TABLE OF CONTENTS CPT t LCD ID... 4 L26500- Autmatic Implantable Cardiac Defibrillatr (AICD) - 4C-58AB... 14 L26529- Cardiac Catheterizatin - 4C-50AB... 23 L26534- Transthracic Echcardigraphy (TTE) - 4C-52AB... 41 L26543- Interventinal Cardilgy - 4C-54AB... 56 L26582- Cardivascular Stress Testing - 4C-55AB... 61 L26583- Cardivascular Nuclear Medicine 4C-57AB... 73 L26584- Bne Mass Measurement (BMM) - 4X-60AB... 82 L26594- Barium Swallw Studies, Mdified - 4F-65AB... 91 L26698- Crysurgical and Radifrequency Ablatin f Hepatic Tumrs - 4S- 152AB... 98 L26701- Vertebrplasty, Kyphplasty; Percutaneus - 4S-153AB... 103 L26723- Transesphageal Echcardigraphy (TEE)... 111 L26725- Endvascular Repair fr Descending Thracic Aneurysm (DTA) - 4S-147AB... 122 L26727- Thracic Artgraphy and Cartid, Vertebral and Subclavian Angigraphy - 4X-59AB... 128 L26728- Nn-Crnary Vascular Stents - 4S-141AB... 136 L26729- Treatment f Varicse Veins in Lwer Extremities - 4S-144AB... 143 L26732- MRI and CT Scans f Thrax and Chest - 4X-58AB... 151 L26736- MRI f a Jint - 4X-47AB... 167 L26737- Vascular Access fr Hemdialysis - 4S-142AB... 177 L26739- Upper Gastrintestinal Endscpy With/Withut Ultrasund - 4S- 133AB... 187 L26740-3D Interpretatin and Reprting f Imaging Studies - 4X-48AB.. 202 L26742- Radipharmaceuticals: Mnclnal Antibdies, Diagnstic - 4X- 50AB... 207 L26743- Pain Management - 4S-149AB... 217 L26744- Nn-Invasive Cerebrvascular Studies - 4U-19AB... 227 L26747- Nn-Invasive Peripheral Arterial Studies - 4U-20AB... 239 L26749- Nn-Invasive Venus Studies - 4U-21AB... 250 L26750- Ultrasund, Abdminal and Retrperitneal - 4U-22AB... 259 L26753- Psitrn Emissin Tmgraphy (PET) - 4X-54AB... 274 Cpyright 2008 CdeMap Page 1
TABLE OF CONTENTS L26754- MRI and CT Scans f the Head and Brain - 4X-57AB... 286 L26755- Diagnstic Abdminal Artgraphy and Renal Angigraphy - 4X- 55AB... 291 L26761- Vertebral Fracture Assessment (VFA) - 4X-49AB... 297 L26763- Magnetic Resnance Angigraphy (MRA) f the Head and Neck, Chest, Abdmen and Pelvis, Lwer Extremities - 4X-56AB... 301 L26764- Mammgraphy, Diagnstic - 4X-61AB... 320 L26770- MRI and CT Scans f the Spine - 4X-62AB... 325 L26772- Thrmblytic Agents - 4I-91AB... 356 L26778- Transcatheter Therapy Other Than Thrmblysis, Chemtherapy r Emblizatin - 4Y-24AB... 361 L26788- Pachymetry - 4O-62AB... 366 L26806- Ophthalmic A and B Scans - 4O 55AB... 372 L26811- Nn-Cvered Services 4Z-18AB... 379 L26814- Helicbacter Pylri Testing 4L-105AB... 402 L26831- Grenz Ray Treatment - 4R-20AB... 410 L26833- Intensity-Mdulated Radiatin Therapy (IMRT) - 4R-22AB... 414 L26834- Brachytherapy: Nn-Intracrnary - 4R-21AB... 428 L26835- Steretactic Bdy Radiatin Therapy - 4R 24AB... 443 L26838- Steretactic Radisurgery - 4R 25AB... 450 L26839- Radiatin Onclgy: External Beam/Teletherapy 4R-23AB... 458 Cpyright 2008 CdeMap Page 2
CPT t LCD ID CPT t LCD ID CPT...LCD ID 19296...L26834 19297...L26834 19298...L26834 31643...L26834 33240...L26500 33249...L26500 35475...L26737 35476...L26737 36005...L26737 36010...L26737 36120...L26727 36145...L26737 36200...L26727 36200...L26755 36215...L26727 36215...L26737 36216...L26727 36216...L26737 36217...L26727 36217...L26737 36218...L26727 36245...L26755 36470...L26729 36471...L26729 36475...L26729 36476...L26729 36478...L26729 36479...L26729 36556...L26737 36558...L26737 36561...L26737 36563...L26737 36565...L26737 36598...L26737 36800...L26737 36810...L26737 36815...L26737 36819...L26737 36821...L26737 37201...L26772 Cpyright 2008 CdeMap Page 4
