Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Obsolete or Unreliable Diagnostic Tests and Medical Services
Policy #:MA00.001a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Obsolete or unreliable diagnostic tests and medical services are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury.

LAB TESTS

The following diagnostic tests are considered obsolete or unreliable and have been replaced by more advanced testing procedures:
  • Amylase, blood isoenzymes, electrophoretic
  • Animal inoculation, small animal; with observation
  • Animal inoculation, small animal; with observation and dissection
  • Bendien's test for cancer and tuberculosis
  • Bolen's test for cancer (Bolen's clot retraction test)
  • Calcium, feces, 24-hour quantitative
  • Calcium saturation clotting time
  • Capillary fragility test (Rumpel-Leede)
  • Cephalin flocculation
  • Chromium, blood
  • Chymotrypsin, duodenal contents
  • Circulation time, one test
  • Colloidal gold
  • Congo red, blood
  • Gastric analysis, pepsin
  • Gastric analysis, tubeless
  • Guanase, blood
  • Hair analysis
  • Hormones, adrenocorticotropin quantitative animal tests
  • Hormones, adrenocorticotropin quantitative bioassay
  • Rehfuss test for gastric acidity
  • Serum seromucoid assay for cancer and other diseases
  • Skin test, actinomycosis
  • Skin test, brucellosis
  • Skin test, cat scratch fever (cat scratch disease; Bartonella infection)
  • Skin test, lymphopathia venereum
  • Skin test, psittacosis
  • Skin test, trichinosis
  • Starch, feces, screening
  • Thymol turbidity, blood
  • Zinc sulphate turbidity, blood

MEDICAL SERVICES

The following medical services are considered obsolete or unreliable:
  • Adrenal tissue transplant to the brain
  • Arthroscopic electrothermal joint repair
  • Cardiointegram (CIG)
  • Continuous noninvasive glucose monitoring using the Glucowatch
  • Fabric wrapping of abdominal aortic aneurysms
  • Intracardiac phonocardiogram
  • Intragastric hypothermia (Gastric freezing)
  • Phonocardiogram with electrocardiogram (ECG) lead, with indirect carotid artery and/or jugular vein tracing, and/or apex cardiogram; with interpretation and report
  • Phonocardiogram with or without electrocardiogram (ECG) lead; with supervision during recording with interpretation and report (when equipment is supplied by the physician)
  • Phonocardiogram; tracing only, without interpretation and report (e.g., when equipment is supplied by the hospital, clinic)
  • Phonocardiogram; without interpretation and report
  • Phonocardiogram; interpretation and report only
  • Vectorcardiogram (VCG), with or without electrocardiogram (ECG); with interpretation and report
  • Vectorcardiogram (VCG); tracing only, without interpretation and report
  • Vectorcardiogram (VCG); interpretation and report only

Policy Guidelines

This policy is consistent with Medicare's coverage determination.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, obsolete or unreliable diagnostic tests and medical services are not eligible for payment under the medical benefits of the Company's Medicare Advantage products because these tests and services are considered not medically necessary and, therefore, not covered.

Description

Obsolete or unreliable diagnostic tests are tests that are no longer routinely used and, in some instances, are outdated and found to be of little clinical value. Some of these tests have been replaced with improved technology. The obsolete or unreliable medical services included in this policy are services or treatments that are rarely performed and lack scientific or statistical evidence in peer-reviewed literature to document their effectiveness.

In 2006, the Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) identifying obsolete or unreliable diagnostic and cardiovascular tests.
References

American Academy of Orthopaedic Surgeons (AAOS). Thermal capsulorrhaphy. [AAOS Web site]. October 2007 (last reviewed September 2010). Available at:http://orthoinfo.aaos.org/topic.cfm?topic=a00034. Accessed November 6, 2018.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD).20.27 Cardiointegram (CIG) as an Alternative to Stress Test or Thallium Stress Test [CMS Web site]. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=259&ncdver=1&DocID=20.27&bc=gAAAABAAAAAA&. Accessed November 20, 2018.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). Fabric Wrapping of Abdominal Aneurysms (20.23). [CMS web site]. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=51&ncdver=1&DocID=20.23&bc=gAAAABAAAAAA&. Accessed November 20, 2018.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 100.6: Gastric freezing [CMS Web site]. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=87&ncdver=1&DocID=100.6&bc=gAAAABAAAAAA&. Accessed November 20, 2018.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 190.6 Hair Analysis [CMS Web site]. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=189&ncdver=1&DocID=190.6&bc=gAAAABAAAAAA&. Accessed November 20, 2018.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 300.1: Obsolete or unreliable diagnostic tests. [CMS Web site]. 06/19/06. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=204&ncdver=2&DocID=300.1&bc=gAAAABAAAAAA&. Accessed Accessed November 20, 2018.

Chen S, Haen PS, Walton J, et al. The effects of thermal capsular shrinkage on the outcomes of arthroscopic stabilization for primary anterior shoulder instability. Am J Sports Med. 2005; 33(5):705-11.

D’Alessandro DF, Bradley JP, Fleischli JE, Connor PM. Prospective evaluation of thermal capsulorrhaphy for shoulder instability: indications and results, two- to five-year follow-up. Am J Sports Med. 2004;32(1):21-33.

Jansen N, Van Riet RP, Meermans G, et al. Thermal capsulorrhaphy in internal shoulder impingement: a 7-year follow-up study. Acta Orthop Belg. 2012;78(3):304-8.

Mohtadi NG, Hollinshead RM, Ceponis PJ, et al. A multi-centre randomized controlled trial comparing electrothermal arthroscopic capsulorrhaphy versus open inferior capsular shift for patients with shoulder instability: protocol implementation and interim performance: lessons learned from conducting a multi-centre RCT [ISRCTN68224911; NCT00251160]. Trials. 2006;7:4.

Oakes DA, McAllister DR. Failure of heat shrinkage for treatment of a posterior cruciate ligament tear. Arthroscopy. 2003;19(6):E1-E4.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

87003


TO REPORT THE FOLLOWING SERVICES, USE THE UNLISTED CODE, 29999

Arthroscopic electrothermal joint repair

TO REPORT THE FOLLOWING SERVICES, USE THE UNLISTED CODE, 84999
Amylase, blood isoenzymes, electrophoretic
Bolen's test for cancer (Bolen's clot retraction test [CRT])
Colloidal gold, spinal
Chromium, blood
Chymotrypsin; duodenal contents
Gastric analysis, pepsin
Gastric analysis, tubeless
Guanase, blood
Hormones, adrenocorticotropin quantitative animal tests
Hormones, adrenocorticotropin quantitative bioassay
Starch, Feces, Screening

TO REPORT THE FOLLOWING SERVICES, USE THE UNLISTED CODE, 85999
Calcium saturation clotting time
Capillary fragility test (Rumpel-Leede)
Circulation time, one test

TO REPORT THE FOLLOWING SERVICES, USE THE UNLISTED CODE, 86486
Skin test, