articular cartilage disorder Loose body in joint Dislocation or displacement of joint, not recurrent and not current Recurrent dislocation of joint Contracture of joint Ankylosis of joint Development dislocation of joint Other joint derangement, not elsewhere classified , Unspecified derangement of joint Adhesive capsulitis of shoulder Rotator cuff syndrome of shoulder and allied disorders Disorders of bursae and tendons in shoulder region, unspecified Calcifying tendinitis of shoulder Bicipital tenosynovitis Partial tear of rotator cuff Rotator cuff syndrome of shoulder and allied disorders, other specified disorders Other affections of shoulder region, not elsewhere classified , Enthesopathy of elbow region Enthesopathy of wrist and carpus Enthesopathy of hip region CBC (NCD) Medical Necessity Guide May 2015 Page 16

24 , , Enthesopathy of knee Enthesopathy of ankle and tarsus Other peripheral enthesopathies Unspecified enthesopathy Other disorders of synovium, tendon, and bursa Disorders of muscle ligament and fascia Osteochondropathies Osteoporosis 734 Flat foot Acquired deformities of toe Other acquired deformities of limb Curvature of spine Other acquired deformity Nonallopathic lesions, not elsewhere classified Decreased libido Dislocation of jaw, shoulder, and elbow Nursemaid s elbow Dislocation of wrist Dislocation of finger Dislocation of hip Dislocation of knee Dislocation of ankle Dislocation of foot Other, multiple and ill-defined dislocations Sprains and strains Late effects of musculoskeletal and connective tissue injuries Superficial injuries Foreign body on external eye, in ear, in nose Injury to peripheral nerve V03.0 V06.9 Need for prophylactic vaccination V11.0 V11.3 Personal history of mental disorder; schizophrenia, affective disorders, neurosis, and alcoholism V11.4 Personal history of combat and operational stress reaction V11.8 V11.9 Personal history of other and unspecified mental disorders V14.0 V14.8 Personal history of allergy to medicinal agents V16.0 Family history of malignant neoplasm, gastrointestinal tract V16.3 Family history of malignant neoplasm, breast V21.0 V21.9 Constitutional states in development V25.01-V25.04 V25.09, Encounter for contraceptive management; general counseling and advice V25.11 Encounter for insertion of intrauterine contraceptive device V25.12 Encounter for removal of intrauterine contraceptive device V25.13 Encounter for removal and reinsertion of intrauterine device CBC (NCD) Medical Necessity Guide May 2015 Page 17

25 V25.2 V25.3, V25.40-V25.43 V25.49, V25.5, V25.8, V25.9 V26.0-V26.39 Encounter for sterilization; menstrual extraction; surveillance of previously prescribed contraceptive methods; and insertion of implantable subdermal contraceptive; other specified and unspecified contraceptive management Procreative management V26.41 Other procreative counseling and advice using natural family planning V26.42 Encounter for fertility preservation counseling V26.49 Other procreative management, counseling and advice V26.5 Sterilization status V26.81 Encounter for assisted reproductive fertility procedure cycle V26.82 Encounter for fertility preservation procedure V V26.9 Other specified and unspecified procreative management V40.0 V40.2 Mental and behavioral problems V40.31 Wandering in disease classified elsewhere V40.39 Other specified behavioral problem V40.9 Unspecified mental or behavioral problem V41.0 V41.9 Problems with special senses and other special functions V43.0 V43.1 Organ or tissue replaced by other means, eye globe or lens V44.0 V44.9 Artificial opening status V V45.02, V45.09 Cardiac device in situ V45.11 Renal dialysis status V45.12 Noncompliance with renal dialysis V V45.4 V45.51, V45.52, V45.59, V45.61, V45.69, Other post surgical states V45.71 V45.79, V45.81 V45.85, V45.86, V45.89 V48.0 V48.9 Problems with head, neck, and trunk V V49.85 Other conditions influencing health status V49.86 Do not resuscitate status V49.87 Physical restraints status V49.89 V49.9 Other specified and unspecified conditions influencing health status V51.0 Encounter for breast reconstruction following mastectomy V51.8 Other aftercare involving the use of plastic surgery V52.0 V52.9 Fitting and adjustment of prosthetic device and implant V53.01 V53.09 Fitting and adjustment of devices related to nervous system and special senses V53.1 Fitting and adjustment of spectacles and contact lenses V53.31 V53.39 Fitting and adjustment of cardiac device V53.4 Fitting and adjustment of orthodontic devices V53.50 Fitting and adjustment of intestinal appliance and device V53.51 Fitting and adjustment of gastric lap band V53.59 Fitting and adjustment of other gastrointestinal appliance and device V53.6 Fitting and adjustment of urinary devices V53.7 Fitting and adjustment of orthopedic devices V53.8 Fitting and adjustment of wheelchair CBC (NCD) Medical Necessity Guide May 2015 Page 18