CPT...LCD ID 37202...L26778 37205...L26728 37206...L26728 37207...L26728 37208...L26728 43202...L26739 43215...L26739 43220...L26739 43226...L26739 43245...L26739 43247...L26739 43248...L26739 43249...L26739 43259...L26739 47380...L26698 47381...L26698 47382...L26698 58970...L26811 62263...L26743 62264...L26743 62280...L26743 62281...L26743 62282...L26743 62310...L26743 62311...L26743 64470...L26743 64472...L26743 64475...L26743 64476...L26743 70336...L26736 70370...L26594 70371...L26594 70450...L26754 70460...L26754 70470...L26754 70544...L26763 70545...L26763 70546...L26763 70547...L26763 70548...L26763 Cpyright 2008 CdeMap Page 5
CPT...LCD ID 70549...L26763 70551...L26754 70552...L26754 70553...L26754 71250...L26732 71260...L26732 71270...L26732 71275...L26732 71550...L26732 71551...L26732 71552...L26732 71555...L26763 72125...L26770 72126...L26770 72127...L26770 72128...L26770 72129...L26770 72130...L26770 72131...L26770 72132...L26770 72133...L26770 72141...L26770 72142...L26770 72146...L26770 72147...L26770 72148...L26770 72149...L26770 72156...L26770 72157...L26770 72158...L26770 72198...L26763 72291...L26701 72292...L26701 73221...L26736 73222...L26736 73223...L26736 73721...L26736 73722...L26736 73723...L26736 73725...L26763 Cpyright 2008 CdeMap Page 6
CPT...LCD ID 74185...L26763 74230...L26594 75605...L26727 75625...L26755 75660...L26727 75662...L26727 75665...L26727 75671...L26727 75676...L26727 75680...L26727 75685...L26727 75710...L26727 75710...L26737 75716...L26727 75722...L26755 75724...L26755 75790...L26737 75820...L26737 75827...L26737 75901...L26737 75902...L26737 75956...L26725 75957...L26725 75958...L26725 75959...L26725 75960...L26728 75962...L26737 75978...L26737 76000...L26834 76001...L26834 76376...L26740 76377...L26740 76380...L26770 76499...L26811 76510...L26806 76511...L26806 76512...L26806 76513...L26806 76514...L26788 76516...L26806 Cpyright 2008 CdeMap Page 7
CPT...LCD ID 76519...L26806 76700...L26750 76705...L26750 76770...L26750 76775...L26750 76776...L26750 76873...L26834 76965...L26834 76975...L26739 76977...L26584 76999...L26811 77003...L26743 77051...L26764 77055...L26764 77056...L26764 77078...L26584 77079...L26584 77080...L26584 77081...L26584 77082...L26761 77083...L26584 77261...L26834 77261...L26839 77262...L26834 77262...L26839 77263...L26834 77263...L26839 77280...L26834 77280...L26839 77285...L26834 77285...L26839 77290...L26834 77290...L26839 77295...L26834 77295...L26839 77299...L26839 77300...L26742 77300...L26834 77300...L26839 77301...L26833 Cpyright 2008 CdeMap Page 8
CPT...LCD ID 77305...L26839 77310...L26839 77315...L26839 77321...L26839 77326...L26834 77327...L26834 77328...L26834 77331...L26839 77332...L26834 77332...L26839 77333...L26834 77333...L26839 77334...L26834 77334...L26839 77336...L26834 77336...L26839 77370...L26834 77370...L26839 77371...L26838 77372...L26838 77373...L26835 77399...L26839 77401...L26839 77402...L26839 77403...L26839 77404...L26839 77406...L26839 77407...L26839 77408...L26839 77409...L26839 77411...L26839 77412...L26839 77413...L26839 77414...L26839 77416...L26839 77417...L26839 77418...L26833 77421...L26839 77427...L26839 77431...L26839 Cpyright 2008 CdeMap Page 9
CPT...LCD ID 77432...L26838 77435...L26835 77470...L26834 77470...L26839 77499...L26831 77499...L26839 77520...L26839 77522...L26839 77523...L26839 77525...L26839 77605...L26811 77620...L26811 77750...L26834 77761...L26834 77762...L26834 77763...L26834 77776...L26834 77777...L26834 77778...L26834 77781...L26834 77782...L26834 77783...L26834 77784...L26834 77789...L26834 77790...L26834 77799...L26834 78267...L26814 78268...L26814 78459...L26753 78460...L26583 78461...L26583 78464...L26583 78465...L26583 78466...L26583 78468...L26583 78469...L26583 78472...L26583 78473...L26583 78478...L26583 78480...L26583 Cpyright 2008 CdeMap Page 10
