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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Unbundling of CT Scans
_0146
Automated
All Provider Specialties
Region-1
1 - All Region 1 states
03/26/2019

Unbundling of CT Scans

Issue Name: Unbundling of CT Scans
Issue Number: _0146
Review Type: Automated
Provider Type: All Provider Specialties
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/26/2019
Dates Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter Date (automated review)
Description: When a more extensive CT Scan is performed on the same site as a less extensive CT Scan, the less extensive CT Scan is bundled into the more extensive CT Scan. Affected codes: See 0146 Appendix D
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 4. 42 CFR §405.986- Good Cause for Reopening 5. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests 6. CMS Pub. 100-04 (Medicare Claims Processing Manual), Chapter 12 (Physicians/Non-physician Practitioners), Sections 30 (H) (Most Extensive Procedures) and J. With/Without Procedures (Effective 10/1/03) 7. CMS Publication 100-04; Chapter 23, § 20.9.2 Fee Schedule Administration and Coding Requirements 8. NCCI Policy Manual for Medicare Services Chapter 1 A 9. CPT Manual year 2015 to current Edit Parameters: 1. Assigned Claims Only 2. Provider Types: Professional Services (Physician/non-physician practitioner) and Outpatient Hospital 3. Error Code: 6000 – Unbundling service – included in allowable for another billed service 4. Exclude claims that have a “paid claim date” which is more than 3 years prior to the Informational Letter Date (automated review). 5. Algorithm identifies all Paid Part B Professional Claims and Outpatient Hospital Claims (Bill Type 12X, 13X), or Provider Types Outpatient Hospital and Professional Services (Physician/non- physician practitioner) with (Allowed Amt>$0.00) for CPT codes listed as Most Extensive Code billed on the same day as one or both of the corresponding Less Extensive Code(s) in the Appendix D table ""Most Extensive CT Scan Procedure Table"" for the same beneficiary, same group practice (Based on Tax ID and Specialty Code) and admit date and discharge date. • The CPT code identified as the Most Extensive Code is the valid, anchor claim. • The CPT code(s) identified as the Less Extensive Code(s), for the identified Most Extensive code, is the finding, overpaid claim. 6. Algorithm excludes claims that do not have matching 26/TC modifiers, in any position, for each of the code combinations. Both the finding and anchor claim must have the same Modifier, either 26 or TC. 7. Exclude all Prior Authorization claims identified with a valid Unique Tracking Number (UTN) 8. Algorithm excludes findings for the following modifiers on either the anchor or findings claim: • 59 – Distinct Procedural Service • 76- Repeat Procedure by Same Physician • 77- Repeat Procedure by Another Physician • XE - Separate Encounter, Service that is distinct - occurred during separate encounter • XS - Separate Structure, Service that is distinct - performed on a separate organ/structure • XP - Separate Practitioner, Service that is distinct - performed by a different practitioner • XU - Unusual Non-Overlapping service, use of a service that is distinct – does not overlap usual components of the main source • GA - Waiver of Liability Statement issued as required by payer policy • GX - Notice of Liability issued, voluntary under payer policy • Q0 - Investigational clinical service provided in a clinical research study that is in an approved clinical research study • Q1 - Routine clinical service provided in a clinical research study that is in an approved clinical research study 9. Algorithm excludes any claims that will have an overpayment adjustment of less than $25. 10. Exclude all claims identified with a valid Unique Tracking Number (UTN)."
Off-the-Shelf Knee Orthosis
_0144
Complex
DME by Supplier/ DME by Physician
Region-5
5 - Nationwide
03/15/2019

Off-the-Shelf Knee Orthosis

Issue Name: Off-the-Shelf Knee Orthosis
Issue Number: _0144
Review Type: Complex
Provider Type: DME by Supplier/ DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 03/15/2019
Dates Service: Less than 3 years and on or after October 1, 2015
Description: Off-the-Shelf Knee Orthoses may have been provided to beneficiaries where all Medicare coverage requirements were not met. This review will determine if the orthoses is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity requirements will be denied. Affected codes: L1812, L1820, L1830, L1831, L1833, L1836, L1848, L1850, L1851 and L1852
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A) - Exclusions from Coverage and Medicare as a Secondary Payer 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 - Special Payment Rules 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1842(p)(4)- Provisions Relating to the Administration of Part B 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 7. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 10. 42 CFR §424.57(c)- Application Certification Standards 11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests 12. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements 13. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 14. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders 15. Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders 16. Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders 17. Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders 18. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 19. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 20. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record 21. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 22. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Determination (LCD) L33318, Knee Orthoses; Effective Date: 10/01/2015; Revision Effective Date 10/16/2017 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Article A52456, Knee Orthoses; Effective Date: 10/01/2015; Revision Effective Date: 01/01/2017 25. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 08/28/2018"
Medical Necessity Cardiac Rehabilitation
_0135
Complex
Outpatient Hospital
Region-1
1 - All Region 1 states
03/07/2019

