Source: Florida Medicare B Update, March/April 2000, Vol 13, Number 2
THE LIST OF MEDICARE NONCOVERED SERVICES
Description
The purpose of these coding guidelines is to create a working list of medical services and procedures that are never covered by the Medicare program. Such services and procedures are always denied either because:
The coding guidelines are developed under an iterative process and will be updated as national and local coverage decisions change.
Policy Type
Coding Guidelines
Indications and Limitations of Coverage and/or Medical Necessity
A service or procedure on the "national noncoverage list" may be noncovered for a variety of reasons. It may be noncovered based on a specific exclusion contained in the Medicare law; for example, acupuncture; it may be viewed as not yet proven safe and effective and, therefore, not medically reasonable and necessary; or it may be a procedure that is always considered cosmetic in nature and is denied on that basis. The precise basis for a national decision to noncover a procedure may be found in references cited in this policy.
A service or procedure on the "local" list is always denied on the basis that we do not believe it is "medically reasonable and necessary." Our list of local medical review policy exclusions contains procedures that, for example, are:
It is important to note that the fact that a new service or procedure has been issued a CPT code or is FDA approved does not, in itself, make the procedure "medically reasonable and necessary." It is our policy that new services, procedures, drugs, or technology must be evaluated and approved either nationally or by our local medical review policy process before they are considered Medicare covered services
HCPCS Codes
Local Noncoverage Decisions
Laboratory Procedures
82016* Acylcarnitines; qualitative, each specimen(Added March/April 2000)
82017* Acylcarnitines; qualititative, each specimen
82172 Apolipoprotein, each
82379* Carnitine (total and free), quantitative, each specimen
82523* Collagen cross links, any method (Urinary Biochemical Assays for Bone Resorption)
83883 Nephelometry each analyte not elsewhere specified
Drugs and Biologicals
90476 Adenovirus vaccine, type 4, live, for oral use
90477 Adenovirus vaccine, type 7, live, for oral use
90581 Anthrax vaccine, for subcutaneous use
90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use
90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use
90632 Hepatitis A vaccine, adult dosage, for intramuscular use
90633 Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use
90634 Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for intramuscular use
90645 Hemophilus Influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use
90646 Hemophilus Influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use
90647 Hemophilus Influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use
90648 Hemophilus Influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use
90660 Influenza virus vaccine, live, for intranasal use
90665 Lyme disease vaccine, adult dosage, for intramuscular use
90680 Rotavirus vaccine, tetravalent, live, for oral use
90690 Typhoid vaccine, live, oral
90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPS), for intramuscular use
90692 Typhoid vaccine, heat-and phenol-inactivated (H-P), for subcutaneous or intradermal use
90693 Typhoid vaccine,Acetone-Killed, Dried (AKD), for subcutaneous or jet injection use (U.S. military)
A9270* Becaplermin (Regranex)
A9270 Muse
J3520 Edetate disodium, per 150 mg (chemical endarterectomy)
J3530 Nasal vaccine inhalation
Procedures
01990 Physiological support for harvesting of organs from brain-dead patientsdeleted March/April 2000
01995 Regional I.V. administration of local anesthetic agent or other medication (upper or lower extremity)
11975 Insertion, implantable contraceptive capsules
11977 Removal with reinsertion, implantable contraceptive capsules
11980 Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets underneath the skin)
15820-15821 Blepharoplasty, lower lid
15824-15829 Rhytidectomy
