MAPPO Policies: Policies

Policies


		(FDG) PET for Brain, Cervical, Ovarian, Pancreatic, Small Cell Lung, and Testicular Cancers - 220.6.14			NCD
		(FDG) PET for Colorectal Cancer - 220.6.4			NCD
		24-Hour Ambulatory Esophageal pH Monitoring - 100.3			NCD
		Abarelix for the Treatment of Prostate Cancer - 110.19			NCD
		Abortion - 140.1			NCD
		Acupuncture - 30.3			NCD
		Acupuncture for Fibromyalgia - 30.3.1			NCD
		Acupuncture for Osteoarthritis - 30.3.2			NCD
		Acute Care: Inpatient, Observation and Treatment Room Services - L27548			Part A/Part B
		Add-on Codes - 00.10.20g			Claim Payment
		Adult Liver Transplantation - 260.1			NCD
		Air-Fluidized Bed - 280.8			NCD
		Alpha-fetoprotein (AFP) - 190.25			NCD
		Ambulance (Ground) Services - L32252			Part A/Part B
		Ambulatory Blood Pressure Monitoring - 20.19			NCD
		Ambulatory EEG Monitoring - 160.22			NCD
		Anesthesia in Cardiac Pacemaker Surgery - 10.6			NCD
		Anesthesia Services for a Cancelled or Discontinued Procedure - 01.00.02b			Claim Payment
		Ankle-Foot/Knee-Ankle-Foot Orthosis - L11527			DME MAC
		Anti-Cancer Chemotherapy for Colorectal Cancer - 110.17			NCD
		Anti-Inhibitor Coagulant Complex (AICC) - 110.3			NCD
		Antigens Prepared for Sublingual Administration - 110.9			NCD
		Apheresis (Therapeutic Pheresis) - 110.14			NCD
		Aprepitant for Chemotherapy-Induced Emesis - 110.18			NCD
		Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee - 150.9			NCD
		Artificial Hearts and Related Devices - 20.9			NCD
		Assessing Patient's Suitability for Electrical Nerve Stimulation Therapy - 160.7.1			NCD
		Autogenous Epidural Blood Graft - 10.5			NCD
		Autologous Cellular Immunotherapy Treatment for Metastatic Prostate Cancer - 110.22			NCD
		Automatic External Defibrillators - L13613			DME MAC
		B-type Natriuretic Peptide (BNP) Assays - L30559			Part A/Part B
		Bariatric Surgery for Treatment of Morbid Obesity - 100.1			NCD
		Biofeedback Therapy - 30.1			NCD
		Biofeedback Therapy for the Treatment of Urinary Incontinence - 30.1.1			NCD
		Bladder Stimulators (Pacemakers) - 230.16			NCD
		Blepharoplasty/Blepharoptosis - L27474			Part A/Part B
		Blood-Derived Products for Chronic Non-Healing Wounds - 270.3			NCD
		Blood Brain Barrier Osmotic Disruption for Treatment of Brain Tumors - 110.20			NCD
		Blood Counts - 190.15			NCD
		Blood Glucose Monitoring in a Skilled Nursing Facility (SNF) - L27475			Part A/Part B
		Blood Glucose Testing - 190.20			NCD
		Blood Platelet Transfusions - 110.8			NCD
		Blood Transfusions - 110.7			NCD
		Bone (Mineral) Density Studies - 150.3			NCD
		Breast Reconstruction Following Mastectomy - 140.2			NCD
		C-Reactive Protein Testing - L30256			Part A/Part B
		Canes and Crutches - L11496			DME MAC
		Carcinoembryonic Antigen (CEA) - 190.26			NCD
		Cardiac Catheterization Performed in Other than a Hospital Setting - 20.25			NCD
		Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (TEB) - 20.16			NCD
		Cardiac Pacemaker Evaluation Services - 20.8.1			NCD
		Cardiac Pacemakers - 20.8			NCD
		Cardiac Rehabilitation Program Services - L31481			Part A/Part B
		Cardiac Rehabilitation Programs - 20.10			NCD
		Cardiac Rhythm Device Evaluation - L30529			Part A/Part B
		Cardiointegram (CIG) as an Alternative to Stress Test or Thallium Stress Test - 20.27			NCD
		Cardiovascular Nuclear Medicine - L31187			Part A/Part B
		Cardiovascular Stress Testing - L27478			Part A/Part B
		Carotid Body Resection/Carotid Body Denervation - 20.18			NCD
		Carotid Sinus Nerve Stimulator - 160.6			NCD
		Cast and Splint Applications and Associated Supplies Provided in the Office Setting - 00.10.15a			Claim Payment
		Cataract Surgery - L27479			Part A/Part B
		Cavernous Nerves by Electrical Stimulation with Penile Plethysmography - 160.26			NCD
		Cellular Therapy - 30.8			NCD
		Certain Drugs Distributed by the National Cancer Institute - 110.2			NCD
		Cervical Traction Devices - L15844			DME MAC