26 V53.90 V53.99 Fitting and adjustment of other and unspecified device V54.01 Encounter for removal of internal fixation device V54.02 Encounter for lengthening/adjustment of growth rod V54.09 Other aftercare involving internal fixation device V V54.19 Aftercare for healing traumatic fracture V54.2 V54.29 Aftercare for healing pathologic fracture V54.81 Aftercare following joint replacement V54.82 Aftercare following explantation of joint prothesis V54.89 Other orthopedic aftercare V54.9 Unspecified orthopedic aftercare V55.0 V55.9 Attention to artificial openings V57.0 V57.2 Care involving use of rehabilitation procedures V57.3 Care involving speech-language therapy V57.4 V57.9 Orthoptic training, other specified, and unspecified rehabilitation procedure V58.5 Orthodontics V59.01 V59.9 Donors V61.01 Family disruption due to family member on military deployment V61.02 Family disruption due to return of family member from military deployment V61.03 Family disruption due to divorce or legal separation V61.04 Family disruption due to parent V61.05 Family disruption due to child in welfare custody V61.06 Family disruption due to child in foster care or in care of non-parental family member V61.07 Family disruption due to death of family member V61.08 Family disruption due to other extended absence of family member V61.09 Other family disruption V61.10 Counseling for marital and partner problems, unspecified V61.11 Counseling for victim of spousal and partner abuse V61.12 Counseling for perpetrator of spousal and patner abuse V61.20 Counseling for parent-child problem V61.21 Conseling for victim of child abuse V61.22 Counseling for perpetrator of parental child abuse V61.23 Counseling for parent-biology child problem V61.24 Counseling for parent-adopted child problem V61.25 Counseling for parent (guardian)-foster child problem V61.29 Other parent-child problems V61.3 Problems with aged parents or in-laws V61.41 Alcoholism in family V61.42 Substance abuse in family V61.49, V61.5 V61.9 Other specified and unspecified family problems V62.21 Personal current military deployment V62.22 Personal history of return from military deployment V62.29 Other occupational circumstances or maladjustment V62.3 V62.84 Educational circumstances; other psychological or physical stress, not elsewhere classified; suicidal ideation CBC (NCD) Medical Necessity Guide May 2015 Page 19

27 V62.85 Homicidal ideation V62.89 V62.9 Other psychological or physical stress, not elsewhere classified; and unspecified psychosocial circumstances V65.2 Person feigning illness V65.3 Dietary surveillance and counseling V65.40 V65.49 Other counseling, not elsewhere classified V65.5 Person with feared complaint in who no diagnosis was made V65.8 Other reasons for seeking consultation V65.9 Unspecified reason for consultation V66.0 V66.9 Convalescence and palliative care V67.3 Follow-up examination following psychotherapy V67.4 Follow-up examination following treatment of healed fracture V69.3 Problems related to lifestyle, gambling and betting V71.01 V71.09 Observation and evaluation for suspected conditions not found, mental V72.0 Examination of eyes and vision V72.11 V72.12 V72.19 V72.2 Dental examination V72.40, V72.41, V72.42 Encounter for hearing conservation and treatment; other examination of ears and hearing Pregnancy examination or test; pregnancy unconfirmed; negative result; positive result V72.5 Radiological examination, not elsewhere classified V72.60 Laboratory examination, unspecified V72.61 Antibody response examination V72.62 Laboratory examination ordered as part of a routine general medical examination V72.63 Pre-procedural laboratory examination V72.69 Other laboratory examination V72.7 Diagnostic skin and sensitization tests V72.9 Unspecified examination V76.10 V76.19 Special screening for malignant neoplasms, breast V76.2 Special screening for malignant neoplasms, cervix V76.44 Special screening for malignant neoplasms, othere sites, prostate V76.51 Special screening for malignant neoplasms, intestine, colon V77.1 Special screening for diabetes mellitus V81.0 Special screening for ischemic heart disease V81.1 Special screening for hypertension V81.2 Special screening for other and unspecified cardiovascular conditions CBC (NCD) Medical Necessity Guide May 2015 Page 20