15831-15839 Excision, excessive skin and subcutaneous tissue (including lipectomy)
15876-15879 Suction assisted lipectomy
17380 Electrolysis epilation, each ˝ hour
20979* Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)
National Noncoverage Decisions
Devices
33999*† Artificial hearts and related devices (CIM 65-15)
A9270* Intrapulmonary percussive ventilator for home use (CIM 60-21)
Laboratory Procedures
80050 General Health Panel
86999*† Cytotoxic leukocyte tests for food allergies (CIM 50-2)
88399*† Human tumor stem cell drug sensitivity assays (CIM 50-41)
Drugs and Biologicals
90669 Pneumococcal conjugate vaccine, polyvalent, for intramuscular use
A4260* Levonorgestral (contraceptive) implants system, including implants and supplies (Statute 1862 [a][1][a])
A4261 Cervical cap for contraceptive use (Statute 1862[a][1][a])
A9270 Oral Medication (MCM 2049)
A9270* Rebetron (MCM 2049)
J3570* Laetrile (Amygdalin, Vit B17) (CIM 45-10)
J8499† Prescription drug, oral, nonchemotherapeutic, not otherwise specfied (MCM 2049)
J8499*† Sublingually administered antigens (CIM 45-28)
Procedures
11920-11922Tattooing (MCM 2329) Delted March/April 200015775-15776 Punch graft for hair transplant (MCM 2329)
32491* Removal of lung, other than total pneumonectomy; excision-plication of emphysematous lung(s) (bullous or non-bullous), for lung volume reduction, sternal split or transthoracic approach, with or without any pleural procedure (prior to 1/1/97 HCPCS code G0061) (CIM 35-93)
35452* Transluminal balloon angioplasty (PTA) in treatment of obstructive lesions of aortic arch (CIM 50-32.3)
53899*† Bladder Stimulator (CIM 65-11)
55970-55980* Intersex surgery (CIM 35-61)
56805 Clitoroplasty for intersex state (CIM 35-61)
57335 Vaginoplasty for intersex state (CIM 35-61)
59899*† Ambulatory home monitoring of uterine contractions (MCM 2005.1)
64999*† Stereotactic cingulotomy as a means of psychosurgery (CIM 35-84)
65760-65767,
65771* Refractive keratoplasty to correct refractive error (CIM 35-54)
69949*† Cochleostomy with neurovascular transplant for Meniere’s Disease (CIM 35-50)
72159 Magnetic resonance angiography, spine canal and contents, with or without contrast material(s) (CIM 50-14)
72198 Magnetic resonance angiography, pelvis, with or without contrast material(s) (CIM 50-14)
73225 Magnetic resonance angiography, upper extremity, with or without contrast material(s) (CIM 50-14)
78351* Dual Photon Absorptiometry, one or more sites (CIM 50-44)
78810* Tumor Imaging, Positron Emission Tomography (PET), metabolic evaluation
90760 Routine physical exam (MCM 2320)
90875-90876 Individual psychophysiological therapy incorporating biofeedback (CIM 35-27)
90899*† Transcendental meditation (CIM 35-92)
90908 (prior to 1/1/97) Biofeedback (psychiatric only) (CIM 35-27)
92310 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia
92314 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens, both eyes, except for aphakia
93760 Thermogram; Cephalic Added March/April 2000
93762 Thermogram; Peripheral Added March/April 2000
93784-93790* Ambulatory blood pressure monitoring (CIM 50-42)
95199† Repository antigen (MCM 2005.2)
95999*† EEG monitoring during open heart surgery and in immediate post-op period (CIM 35-57.1)
97780-97781* Acupuncture (CIM 35-8)
98943 Chiropractic manipulative treatment (CMT); extraspinal, one or more regions (MCM 2251)
A9160 Noncovered service by podiatrist (MCM 2020.4)
A9170 Noncovered service by chiropractor (MCM 2026.26)
A9270 Carbon Dioxide Therapy (CIM 35-29)
A9270* Cardiointegram (CIG) as an alternative to stress test or thallium stress test (CIM 50-47)
A9270* Carotid body resection to relieve pulmonary symptoms, including asthma (CIM 35-7)
A9270* Carotid sinus nerve stimulator for treatment of paroxysmal supraventricular tachycardia (CIM 65-4)
A9270* Chelation Therapy (EDTA) for treatment of arteriosclerosis (CIM 35-64)
A9270* Colonic irrigation (CIM 35-1)
A9270 Cosmetic surgery (MCM 2329)
A9270* Diathermy or ultrasound treatments performed for respiratory conditions or diseases (CIM 35-41).