CPT...LCD ID 78481...L26583 78483...L26583 78491...L26753 78492...L26753 78494...L26583 78496...L26583 78608...L26753 78699...L26811 78800...L26742 78801...L26742 78802...L26742 78803...L26742 78804...L26742 78811...L26753 78812...L26753 78813...L26753 78814...L26753 78815...L26753 78816...L26753 92980...L26543 92981...L26543 92982...L26543 92984...L26543 92995...L26543 92996...L26543 92997...L26811 92998...L26811 93015...L26582 93016...L26582 93017...L26582 93018...L26582 93303...L26534 93304...L26534 93307...L26534 93308...L26534 93312...L26723 93313...L26723 93314...L26723 93315...L26723 93316...L26723 Cpyright 2008 CdeMap Page 11
CPT...LCD ID 93317...L26723 93318...L26723 93320...L26534 93321...L26534 93325...L26534 93350...L26534 93501...L26529 93505...L26529 93508...L26529 93510...L26529 93511...L26529 93514...L26529 93524...L26529 93526...L26529 93527...L26529 93528...L26529 93529...L26529 93530...L26529 93531...L26529 93532...L26529 93533...L26529 93539...L26529 93540...L26529 93541...L26529 93542...L26529 93543...L26529 93544...L26529 93545...L26529 93555...L26529 93556...L26529 93875...L26744 93880...L26744 93882...L26744 93886...L26744 93888...L26744 93890...L26744 93892...L26744 93893...L26744 93922...L26747 93923...L26747 Cpyright 2008 CdeMap Page 12
CPT...LCD ID 93924...L26747 93925...L26747 93926...L26747 93930...L26747 93931...L26747 93965...L26749 93970...L26749 93971...L26749 93990...L26737 G0130...L26584 G0204...L26764 G0206...L26764 Cpyright 2008 CdeMap Page 13
L26500 L26500- Autmatic Implantable Cardiac Defibrillatr (AICD) - 4C-58AB L26500 LCD ID Number: L26500 LCD Title: Autmatic Implantable Cardiac Defibrillatr (AICD) - 4C-58AB Cntractr's Determinatin Number: 4C-58 CMS Natinal Cverage Plicy: Medicare Benefit Plicy Manual Pub. 100-02. Medicare Natinal Cverage Determinatins Manual Pub. 100-03. Crrect Cding Initiative Medicare Cntractr Beneficiary and Prvider Cmmunicatins Manual Pub. 100-09, Chapter 5. Scial Security Act (Title XVIII) Standard References, Sectins: 1862 (a)(1)(a) Medically Reasnable and Necessary. 1862 (a)(1)(d) Investigatinal r Experimental. 1833 (e) Incmplete Claim. Primary Gegraphic Jurisdictin: Texas Original Determinatin Effective Date: 03/01/2008 Revisin Effective Date: 03/01/2008 Indicatins and Limitatins f Cverage and/r Medical Necessity: Implantatin r replacement f autmatic implantable cardiac defibrillatr, with r withut sensing electrdes. The fllwing are the nly cvered indicatins as published CMS in the Natinal Cverage Determinatins (NCD) Manual, Publicatin 100-3, Sectin 20.4 (frmerly CIM 35-85) quted belw exactly and as amended by Change Request 3604 fr dates f service n r after January 27, 2005). Based n this, these are the nly circumstances under which prviders shuld submit claims fr Medicare payment (even thugh the ICD-9-CMs used fr cverage might therwise indicate ther cnditins): The implantable autmatic defibrillatr is an electrnic device designed t detect and treat life-threatening tachyarrhythmias. The device cnsists f a pulse generatr and electrdes fr sensing and defibrillating. A. Cvered Indicatins Cpyright 2008 CdeMap Page 14