		Challenge Ingestion Food Testing - 110.12			NCD
		Chelation Therapy for Treatment of Atherosclerosis - 20.21			NCD
		Chemical Aversion Therapy for Treatment of Alcoholism - 130.3			NCD
		Chiropractic Services - L27480			Part A/Part B
		Closed-Loop Blood Glucose Control Device (CBGCD) - 40.3			NCD
		Co-Management of Surgical Procedures - L27481			Part A/Part B
		Cochlear Implantation - 50.3			NCD
		Cochleostomy with Neurovascular Transplant for Meniere's Disease - 50.7			NCD
		Cold Therapy - L5038			DME MAC
		Collagen Crosslinks, any Method - 190.19			NCD
		Collagen Meniscus Implant - 150.12			NCD
		Collection and Interpretation of Physiologic Data - 00.10.21b			Claim Payment
		Colonic Irrigation - 100.7			NCD
		Colorectal Cancer Screening Tests - 210.3			NCD
		Commodes - L11497			DME MAC
		Complex Cataract Extraction - L27482			Part A/Part B
		Computed Tomographic Angiography of the Chest - L27483			Part A/Part B
		Computed Tomography - 220.1			NCD
		Computer Analysis and Generation of Automated Data in Conjunction with Diagnostic Studies - 06.00.01d			Claim Payment
		Computer Enhanced Perimetry - 80.9			NCD
		Consultation Services Rendered by a Podiatrist in a Skilled Nursing Facility - 70.2			NCD
		Consultations with a Beneficiary's Family and Associates - 70.1			NCD
		Continuous Glucose Monitoring (CGM) - L31165			Part A/Part B
		Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) - 240.4			NCD
		Corset Used as Hernia Support - 280.11			NCD
		Counseling to Prevent Tobacco Use - 210.4.1			NCD
		Coverage of Services and Procedures in Nursing Facilities - L27485			Part A/Part B
		Cryosurgery of Prostate - 230.9			NCD
		Cytogenetic Analysis - L30538			Part A/Part B
		Cytogenetic Studies - 190.3			NCD
		Cytotoxic Food Tests - 110.13			NCD
		Debridement of Mycotic Nails - L27487			Part A/Part B
		Deep Brain Stimulation for Essential Tremor and Parkinson's Disease - 160.24			NCD
		Dental Examination Prior to Kidney Transplantation - 260.6			NCD
		Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS) - 250.5			NCD
		Diabetes Outpatient Self-Management Training - 40.1			NCD
		Diagnosis and Treatment of Impotence - 230.4			NCD
		Diagnostic and Therapeutic Radiopharmaceutical Agents - 09.00.32g			Claim Payment
		Diagnostic Breath Analyses - 100.5			NCD
		Diagnostic Endocardial Electrical Stimulation (Pacing) - 20.12			NCD
		Diagnostic Laryngoscopy - L27488			Part A/Part B
		Diagnostic Pap Smears - 190.2			NCD
		Diathermy Treatment - 150.5			NCD
		Digital Subtraction Angiography - 220.9			NCD
		Digoxin Therapeutic Drug Assay - 190.24			NCD
		Dimethyl Sulfoxide (DMSO) - 230.12			NCD
		Displacement Cardiography - 20.24			NCD
		Durable Medical Equipment Reference List - 280.1			NCD
		Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum - 05.00.48e			Claim Payment
		Dynamic Electrocardiography - L31173			Part A/Part B
		Dysphagia - Home Health - L336			RHHI
		Echocardiography Contrast Agents - 09.00.11b			Claim Payment
		Electrical Aversion Therapy for Treatment of Alcoholism - 130.4			NCD
		Electrical Continence Aid - 230.15			NCD
		Electrical Nerve Stimulators - 160.7			NCD
		Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds - 270.1			NCD
		Electrocardiogram (ECG/EKG) Reported with Single Photon Emission Computed Tomography (SPECT) for Myocardial Perfusion Imaging (MPI) - 03.02.12b			Claim Payment
		Electrocardiographic (EKG) Services - 20.15			NCD
		Electrocardiography - L27490			Part A/Part B
		Electroencephalographic (EEG) Monitoring During Surgical Procedures Involving the Cerebral Vasculature - 160.8			NCD
		Electromyography (EMG) and Nerve Conduction Studies - L29547			Part A/Part B
		Electron Microscope - 190.4			NCD
		Electronecephalographic (EEG) Monitoring During Open-Heart Surgery - 160.9			NCD
		Electronic Speech Aids - 50.2			NCD
		Electrosleep Therapy - 30.4			NCD