Medical Necessity Cardiac Rehabilitation

Issue Name: Medical Necessity Cardiac Rehabilitation
Issue Number: _0135
Review Type: Complex
Provider Type: Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/07/2019
Dates Service: 3 years
Description: Cardiac rehabilitation (CR) is a physician-supervised program that furnishes physician prescribed exercise, cardiac risk factor modification, psychosocial assessment, and outcome assessment. Medical Documentation will be reviewed to determine if cardiac rehabilitation is medically reasonable and necessary as well as meeting federal guidelines and Medicare coverage criteria.
References: Social Security Act § 1862 (a)(1)(A); Social Security Act § 1833 (e); Social Security Act § 1861 (s)(2)(CC)(e); 42 .F.R. §§ 410.49 ; CMS National Coverage Determinations (NCD), Pub. 100-03, Section 20.10.1, 20.31, 20.31.1, 20.31.2, and 20.31.3; CMS Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 232; CMS Claim Processing Manual, Pub. 100-04, Chapter 32, Section 140; CMS Transmittal R1974CP, Issued /21/2010, Implementation Date 10/4/2010; CMS Transmittal R126BP, Issued 5/21/2010, Implementation Date 10/4/2010; CMS Transmittal R339PI, Issued 5/21/2010, Implementation Date 10/4/2010; Palmetto LCD L34412 Cardiac Rehabilitation, Effective Date 10/1/2015; Palmetto LCA A53775 Frequency and Duration for Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Supplemental Instruction Article, Effective Date 10/1/2015
Skilled Nursing Facility (SNF) Consolidated Billing for Therapies
_0138
Automated
Physician/non-physician practitioner, Physical Therapist, Occupational Therapist, Speech-language Pathologist
Region-1
1 - All Region 1 states
02/19/2019

Skilled Nursing Facility (SNF) Consolidated Billing for Therapies

Issue Name: Skilled Nursing Facility (SNF) Consolidated Billing for Therapies
Issue Number: _0138
Review Type: Automated
Provider Type: Physician/non-physician practitioner, Physical Therapist, Occupational Therapist, Speech-language Pathologist
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/19/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review).
Description: Physical therapy, speech-language pathology services, and occupational therapy are bundled into the SNF’s global per diem payment for a resident’s covered Part A stay. They are also subject to the SNF “Part B” consolidated billing requirement for services furnished to SNF Part B residents. Affected codes: Therapy CPT/HCPCS codes Included in File 4. SNF Part B Consolidated Billing tables (See Appendix D in downloadable file for a detailed list of CPT/HCPCS including descriptions).
References: Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits ; 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor;  and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party ; 42 CFR §405.986- Good Cause for Reopening   Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests ; Medicare Claims Processing Manual: Publication 100-04; Chapter 6; 10.3 – Types of Services Subject to the Consolidated Billing Requirement for SNF; 20.5- Therapy Services; Medicare Claims Processing Manual: Publication 100-04; Chapter 7; 110, Carrier Claims Processing for Consolidated Billing for Physician and Non-Physician Practitioner Services Rendered to Beneficiaries in a Non-Covered SNF Stay
Excessive Units of Subsequent Hospital and Nursing Facility Care Services (Telehealth)
_0125
Automated
Professional Services (Physician/non-physician practitioner)
Region-1
1 - All Region 1 states
02/21/2019

Excessive Units of Subsequent Hospital and Nursing Facility Care Services (Telehealth)

