Jurisdiction Nebraska. Retirement Date N/A

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1 If you wish to save the PDF, please ensure that you change the file extension to.pdf (from.ashx). Local Coverage Determination (LCD): BONE Mass Measurement (L31620) Contractor Information Contractor Name Wisconsin Physicians Service Insurance Corporation opens in new window Contract Number Contract Type MAC - Part B LCD Information Document Information LCD ID L31620 LCD Title BONE Mass Measurement AMA CPT/ADA CDT Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. Jurisdiction Nebraska Original Effective Date For services performed on or after 08/15/2011 Revision Effective Date For services performed on or after 09/07/2013 Revision Ending Date Retirement Date Notice Period Start Date 06/01/2012 Notice Period End Date CMS National Coverage Policy Jurisdiction 8 Notice: Jurisdiction 8 comprises the states of Indiana and Michigan. WPS is responsible for claims payment and Local Coverage Determination (LCD) development for this jurisdiction. This LCD was created as a part of the legacy transition (7/16/2012 8/20/2012); and, is a consolidation of the previous legacy contractors policies. Coverage of each LCD begins when the state/contract number combination officially is integrated into the Jurisdiction. On the CMS MCD, this date is known as either the Original Effective Date or the Revision Effective Date. The following table details the official effective dates for each state/contract number combination. ST Legacy A Contractor & Contract Number Legacy B Contractor & Contract Number J "8" MAC A Contractor & Contract Number J "8" MAC B Contractor & Contract Number J "8" Effective Date IN NGS: WPS: /20/12 MI WPS: WPS: /16/12 IN NGS: WPS: /23/12 MI NGS: WPS: /23/12

2 CMS Pub ; ; ; CMS Pub , Medicare National Coverage Determinations, Ch. 1, Part 2, CMS Pub.100-2, Ch. 15, 80.5 Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Abstract Bone mass measurement (BMM) studies are radiologic, radioisotopic or other procedures that meet all of the following conditions: 1. Quantify bone mineral density, detect bone loss or determine bone quality; 2. Are performed with either a bone densitometer (other than single-photon or dual-photon absorptionmetry) or a bone sonometer system that has been cleared for marketing for BMM by the Food and Drug Administration (FDA) under 21 CFR part 807, or approved for marketing under 21 CFR part Include a physician's interpretation of the results The following procedures are used to measure bone mineral density: 1. Dual energy x-ray absorptiometry (DXA) 2. Radiographic absorptiometry (RA) 3. Bone sonometry (ultrasound) 4. Single energy x-ray absorptiometry (SEXA) 5. Quantitative computed tomography (QCT) Earlier technologies, such as single and dual photon absorptiometry (CPT codes or 78351) are no longer used. Indications A. Medicare covers a bone mass measurement (BMM) for a beneficiary once every two years (if at least 23 months have past since the month the last bone mass measurement was performed). The criteria for bone mass measurement every two years are listed below; 1. It is performed with a bone densitometer, other than dual photon absorptiometry (DPA) or a bone sonometer (e.g., ultrasound) device that has been approved or cleared for marketing by the Food and Drug Administration (FDA). 2. It is performed on a qualified individual for the purpose of identifying bone mass, detecting bone loss or determining bone quality. The term "qualified individual" means an individual who meets the medical indications for at least one of the criteria listed below: a. A woman who has been determined by the physician or a qualified non-physician treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other indicators. b. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture. c. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5 mg of prednisone, or greater, per day for more than three months. d. An individual with primary hyperparathyroidism, e. An individual being monitored to assess the response to or efficacy of an FDA approved osteoporosis drug therapy. 3. If it is furnished by a qualified supplier or provider of such services, under at least the general level of supervision of a physician as defined in section 1861 of the Social Security Act. 4. If the test is ordered by the individual's physician or qualified non- physician practitioner, who is treating the beneficiary following an evaluation of the need for the measurement, including a determination as to the medically appropriate measurement to be used for the individual, and who uses the results in the management of the patient. 5. The test is reasonable and necessary for diagnosing, treating or monitoring of a "qualified" individual as defined above.