A9270* Ear/carbon therapy (CIM 35-29)
A9270* Electrical aversion therapy for treatment of alcoholism (CIM 35-23.1)
A9270* Electrical continence (CIM 65-2)
A9270* Electrosleep therapy (CIM 35-18)
A9270 Electrotherapy for the treatment of facial nerve paralysis (Bell’s Palsy) (CIM 35-72)
A9270 Eye exam, routine (MCM 2320)
A9270* Fabric wrapping of abdominal aneurysms (CIM 35-34)
A9270* Gastric balloon for treatment of obesity (CIM 35-86)
A9270* Hair analysis (CIM 50-24)
A9270* Hemodialysis for treatment of schizophrenia (CIM 35-51)
A9270* Indirect Calorimetry used to assess nutritional status as a respiratory therapy
A9270 Intestinal bypass for obesity (CIM 35-33)
A9270* Intravenous histamine therapy (CIM 35-19)
A9270* Investigational IOLS in FDA Core Study or Modified Core Study (MCM 2020.25)
A9270* Partial ventriculectomy (also known as ventricular reduction, ventricular remodeling, or heart volume reduction surgery)
(CIM 35-95)
A9270* Pelvic floor stimulator (CIM 65-9)
A9270* Platelet-derived wound healing formula (Procuren) (CIM 45-26)
A9270* Prolotherapy, joint sclerotherapy and ligamentous injections with sclerosing agents (CIM 35-13)
A9270 Speech therapy by pathologist/speech therapist (MCM 2206.2)
A9270* Sweat test as predictor of efficacy of sympathectomy in PVD (CIM 50-3)
A9270* Thermogenic therapy (CIM 35-6)
A9270* Tinnitus masking (CIM 35-63)
A9270* Transfer factor for treatment of multiple sclerosis (CIM 45-17)
A9270* Transilluminator light scanning or diaphanography (CIM 50-46)
A9270* Transvenous (catheter) pulmonary embolectomy (CIM 35-55)
A9270* Treatment of decubitus ulcers by ultraviolet light, low intensity direct current, topical application of oxygen and topical dressings with balsam of Peru in castor oil (CIM 35-31)
A9270* Treatment of motor function disorders with electrical nerve stimulation (CIM 35-20)
A9270* Ultrafiltration independent of conventional dialysis (CIM 55-3)
A9270* Vertebral Axial Decompression (VAX-D) (CIM 35-97)
A9270 Vitamin B12 injections to strengthen tendons, ligaments of the foot (CIM 45-4)
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0122 Colorectal cancer screening; barium enema
M0100* Gastric freezing (CIM 35-65)
V5010 Hearing exam for the purpose of a hearing aid (MCM 2320)
These lists of noncovered services are not all inclusive.
* Services which are noncovered due to their being investigational/experimental
† Claims for these services will always be reviewed, as they must currently be billed with an unlisted procedure code.
Deletions from National Noncoverage 11920-11922 Tattooing
Added March/April 2000Documentation must be submitted with the claim for coverage of tattooing to be considered. Reimbursement will be made on an individual consideration basis.
ICD-9 Codes That Support Medical Necessity
N/A
HCPCS Section and Benefit Category
N/A
HCFA National Coverage Policy
N/A
Reasons for Denial
See criteria for noncoverage.
An advance notice of Medicare’s denial of payment must be provided to the patient when the provider does not want to accept financial responsibility for a service that is considered investigational/experimental, or is not approved by the FDA, or because there is a lack of scientific and clinical evidence to support the procedure’s safety and efficacy.