Issue Name: Excessive Units of Subsequent Hospital and Nursing Facility Care Services (Telehealth)
Issue Number: _0125
Review Type: Automated
Provider Type: Professional Services (Physician/non-physician practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/21/2019
Dates Service: Exclude claims having a "claim paid date" which is more than 3 years prior to the informational letter (automated review).
Description: Medicare reimbursement for telehealth services include subsequent hospital care services and subsequent nursing facility care services. However, subsequent hospital care visits are limited to one telehealth visit every three days for hospital inpatients and one subsequent nursing facility telehealth visit every 30 days for nursing facility residents. Affected codes: Telehealth eligible CPT Codes 99231, 99232, 99233, 99307, 99308, 99309, 99310
References: Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits;42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, ;ecisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party;42 CFR §405.986- Good Cause for Reopening ;Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests; Medicare Claims Processing Manual: Publication 100-04; Chapter 12; Section 190.3.5 – Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services (Rev. 3476, Issued: 03-11-16, Effective: 01-01-15, Effective: 04-11-16); Medicare Claims Processing Manual: Publication 100-04; Chapter 12; Section 190.3 - List of Medicare Telehealth Services (Rev. 3476, Issued: 03-11-16, Effective: 01-01-15, Effective: 04-11-16); Medicare Claims Processing Manual: Publication 100-04; Chapter 12; Section 190.2 - Eligibility Criteria (Rev. 2848, Issued 12-30-13; Effective 01-01-14; Implementation 01-06-14)/ (3) Originating site defined; Medicare Claims Processing Manual: Publication 100-04; Chapter 12; Section; 190.6 - Payment Methodology for Physician/Practitioner at the Distant ; Site (Rev. 3586, Issued: 08-12-16, Effective: 01-01-17, Implementation: 01-03-17); 10. Medicare Claims Processing Manual: Publication 100-04; Chapter 12; Section 190.6.1 - Submission of Telehealth Claims for Distant Site Practitioners (Rev. 3817; Issued; 07-28-17 Effective; 01-01-18 Implementation: 01-02-18)
Medical Necessity Vertebroplasty and Kyphoplasty
_0139
Complex
Hospital Outpatient; Ambulatory Surgery Center (ASC); Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
02/19/2019

Medical Necessity Vertebroplasty and Kyphoplasty

Issue Name: Medical Necessity Vertebroplasty and Kyphoplasty
Issue Number: _0139
Review Type: Complex
Provider Type: Hospital Outpatient; Ambulatory Surgery Center (ASC); Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/19/2019
Dates Service: Claims having a “paid claim date” which is less than 3 years prior to the ADR letter date and on/or after 10/01/2015
Description: Medical documentation will be reviewed for correct coding and to determine if vertebroplasty was medically necessary. Affected codes: 22510, 22511, 22512, 22513, 22514, 22515, 20225, 22310, 22315, 22325, 22327 see Appendix D in downloadable xls file
References: "1. Title XVIII of the Social Security Act (SSA): §§1833(e); 1862(a)(1)(A); 1862(a)(10). Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A) - Exclusions from Coverage and Medicare as a Secondary Payer 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 - Special Payment Rules 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1842(p)(4)- Provisions Relating to the Administration of Part B 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Part 6. 42 CFR §405.986- Good Cause for reopening 7. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 General exclusion from coverage §§10 General exclusions from coverage 8. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 General exclusion from coverage §§20 Services not reasonable and Necessary 9. First Coast Service Options (FCSO) Local overage Determination (LCD) Vertebroplasty, Vertebral Augmentation, percutaneous L34976: Effective 10/01/2015; revised 4/17/18. 10. Novitas LCD L35130 Vertebroplasty, Vertebral Augmentation, percutaneous: Effective 10/01/2015; Revised 05/04/2017. 11. Palmetto LCD L33473 Vertebroplasty/Kyphoplasty: Effective 10/01/2015; Revised 08/09/2018. 12. WPS LCD L34592 Vertebroplasty, Vertebral Augmentation, percutaneous: Effective 10/01/2015; Revised 2/1/18. 13. NGS LCD L33569 Vertebroplasty, Vertebral Augmentation, percutaneous: Effective 10/01/2015. 14. Noridian LCD, Percutaneous Vertebral Augmentation, L34106, Effective 10/01/2015 15. Noridian LCD, Percutaneous Vertebral Augmentation, L34228, Effective 10/01/2015 16. CGS LCD, Vertebroplasty and Vertebral Augmentation, L34048, effective 10/01/2015 17. Annual American Medical Association: CPT Manual."
Complex Medical Necessity Panniculectomy
_0130
Complex
Hospital Outpatient; ASC; Professional Services (physician/non-physician practitioner)
Region-1
1 - All Region 1 states
02/12/2019