L26500 Dcumented episde f cardiac arrest due t Ventricular Fibrillatin (VF), nt due t a transient r reversible cause (effective July 1, 1991). Dcumented sustained Ventricular Tachyarrhythmia (VT), either spntaneus r induced by an Electrphysilgy (EP) study, nt assciated with an acute Mycardial Infarctin (MI) and nt due t a transient r reversible cause (effective July 1, 1999). Dcumented familial r inherited cnditins with a high risk f life-threatening VT, such as lng QT syndrme r hypertrphic cardimypathy (effective July 1, 1999). Additinal indicatins effective fr services perfrmed n r after Octber 1, 2003 are: Crnary artery disease with a dcumented prir MI, a measured Left Ventricular Ejectin Fractin (LVEF) 0.35 and inducible, sustained VT r VF at EP study. (The MI must have ccurred mre than 40 days prir t defibrillatr insertin. The EP test must be perfrmed mre than fur weeks after the qualifying MI.) Dcumented prir MI and a measured LVEF 0.30 and a QRS duratin f > 120 millisecnds (the QRS restrictin des nt apply t services perfrmed n r after January 27, 2005). Patients must nt have: New Yrk Heart Assciatin (NYHA) classificatin IV. Cardigenic shck r symptmatic hyptensin while in a stable baseline rhythm. Had a Crnary Artery Bypass Graft (CABG) r Percutaneus Transluminal Crnary Angiplasty (PTCA) within the past three mnths. Had an enzyme-psitive MI within the past mnth. (Effective fr services n r after January 27, 2005, patients must nt have an acute MI in the past 40 days.) Clinical symptms r findings that wuld make them a candidate fr crnary revascularizatin. Any disease, ther than cardiac disease (e.g., cancer, uremia, liver failure), assciated with a likelihd f survival less than ne year. Additinal indicatins effective fr services perfrmed n r after January 27, 2005 are: Patients with ischemic dilated cardimypathy (IDCM), dcumented prir MI, NYHA Class II and III heart failure, and measured LVEF 35. Patients with nn-ischemic dilated cardimypathy (NIDCM) > 9 mnths, NYHA Class II and III heart failure, and measured LVEF 35 Cpyright 2008 CdeMap Page 15
L26500. Patients wh meet all current Centers fr Medicare Medicaid Services (CMS) cverage requirements fr a cardiac resynchrnizatin therapy (CRT) device and have NYHA Class IV heart failure. All indicatins must meet the fllwing criteria: Patients must nt have irreversible brain damage frm preexisting cerebral disease. MIs must be dcumented and defined accrding t the cnsensus dcument f the Jint Eurpean Sciety f Cardilgy/American Cllege f Cardilgy Cmmittee fr the Redefinitin f Mycardial Infarctin. 1 When Autmatic Implantable Cardiac Defibrillatr (AICD) is used fr primary preventin f sudden cardiac death, the fllwing criteria must als be met: Patients must be able t give infrmed cnsent. Patients must nt have: Cardigenic shck r symptmatic hyptensin while in a stable baseline rhythm. Had a CABG r PTCA within the past three mnths. Had an acute MI within the past 40 days. Clinical symptms r findings that wuld make them a candidate fr crnary revascularizatin. Any disease, ther than cardiac disease (e.g., cancer, uremia, liver failure), assciated with a likelihd f survival less than ne year. Ejectin fractins must be measured by angigraphy, radinuclide scanning r echcardigraphy. The beneficiary receiving the defibrillatr implantatin fr primary preventin is enrlled in either a Fd and Drug Administratin (FDA)- apprved categry B Investigatinal Device Exemptin (IDE) clinical trial (42 CFR Sectin 405.201), a trial under the CMS Clinical Trial Plicy (NCD, Sectin 310.1) r a qualifying data cllectin system including apprved clinical trials and registries. Initially, an Implantable Cardiac Defibrillatr (ICD) database will be maintained using a data submissin mechanism that is already in use by Medicare-participating hspitals t submit data t the Iwa Fundatin fr Medical Care (IFMC) a Quality Imprvement Organizatin (QIO) cntractr fr determinatin f Cpyright 2008 CdeMap Page 16