3 B. For conditions specified below, Medicare will cover a bone mass measurement for a qualified beneficiary more frequently than every two years, if medically necessary for the diagnosis or treatment of the patient and if related to the condition listed. To be considered at least eleven months must have elapsed since the previous bone mass measurement test. Such conditions are; 1. Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy, equal to 5 mg of prednisone or greater, for more than three months. (Patients must be on glucocorticoids for greater than three months duration, but BMM monitoring is at yearly intervals). 2. Confirming baseline BMMs to permit monitoring of beneficiaries in the future. (CMS Publication , Ch. 15, ). In addition, bone mass measurement for the following may be reimbursed more frequently than every two years: 3. Follow up bone mineral density testing to assess FDA-approved osteoporosis drug therapy until a response to such therapy has been documented over time. C. Medicare will cover a confirmatory baseline bone mass measurement when it is performed with a dual energy x-ray absorptionmetry system (axial skeletal) to permit monitoring of beneficiaries in the future, if the initial test was performed with a technique that is different from the proposed monitoring method (for example, if the initial test was bone sonometry and the patient will be monitored with bone densitometry, a second test utilizing densitometry will be paid). If the initial bone mass measurement was performed by a dual-energy x-ray absorptionmetry system (axial skeletal), than a confirmatory BMM is not covered. D. There are multiple techniques for obtaining bone mass or bone density information. There is a difference in the precision, and accuracy of the different techniques and the sensitivity of measurement in axial (central) or peripheral sites. In general, because cancellous bone changes more rapidly in time and with therapeutic intervention, the sites of cancellous bone (lumbar spine, proximal femur) are more likely than peripheral sites or cortical bone to show a response to FDA approved osteoporosis drug therapy and are preferred for baseline and drug monitoring purposes. The most reliable comparative results for drug monitoring are obtained when the same BMM instrument is used. Based on this, Medicare coverage is limited to those techniques which have been rated favorably in clinical studies. Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 034x Home Health - Other (for medical and surgical services not under a plan of treatment) 071x Clinic - Rural Health 072x Clinic - Hospital Based or Independent Renal Dialysis Center 073x Clinic - Freestanding 085x Critical Access Hospital

4 Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. Revenue codes only apply to providers who bill these services to the fiscal intermediary. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier. Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes. Revenue codes 096X, 097X and 098X are to be used only by Critical Access Hospitals (CAHs) choosing the optional payment method (also called Option 2 or Method 2) and only for services performed by physicians or practitioners who have reassigned their billing rights. When a CAH has selected the optional payment method, physicians or other practitioners providing professional services at the CAH may elect to bill their carrier or assign their billing rights to the CAH. When professional services are reassigned to the CAH, the CAH must bill the FI using revenue codes 096X, 097X or 098X. Note: Any explanatory text for this field now allows comments Radiology - Diagnostic - General Classification 0333 Radiology - Therapeutic and/or Chemotherapy Administration - Radiation Therapy 034X Nuclear Medicine - General Classification 035X CT Scan - General Classification 040X Other Imaging Services - General Classification 052X Free-Standing Clinic - General Classification 061X Magnetic Resonance Technology (MRT) - General Classification 0960 Professional Fees - General Classification 0969 Professional Fees - Other Professional Fee 0972 Professional Fees - Radiology - Diagnostic 0982 Professional Fees - Outpatient Services 0983 Professional Fees - Clinic CPT/HCPCS Codes Group 1 Paragraph: Note: CPT codes and are non-covered procedures under Medicare Group 1 Codes: ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION, PERIPHERAL SITE(S), ANY METHOD COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL) BONE DENSITY (BONE MINERAL CONTENT) STUDY, 1 OR MORE SITES; SINGLE PHOTON ABSORPTIOMETRY BONE DENSITY (BONE MINERAL CONTENT) STUDY, 1 OR MORE SITES; DUAL PHOTON ABSORPTIOMETRY, 1 OR MORE SITES SINGLE ENERGY X-RAY ABSORPTIOMETRY (SEXA) BONE DENSITY STUDY, ONE OR MORE SITES; G0130 APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL) ICD-9 Codes that Support Medical Necessity Group 1 Paragraph: Note: ICD-9 codes must be coded to the highest level of specificity.