Complex Medical Necessity Panniculectomy

Issue Name: Complex Medical Necessity Panniculectomy
Issue Number: _0130
Review Type: Complex
Provider Type: Hospital Outpatient; ASC; Professional Services (physician/non-physician practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/12/2019
Dates Service: Include claims that have a “claim paid date” which is less than 3 years prior to the ADR date.
Description: Panniculectomy billed for cosmetic purposes will not be deemed medically necessary. In addition, panniculectomy billed at the same time as an open abdominal surgery, or if is incidental to another procedure, is not separately coded per Coding Guidelines. Affected codes: 15830, 15847, 12031, 12032, 12034, 12035, 12036, 12037, 13100, 13101, 13102, 14000, 14001, 14302, 49491, 49492, 49495, 49496, 49500, 49501, 49505, 49507, 49520, 49521, 49525, 49540, 49550, 49553, 49555, 49557, 49560, 49561, 49565, 49566, 49568, 49570, 49572, 49580, 49582, 49585, 49587
References: "1. Title XVIII of the Social Security Act (SSA): §§1833(e); 1862(a)(1)(A); 1862(a)(10) 2. 42 CFR §§405.980(b) and (c); 405.986; 411.15(k)(1); 424.5(a)(6) 3. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 §§10, 20 4. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 §120 – Cosmetic Surgery 5. National Correct Coding Initiative Policy Manual, Chapter 6, E, 7 6. Medicare Claims Processing Manual Chapter 12, §40.6 (A) 7. Novitas LCD L35090: Effective 10/1/2015; Revised 4/14/2017 8. WPS L34698: Effective 10/01/2015; Revised 01/01/2018; 02/01/2016; 10/01/2016; 01/01/2017 9. Palmetto GBA L33428: Effective 10/01/2015; Revised 10/1/18 10. Noridian LCD L35163: Effective 10/1/2015; Revised 10/10/2017 11. Noridian LCD L37020: Effective 10/10/2017 12. Annual American Medical Association: CPT Manual"
Evaluation and Management (E/M) Same Day as Admission to a Nursing Facility
_0132
Automated
Physician/ Non-Physician Practitioner
Region-1
1 - All Region 1 states
02/14/2019

Evaluation and Management (E/M) Same Day as Admission to a Nursing Facility

Issue Name: Evaluation and Management (E/M) Same Day as Admission to a Nursing Facility
Issue Number: _0132
Review Type: Automated
Provider Type: Physician/ Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/14/2019
Dates Service: Exclude from this automated review, claims having a paid claim date which is more than 3 years prior to the Informational letter date
Description: CMS will not pay a physician for an emergency department visit or an office visit and a comprehensive nursing facility assessment on the same day. Bundle E/M visits on the same date provided in sites other than the nursing facility into the initial nursing facility care code when performed on the same date as the nursing facility admission by the same physician. Affected codes: CPT 99201 -99215, 99281 – 99285
References: Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits; Medicare Claims Processing Manual: Publication 100-04; Chapter 12 Physicians/Nonphysician Practitioners, §30.6.7 Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201 - 99215), (C) ; Office/Outpatient or Emergency Department E/M Visit on Day of Admission to Nursing Facility; Medicare Claims Processing Manual: Publication 100-04; Chapter 12 Physicians/Nonphysician Practitioners, §30.6.11 Emergency Department Visits (Codes 99281 - 99288), (D) Emergency Department or Office/Outpatient Visits on Same Day As Nursing Facility Admission; Medicare Claims Processing Manual: Publication 100-04; Chapter 12 Physicians/Nonphysician Practitioners, §30.6.13 Nursing Facility Services, (A) Visits to Perform the Initial Comprehensive Assessment and Annual Assessments
Cryosurgery of the Prostate Medical Necessity
_0134
Complex
Outpatient Hospital, Ambulatory Surgery Center (ASC) and Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
02/14/2019

Cryosurgery of the Prostate Medical Necessity

Issue Name: Cryosurgery of the Prostate Medical Necessity
Issue Number: _0134
Review Type: Complex
Provider Type: Outpatient Hospital, Ambulatory Surgery Center (ASC) and Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/14/2019
Dates Service: 3 years
Description: Claims for Cryosurgery of the Prostate are not deemed to be medically necessary based on the guidelines outlined in the Centers for Medicare and Medicaid National Coverage Determination Manual (Publication 100-03, Part 4, § 230.9).
References: Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits; 42 CFR §405.986 Good Cause for Reopening ; 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party; CMS National Coverage Determinations Manual (NCD), Pub 100-03, Part 4, §230.9 Cryosurgery of Prostate (Rev. 1, 10-03-03).; CMS Claims Processing Manual, Pub 100-04, Ch. 32, §180 Cryosurgery of the Prostate Gland (Rev. 1111, Issued: 11-09-06, Effective: 04-01-07, Implementation: 04-02-07).