L26500 reasnableness and necessity and quality imprvement. Initial hypthesis and data elements are specified in this decisin (Appendix VI) and are the minimum necessary t ensure that the device is reasnable and necessary. Data cllectin will be cmpleted using the ICDA (ICD Abstractin Tl) and transmitted via Quality Netwrk Exchange (QNet) t the IFMC, which will cllect and maintain the database. Additinal stakehlderdevelped data cllectin systems t augment r replace the initial QNet system, addressing at a minimum the hyptheses specified in this decisin, must meet the fllwing basic criteria: Written prtcl n file. Institutinal review bard review and apprval. Scientific review and apprval by tw r mre qualified individuals wh are nt part f the research team. Certificatin that investigatrs have nt been disqualified. Fr purpses f this cverage decisin, CMS will determine whether specific registries r clinical trials meet these criteria. Prviders must be able t justify the medical necessity f devices ther than single lead devices. This justificatin shuld be available in the patient s medical recrd. Patients with NIDCM > three mnths, NYHA Class II r III heart failure and measured LVEF 35, nly if the fllwing additinal criteria are als met: Patients must be able t give infrmed cnsent. Patients must nt have: Cardigenic shck r symptmatic hyptensin while in a stable baseline rhythm. Had a CABG r PTCA within the past three mnths. Had an acute MI within the past 40 days. Clinical symptms r findings that wuld make them a candidate fr crnary revascularizatin. Irreversible brain damage frm preexisting cerebral disease. Any disease, ther than cardiac disease (e.g. cancer, uremia, liver failure), assciated with a likelihd f survival less than ne year. Cpyright 2008 CdeMap Page 17
L26500 Ejectin fractins must be measured by angigraphy, radinuclide scanning r echcardigraphy. MIs must be dcumented and defined accrding t the cnsensus dcument f the Jint Eurpean Sciety f Cardilgy/American Cllege f Cardilgy Cmmittee fr the Redefinitin f Mycardial Infarctin. 2 ) The beneficiary receiving the defibrillatr implantatin fr this indicatin is enrlled in either an FDA-apprved categry B IDE clinical trial (42 CFR Sectin 405.201), a trial under the CMS Clinical Trial Plicy (NCD, Sectin 310.1) r a prspective data cllectin system meeting the fllwing basic criteria: Written prtcl n file. Institutinal Review Bard review and apprval. Scientific review and apprval by tw r mre qualified individuals wh are nt part f the research team. Certificatin that investigatrs have nt been disqualified. Fr purpses f this cverage decisin, CMS will determine whether specific registries r clinical trials meet these criteria. Prviders must be able t justify the medical necessity f devices ther than single-lead devices. This justificatin shuld be available in the patient's medical recrd. B. Other Indicatins All ther indicatins fr implantable autmatic defibrillatrs nt currently cvered in accrdance with this decisin will cntinue t be cvered under Categry B IDE trials (42 CFR Sectin 405.201) and the CMS Rutine Clinical Trials Plicy (NCD, Sectin 310.1). Either ne f the fllwing criteria satisfies the diagnsis fr an acute, evlving r recent MI: Typical rise and gradual fall (trpnin) r mre rapid rise and fall (CK-MB) f bichemical markers f mycardial necrsis with at least ne f the fllwing: Ischemic symptms. Develpment f pathlgic Q waves n the ECG. ECG changes indicative f ischemia (ST segment elevatin r depressin). Crnary artery interventin (e.g., crnary angiplasty). Pathlgic findings f an acute MI. Cpyright 2008 CdeMap Page 18