5 When 77078, 77081, or G0130 is done as an initial diagnostic test that determines a diagnosis of 255.0, , , , , or , code as a secondary diagnosis the reason for the bone mass density test. Patients who qualify by statute for osteoporosis screening may be evaluated by studies that are characterized by CPT codes 77078, 77079, 77080, 77081, 76977, and G0130. The following is a list of ICD-9-CM codes that support the medical necessity of osteoporosis screening For Use with CPT Codes 77078, 77080, 77081, 76977, G0130 Group 1 Codes: TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM TOXIC DIFFUSE GOITER WITH THYROTOXIC CRISIS OR STORM opens TOXIC UNINODULAR GOITER WITHOUT THYROTOXIC CRISIS OR STORM - TOXIC UNINODULAR GOITER WITH THYROTOXIC CRISIS OR STORM opens TOXIC MULTINODULAR GOITER WITHOUT THYROTOXIC CRISIS OR STORM - TOXIC MULTINODULAR GOITER WITH THYROTOXIC CRISIS OR STORM opens TOXIC NODULAR GOITER UNSPECIFIED TYPE WITHOUT THYROTOXIC CRISIS OR STORM - TOXIC NODULAR GOITER UNSPECIFIED TYPE WITH THYROTOXIC CRISIS OR STORM opens opens opens THYROTOXICOSIS FROM ECTOPIC THYROID NODULE WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS FROM ECTOPIC THYROID NODULE WITH THYROTOXIC CRISIS OR STORM THYROTOXICOSIS OF OTHER SPECIFIED ORIGIN WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS OF OTHER SPECIFIED ORIGIN WITH THYROTOXIC CRISIS OR STORM THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE AND WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC CRISIS OR STORM DISORDERS OF THYROCALCITONIN SECRETION opens HYPERPARATHYROIDISM, UNSPECIFIED - SECONDARY HYPERPARATHYROIDISM, NONin RENAL OTHER HYPERPARATHYROIDISM PANHYPOPITUITARISM POSTABLATIVE OVARIAN FAILURE PREMATURE MENOPAUSE OTHER OVARIAN FAILURE OTHER TESTICULAR HYPOFUNCTION ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED 262 OTHER SEVERE PROTEIN-CALORIE MALNUTRITION opens in MALNUTRITION OF MODERATE DEGREE - UNSPECIFIED PROTEIN-CALORIE MALNUTRITION OSTEOMALACIA UNSPECIFIED UNSPECIFIED VITAMIN D DEFICIENCY opens UNSPECIFIED DISORDER OF CALCIUM METABOLISM - OTHER DISORDERS OF CALCIUM METABOLISM opens in REGIONAL ENTERITIS OF SMALL INTESTINE - REGIONAL ENTERITIS OF UNSPECIFIED SITE opens in ULCERATIVE (CHRONIC) ENTEROCOLITIS - ULCERATIVE COLITIS UNSPECIFIED opens in CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION opens in CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED RENAL OSTEODYSTROPHY SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN) OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION ABSENCE OF MENSTRUATION opens in PREMENOPAUSAL MENORRHAGIA - UNSPECIFIED MENOPAUSAL AND POSTMENOPAUSAL DISORDER OSTEITIS DEFORMANS WITHOUT BONE TUMOR