28 Cytogenetic Studies LCD - L30487 Order # CPT Estimated Fee Chromosome Analysis, Blood Chromosome Analysis, Breakage Syndrome Analysis ; 88261; 88280; $ ; 88248; $ Chromosome Analysis, Tissue (Non neoplastic) ; $ Chromosome Analysis, Amniotic Fluid Chromosome Analysis, Chorionic Villus ; 88269; 88280; $ ; 88267; 88280; $ Chromosome Analysis, Oncology, Bone Marrow or Blood ; 88261; 88280; $ Chromosome Analysis, Oncology, Solid Tumor ; 88261; 88280; $ Angelman Syndrome, FISH x4; 88273x2 $ BCR/ABL t(9;22) Translocation, D-FISH Chronic Lymphocytic Leukemia Panel, FISH x $ x6; 88275x3 $ PML/RARa t(15;17) Translocation, FISH x $ Prader-Willi Syndrome, FISH x4, 88273x2 $1, CHIC2, 4q12 Deletion (FIP1L1 And Prgfra Fusion), FISH x3; $ Digeorge Syndrome (VCFS), FISH Aneuvysion FISH, Amniotic Fluid Myelodysplastic Syndromes (Mds) Panel, Fish IGH/BCL2 T(14;18) Translocation, FISH CCND1/IGH T(11;14) Translocation, FISH Burkitt Lymphoma Panel, Fish x2; x5; 88275x x8; 88275x x2; x2; x4; 88275x2 $ $1, $1, $ $ $1, Cytogenetic Studies (LCD) Medical Necessity Guide May 2015 Page 21

29 Multiple Myeloma Panel, Fish IGH Probe Set Acute Myeloid Leukemia (AML) Panel, FISH x8; 88275x x6; 88275x x8; 88275x4 $1, $1, $1, Constitutional Cytogenetic Studies CPT Codes: 88230, 88235, 88262, 88267, 88269, 88283, Lymphangioma any site Other ovarian failure Other testicular dysfunction Delay in sexual development and puberty not elsewhere classified Primary hypercoagulable state Myelofibrosis Autistic disorder, current or active state - childhood disintegrative disorder, residual state Mild intellectual disabilities - unspecified intellectual disabilities Other spinocerebellar diseases Disorders of acoustic nerve Azoospermia Oligospermia Hypertrophy of breast Infertility female of unspecified origin Hydatidiform mole - other abnormal products of conception 632 Missed abortion Spontaneous abortion unspecified complicated by genital tract and pelvic infection - spontaneous abortion complete without complication Recurrent pregnancy loss, antepartum condition or complication Other fetal abnormality causing disproportion unspecified as to episode of care Other fetal abnormality causing disproportion delivered Other fetal abnormality causing disproportion antepartum Chromosomal abnormality in fetus affecting management of mother unspecified as to episode of care in pregnancy - chromosomal abnormality in fetus affecting management of mother antepartum Hereditary disease in family possibly affecting fetus affecting management of mother unspecified as to episode of care in pregnancy - hereditary disease in family possibly affecting fetus affecting management of mother antepartum condition or complication Intrauterine death affecting management of mother unspecified as to episode of care Intrauterine death affecting management of mother delivered Intrauterine death affecting management of mother antepartum Poor fetal growth affecting management of mother unspecified as to episode of care Poor fetal growth affecting management of mother delivered Poor fetal growth affecting management of mother antepartum condition or complication Excessive fetal growth affecting management of mother unspecified as to episode of care Excessive fetal growth affecting management of mother delivered Excessive fetal growth affecting management of mother antepartum Polyhydramnios unspecified as to episode of care - polyhydramnios antepartum complication Cytogenetic Studies (LCD) Medical Necessity Guide May 2015 Page 22