L26500 C. Criteria fr Established MI Any ne f the fllwing criteria satisfies the diagnsis fr established MI: 1 Alpert and Thygesen et al., 2000. Criteria fr acute, evlving r recent MI. 2 Ibid Develpment f new pathlgic Q waves n serial ECGs. The patient may r may nt remember previus symptms. Bichemical markers f mycardial necrsis may have nrmalized, depending n the length f time that has passed since the infarctin develped. Pathlgic findings f a healed r healing MI. Nte: Type f Bill and Revenue Cdes DO NOT apply t Part B. Cverage Tpic: Surgical Services Bill Type Cdes: Cntractrs may specify Bill Types t help prviders identify thse Bill Types typically used t reprt this service. Absence f a Bill Type des nt guarantee that the plicy des nt apply t that Bill Type. Cmplete absence f all Bill Types indicates that cverage is nt influenced by Bill Type and the plicy shuld be assumed t apply equally t all claims. Revenue Cdes: Cntractrs may specify Revenue Cdes t help prviders identify thse Revenue Cdes typically used t reprt this service. In mst instances Revenue Cdes are purely advisry; unless specified in the plicy services reprted under ther Revenue Cdes are equally subject t this cverage determinatin. Cmplete absence f all Revenue Cdes indicates that cverage is nt influenced by Revenue Cde and the plicy shuld be assumed t apply equally t all Revenue Cdes. CPT/HCPCS Cdes: Nte: Prviders are reminded t refer t the lng descriptrs f the CPT cdes in their CPT bk. The American Medical Assciatin (AMA) and the Centers fr Medicare and Medicaid Services (CMS) require the use f shrt CPT descriptrs in plicies published n the Web. 33240 INSERTION OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR 33241 SUBCUTANEOUS REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR 33243 REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR ELECTRODE(S); BY THORACOTOMY Cpyright 2008 CdeMap Page 19
L26500 33244 REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION 33249 INSERTION OR REPOSITIONING OF ELECTRODE LEAD(S) FOR SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR AND INSERTION OF PULSE GENERATOR ICD-9 Cdes that Supprt Medical Necessity: The CPT/HCPCS cdes included in this LCD will be subjected t prcedure t diagnsis editing. The fllwing lists include nly thse diagnses fr which the identified CPT/HCPCS prcedures are cvered. If a cvered diagnsis is nt n the claim, the edit will autmatically deny the service as nt medically necessary. Nte: Prviders shuld cntinue t submit ICD-9-CM diagnsis cdes withut decimals n their claim frms and electrnic claims. Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cdes 33240, 33241, 33243, 33244 and 33249: Cvered fr: 402.01 Malignant hypertensin with cngestive heart failure 402.11 Benign hypertensin with cngestive heart failure 402.91 Unspecified hypertensin with cngestive heart failure 404.01 Hypertensive heart and chrnic kidney disease, malignant, with heart failure and with chrnic kidney disease stage I thrugh stage IV, r unspecified 404.11 Hypertensive heart and chrnic kidney disease, benign, with heart failure and with chrnic kidney disease stage I thrugh stage IV, r unspecified 404.13 Hypertensive heart and chrnic kidney disease, benign, with heart failure and chrnic kidney disease stage V r end stage renal disease 404.91 Hypertensive heart and chrnic kidney disease, unspecified, with heart failure and with chrnic kidney disease stage I thrugh stage IV, r unspecified 404.93 Hypertensive heart and chrnic kidney disease, unspecified, with heart failure and chrnic kidney disease stage V r end stage renal disease 410.00-410.02 Infarctin f anterlateral wall, episde f care unspecified - Infarctin f anterlateral wall, subsequent episde f care 410.10-410.12 Infarctin f ther anterir wall, episde f care