6 opens PATHOLOGICAL FRACTURE UNSPECIFIED SITE - PATHOLOGICAL FRACTURE OF OTHER SPECIFIED SITE opens STRESS FRACTURE OF TIBIA OR FIBULA - STRESS FRACTURE OF OTHER BONE KYPHOSIS (ACQUIRED) (POSTURAL) opens POLYCYSTIC KIDNEY UNSPECIFIED TYPE - OTHER SPECIFIED CYSTIC KIDNEY DISEASE GONADAL DYSGENESIS LOSS OF HEIGHT opens CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - CLOSED FRACTURE OF MULTIPLE CERVICAL VERTEBRAE opens OPEN FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - OPEN FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY opens CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY opens OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY opens CLOSED FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY opens OPEN FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY OPEN FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY opens CLOSED FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY opens OPEN FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY opens FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR CLOSED - FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR OPEN POISONING BY ADRENAL CORTICAL STEROIDS UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE V45.77 ACQUIRED ABSENCE OF ORGAN GENITAL ORGANS V49.81 ASYMPTOMATIC POSTMENOPAUSAL STATUS (AGE-RELATED) (NATURAL) V50.42 PROPHYLACTIC OVARY REMOVAL V58.65 LONG-TERM (CURRENT) USE OF STEROIDS Group 2 Paragraph: For use with CPT Code (DXA) Once the diagnosis of osteoporosis has been established, the effectiveness of treatment can ONLY be monitored using a dual energy x-ray absorptiometry (CPT code 77080). Group 2 Codes: CUSHING'S SYNDROME OSTEOPOROSIS UNSPECIFIED SENILE OSTEOPOROSIS IDIOPATHIC OSTEOPOROSIS DISUSE OSTEOPOROSIS OTHER OSTEOPOROSIS DISORDER OF BONE AND CARTILAGE UNSPECIFIED V58.65 LONG-TERM (CURRENT) USE OF STEROIDS V58.68* LONG TERM (CURRENT) USE OF BISPHOSPHONATES V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED Group 2 Medical Necessity ICD-9 Codes Asterisk Explanation: *V58.65, V58.68 and/or V67.51, when used to monitor effectiveness of drug treatment, require a primary ICD-9-CM diagnosis code from the list directly above.

7 ICD-9 Codes that DO NOT Support Medical Necessity Paragraph: ICD-9 Codes not listed above General Information Associated Information Documentation Requirements 1. Physicians' Services and diagnostic tests must be submitted with an ICD-9 code to support the medical necessity for the service and must be coded to the greatest level of accuracy and highest level of digit completeness. This means the precise ICD-9 code that fully explains the narrative description of the diagnosis contained in the medical record or the test interpretation and report including the 4th or 5th digit subclassification for the diagnosis category. The ICD-9 code based on the results of the test should be the primary diagnosis. If the diagnostic test results are normal or inconclusive the ICD-9 code representing the sign, symptom, illness or injury prompting the ordering of the test should be reported as the primary diagnosis. 2. Medical records should be legible, contain the relevant history, physical findings conforming to the criteria stated in the "Indications and Limitation of Coverage/Medical Necessity" section of this policy and must be made available to the Carrier on request. This documentation (medical records/history or and x-ray report) must be available for submission with the original and all subsequent claims upon request 3. Documentation supporting medical necessity including the reason for testing, the method used, and the site(s) evaluated, plus a test report should be in the patient's record. 4. The patient's medical record must document that patient meets one of the requirements of a "qualified individual" as described in the Indications and Limitations of Coverage section of this policy. 5. Documentation supporting medical necessity must be indicated in the narrative field and available upon request 6. ICD-9-CM code V45.77 should be reported for women s/p oophorectomy. 7. ICD-9-CM code V58.65 should be reported for an individual on glucocorticoid therapy. 8. ICD-9-CM code V58.68 should be reported for DXA testing while taking medicines for osteoporosis/osteopenia. 9. ICD-9-CM code V67.51 should be reported for an individual who has COMPLETED drug therapy for osteoporosis and is being monitored for response to therapy. Utilization Guidelines Refer to Indications and Limitations of Coverage and/or Medical Necessity sections of this LCD. 1. Medicare reimbursement for an initial bone mass measurement may be allowed only once, regardless of sites studied (e.g., if the spine and hip are studied, CPT code should be billed only once). 2. It is not medically necessary to perform more than one type of BMM test in any individual, unless a DXA confirmatory test is performed as a baseline for future monitoring. (See paragraph C in Indications and Limitations of Coverage section). 3. It is normally not medically necessary to have both peripheral and axial BMM tests performed. In the rare instance of an indeterminate confirmatory diagnosis, upon appeal documentation submitted will be evaluated for possible payment. 4. Medicare will not reimburse BMM tests performed by a second provider, when a test has already been performed within the defined coverage period. Sources of Information and Basis for Decision