		Electrotherapy for Treatment of Facial Nerve Paralysis (Bell's Palsy) - 160.15			NCD
		Endoscopy - 100.2			NCD
		Endothelial Cell Photography - 80.8			NCD
		Enteral and Parenteral Nutritional Therapy - 180.2			NCD
		Enteral Nutrition - L5041			DME MAC
		Erythropoiesis Stimulating Agents (ESAs) - L27492			Part A/Part B
		Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions - 110.21			NCD
		Esophageal Manometry - 100.4			NCD
		Ethylenediamine-Tetra-Acetic (EDTA) Chelation Therapy for Treatment of Atherosclerosis - 20.22			NCD
		Evaluation and Management Services in a Nursing Facility - L27496			Part A/Part B
		Evaluation or Setup of a Cardiac Pacemaker Reported with an Electrocardiogram (ECG/EKG) - 03.02.13b			Claim Payment
		Evoked Response Tests - 160.10			NCD
		Extended Ophthalmoscopy - L27509			Part A/Part B
		External Breast Prostheses - L5043			DME MAC
		External Counterpulsation (ECP) for Severe Angina - 20.20			NCD
		External Infusion Pumps - L5044			DME MAC
		Extracorporeal Immunoadsorption (ECI) Using Protein A Columns - 20.5			NCD
		Extracorporeal Photopheresis - 110.4			NCD
		Extracranial-Intracranial (EC-IC) Arterial Bypass Surgery - 20.2			NCD
		Eye Prosthesis - L11529			DME MAC
		Fabric Wrapping of Abdominal Aneurysms - 20.23			NCD
		Facial Prostheses - L5046			DME MAC
		Fecal Occult Blood Test (FOBT) - 190.34			NCD
		Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders - 150.8			NCD
		Fluorescein and Indocyanine Green Angiography - L27497			Part A/Part B
		Food Allergy Testing and Treatment - 110.11			NCD
		Fundus Photography - L27498			Part A/Part B
		Gamma Glutamyl Transferase (GGT) - 190.32			NCD
		Gastric Balloon for Treatment of Obesity - 100.11			NCD
		Gastric Freezing - 100.6			NCD
		Gastrophotography - 100.12			NCD
		Glucose Monitors - L11530			DME MAC
		Glycated Hemoglobin/Glycated Protein - 190.21			NCD
		Granulocyte Transfusions - 110.5			NCD
		Gravlee Jet Washer - 230.5			NCD
		Hair Analysis - 190.6			NCD
		Heart Transplants - 260.9			NCD
		Heartsbreath Test for Heart Transplant Rejection - 260.10			NCD
		Heat Treatment, including the Use of Diathermy and Ultrasound for Pulmonary Conditions - 240.3			NCD
		Heating Pads and Heat Lamps - L28480			DME MAC
		Hemodialysis for Treatment of Schizophrenia - 130.8			NCD
		Hemorheograph - 250.2			NCD
		Hepatitis Panel/Acute Hepatitis Panel - 190.33			NCD
		High Frequency Chest Wall Oscillation Devices - L12870			DME MAC
		High Osmolar Contrast Agents - 09.00.13b			Claim Payment
		HIS Bundle Study - 20.13			NCD
		Histocompatibility Testing - 190.1			NCD
		Home Blood Glucose Monitors - 40.2			NCD
		Home Health Nurses' Visits to Patients Requiring Heparin Injection - 290.2			NCD
		Home Health Visits to a Blind Diabetic - 290.1			NCD
		Home Oxygen Use to Treat Cluster Headache - 240.2.2			NCD
		Home Prothrombin Time INR Monitoring for Anticoagulation Management - 190.11			NCD
		Home Use of Oxygen - 240.2			NCD
		Home Use of Oxygen in Approved Clinical Trials - 240.2.1			NCD
		Hospital and Skilled Nursing Facility Admission Diagnostic Procedures - 70.5			NCD
		Hospital Beds - 280.7			NCD
		Hospital Beds And Accessories - L5049			DME MAC
		Human Chorionic Gonadotropin (hCG) - 190.27			NCD
		Human Immunodeficiency Virus (HIV) Testing (Diagnosis) - 190.14			NCD
		Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring) - 190.13			NCD
		Human Skin Equivalents (HSE) - Use in the Treatment of Chronic Cutaneous Ulcer Wounds - L27549			Part A/Part B
		Human Tumor Stem Cell Drug Sensitivity Assays - 190.7			NCD
		Hyaluronan Acid Therapies for Osteoarthritis of the Knee - L32237			Part A/Part B
		Hydrophilic Contact Lens For Corneal Bandage - 80.1			NCD
		Hydrophilic Contact Lenses - 80.4			NCD
		Hyperbaric Oxygen Therapy - 20.29			NCD
		Hyperbaric Oxygen (HBO) Therapy - L32018			Part A/Part B
		Hyperthermia for Treatment of Cancer - 110.1			NCD
		Immunosuppressive Drugs - L11531			DME MAC