Noncovered ICD-9 Code(s)
N/A
Sources of Information
HCPCS Level II Codes
CPT 1997
CMD
Coding Guidelines
N/A.
Documentation Requirements
National noncovered services may not be covered by the local carrier. In order for noncovered services to be evaluated for coverage, the following documentation must be submitted to the local carrier. In order for noncovered services to be evaluated for coverage, the following documentation must be submitted to the local carrier:
Effectiv Date
The procedures identified in this policy in bold type are effective for services processed on or after April 17, 2000.
Other Comments
N/A
CAC Notes
This policy does not express the sole opinion of the carrier or Carrier Medical Director. Although the final decision rests with the carrier, this policy was developed in cooperation with the Carrier Advisory Committee, which includes representatives from numerous societies.
Start Date of Comment Period:
N/AStart Date of Notice Period:
01/2000 Jan/Feb 2000 UpdateOriginal Effective Date:
10/20/97Revision Date/Number:
01/01/2000 14 (PCR B2000-031) HCPCS 2000Revision History:
Start Date of Comment Period: N/A
Start Date of Notice Period: Mar/April 2000 Update
Original Effective Date: 10/20/97
Revision Date/Number: 14
Start Date of Comment Period: N/A
Start Date of Notice Period: 01/2000 Jan/Feb 2000 Update
Original Effective Date: 10/20/97
Revision Date/Number: 13 (PCR B99-153)
Start Date of Comment Period: 04/30/99
Start Date of Notice Period: 09/01/99 Sept/Oct ‘99 Update
Original Effective Date: 10/20/97
Revision Date/Number: 10/18/99 12 (PCR B99-111)
Start Date of Comment Period: N/A
Start Date of Notice Period: 07/01/99 (July/Aug 1999 Update)
Original Effective Date: 10/20/97
Revision Date/Number: 08/16/99 11 (PCR B99-082).
Start Date of Comment Period: 02/12/99
Start Date of Notice Period: 07/01/99 (July/Aug 1999 Update)
Original Effective Date: 10/20/97
Revision Date/Number: 08/16/99 10 (PCR B99-071)
Start Date of Comment Period:
Start Date of Notice Period:
Original Effective Date: 10/20/97
Revision Date/Number: 04/19/99 9 (PCR B99-051)
Start Date of Comment Period:
Start Date of Notice Period:
Original Effective Date: 10/20/97
Revision Date/Number: 01/01/99 8 (PCR B99-039) ‘99 HCPCS
Start Date of Comment Period: 08/21/98
Start Date of Notice Period:
Original Effective Date: 10/20/97
Revision Date/Number: 01/01/99 7 (PCR B98-167)
Start Date of Comment Period:
Start Date of Notice Period: 07/01/98 (July/August 1998 Update)
Original Effective Date: 10/20/97
Revision Date/Number: 08/17/98 6 (PCR B98-117)
Start Date of Comment Period: 02/13/98
Start Date of Notice Period: 05/98
Original Effective Date: 10/20/97
Revision Date/Number: 06/22/98 5 (PCR B98-077)
Start Date of Comment Period: 11/08/97
Start Date of Notice Period: 03/98
Original Effective Date: 10/20/97
Revision Date/Number: 04/20/98 4 (PCR B98-051)
Start Date of Comment Period: N/A
Start Date of Notice Period: 12/97
Original Effective Date: 10/20/97
Revision Date/Number: 01/01/98 3 (PCR B98-048)
Start Date of Comment Period: N/A
Start Date of Notice Period: 12/97
Original Effective Date: 10/20/97
Revision Date/Number: 01/01/98 2 (‘98 HCPCS)(PCR B98-029)
Start Date of Comment Period: N/A
Start Date of Notice Period: N/A
Original Effective Date: 10/20/97
Revision Date/Number: 1 (PCR B97-138A)
Start Date of Comment Period: 08/23/97
Start Date of Notice Period:
Original Effective Date: 10/20/97 PCR B97-138