8 1. American College of Radiology, ACR Appropriateness Criteria - Osteoporosis and bone mineral density (2001 and 2010 revised) 2. DEXA National Workgroup Memo, American Association of Clinical Endocrinologists - Osteoporosis Clinical Practice Guidelines (2001). 3. Institute for Clinical System Improvement, Health Care Guidelines: Diagnosis and Treatment of Osteoporosis (July 2002) 4. National Osteoporosis Foundation Physicians Guide to Prevention and Treatment of Osteoporosis 2000, Update on Medication (2002) 5. The International Society for Clinical Densitometry (2007); Official position of the International Society for Clinical Densitometry. Retrieved from the internet 05/25/2011 at 6. The U.S. Preventive Services Task Force (USPSTF) Recommendation: Screening for Osteoporosis in Postmenopausal Women (September 2002) Revision History Information Please note: The Revision History information included in this LCD prior to 1/24/2013 will now display with a Revision History Number of "R1" at the bottom of this table. All new Revision History information entries completed on or after 1/24/2013 will display as a row in the Revision History section of the LCD and numbering will begin with "R2". Revision History Date 09/07/2013 R3 Revision History Number Revision History Explanation The WPS Carrier Contract Numbers 00951(WI), 00952(IL), and 00954(MN) were removed from this LCD. Effective 09/07/2013, the Jurisdiction 6 Part B MAC contractor for Illinois, Wisconsin, and Minnesota is National Government Services (NGS). Reason(s) for Change Change in Assigned States or Affiliated Contract Numbers 10/22/2012 R2 03/01/2013: Annual update. No changes to coverage. Other 10/22/2012: In accordance with Section 911 of the Medicare Modernization Act of 2003 and CMS Change Request 8059, contractor numbers in this LCD policy were updated due to the transition from WPS Fiscal Intermediary Contract Number to WPS Part A MAC Contractor Number No other changes were made to this LCD policy. 10/22/2012 R1 08/20/2012: This LCD was revised to add the Jurisdiction 8 (J-8) Indiana Part B MAC Contract Number The CMS Statement of Work for the J8 Medicare Administrative Contract (MAC) requires that the contractor retain the most clinically appropriate LCD within the jurisdiction. This WPS policy is being promulgated to the J8 MAC as the most clinically appropriate LCD within this jurisdiction. No coverage changes were made to this LCD for this revision. 07/23/2012: This LCD was revised to add the Jurisdiction 8 (J-8) Indiana and Michigan Part A MAC Contract Numbers and The CMS Statement of Work for the J8 Medicare Administrative Contract (MAC) requires that the contractor retain the most clinically appropriate LCD within the jurisdiction. This WPS policy is being promulgated to the J8 MAC as the most clinically appropriate LCD within this jurisdiction. No coverage changes were made to this LCD for this revision. Other

9 Revision History Date Revision History Number Revision History Explanation 07/16/2012: This LCD was revised to add the Jurisdiction 8 (J-8) Michigan Part B MAC Contract Number and remove the legacy Michigan Part B Carrier Contract Number The CMS Statement of Work for the J8 Medicare Administrative Contract (MAC) requires that the contractor retain the most clinically appropriate LCD within the jurisdiction. This WPS policy is being promulgated to the J8 MAC as the most clinically appropriate LCD within this jurisdiction. No coverage changes were made to this LCD for this revision. Reason(s) for Change 02/21/2011 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901). 07/01/ Draft policy being released to Final. 10/12/2011: Deleted ICD-9-CM code V58.69 and replaced all references to it with ICD-9-CM new for 2012 code V58.68, which is specific for long term (current) use of bisphosphonates. Added the second sentence to statement number three (3) found in the Utilization Guidelines. Sentence number (3) now states; It is normally not medically necessary to have both peripheral and axial BMM tests performed. In the rare instance of an indeterminate confirmatory diagnosis, upon appeal documentation submitted will be evaluated for possible payment. Effective 10/01/2011 (one). 11/21/ The following CPT/HCPCS codes were deleted: was deleted from Group was deleted from Group 1 01/01/2012: 2012 CPT update; Discontinued CPT code (two). 04/01/2012: CPT 2012 coding update discontinued CPT code Effective 01/01/2012 (three). Associated Documents Attachments Coding & Billing Guidelines 6/1/12 opens (PDF KB ) Related Local Coverage Documents Related National Coverage Documents Public Version(s) Updated on 08/26/2013 with effective dates 09/07/ Updated on 02/18/2013 with effective dates 10/22/ /06/2013 Updated on 10/09/2012 with effective dates 10/22/ Some older versions have been archived. Please visit the MCD Archive Site opens to retrieve them.

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