unspecified - Infarctin f ther anterir wall, subsequent episde f care 410.20-410.22 Infarctin f inferlateral wall, episde f care unspecified - Infarctin f inferlateral wall, subsequent episde f care 410.30-410.32 Infarctin f inferpsterir wall, episde f care unspecified - Infarctin f inferpsterir wall,subsequent episde f care 410.40-410.42 Infarctin f ther inferir wall, episde f care unspecified - Infarctin f ther inferir wall, subsequent episde f care 410.50-410.52 Infarctin f ther lateral wall, episde f care unspecified - Infarctin f ther lateral wall, subsequent episde f care 410.60-410.62 True psterir wall infarctin, episde f care unspecified - True psterir wall infarctin, subsequent episde f care 410.70-410.72 Subendcardial infarctin, episde f care unspecified - Subendcardial infarctin, subsequent episde f care Cpyright 2008 CdeMap Page 20
L26500 410.80-410.82 Infarctin f ther specified sites, episde f care unspecified - Infarctin f ther specified sites, subsequent episde f care 410.90-410.92 Infarctin, unspecified site, episde f care unspecified - Infarctin, unspecified site, subsequent episde f care 412 Old mycardial infarctin 414.8 Other specified frms f chrnic ischemic heart disease 425.1 Hypertrphic bstructive cardimypathy 425.4 Other primary cardimypathies 426.82 Lng QT syndrme 427.1 Parxysmal ventricular tachycardia 427.41 Ventricular fibrillatin 427.5 Cardiac arrest 427.89 Other nde dysfunctin 428.0 Cngestive heart failure 428.1 Left heart failure 428.20-428.23 Systlic heart failure, unspecified - Systlic heart failure, acute n chrnic 428.30-428.33 Diastlic heart failure, unspecified - Diastlic heart failure, acute n chrnic 428.40-428.43 Cmbined systlic and diastlic heart failure, unspecified - Cmbined systlic and diastlic heart failure, acute n chrnic 428.9 Heart failure, unspecified 746.89 Other heart anmalies 996.72 Other cmplicatins due t ther cardiac device, implant, and graft Diagnsis that supprt medical necessity. N/A ICD-9 Cdes that DO NOT Supprt Medical Necessity Asterisk Explanatin N/A Diagnses that DO NOT Supprt Medical Necessity All diagnses nt listed in the ICD-9-CM Cdes That Supprt Medical Necessity sectin f this LCD. Dcumentatin Requirements Dcumentatin supprting medical necessity shuld be legible, maintained in the patient s medical recrd and made available t Medicare upn request. Only ne f the diagnses listed abve is required, but the criteria listed in the Indicatins and Limitatins f Cverage and/r Medical Necessity sectin must be fulfilled t bill Medicare. The medical recrd must specify explicitly hw the criteria have been fulfilled. Appendices N/A Utilizatin Guideline N/A Surces f Infrmatin and Basis fr Decisin J4 (CO, NM, OK, TX) MAC Integratin TrailBlazer adpted the Nridian Administrative Services, LLC LCD, Autmatic Cpyright 2008 CdeMap Page 21
L26500 Implantable Cardiac Defibrillatr (AICD), fr the Jurisdictin 4 (J4) MAC transitin. Full disclsure f surces f infrmatin is fund with riginal cntractr LCD. Other Cntractr Lcal Cverage Determinatins Autmatic Implantable Cardiac Defibrillatr (AICD), Nridian Administrative Services, LLC LCD, (CO) L18054. Advisry Cmmittee Meeting Ntes Start Date f Cmment Perid: End Date f Cmment Perid: Start Date f Ntice Perid: 12/20/2007 Revisin Histry Number: J4 Revisin Histry Explanatin N/A 06/13/2008 LCD effective in TX Part A and Part B and Part A CO and NM 06/13/2008 N/A 03/21/2008 LCD effective in CO Part B 03/21/2008 N/A 03/01/2008 LCD effective in NM Part B and OK Part A and Part B 03/01/2008 12/20/2007 Cnslidated LCD psted fr ntice effective: 12/20/2007 Last Reviewed On Date: 06/12/2008 Cpyright 2008 CdeMap Page 22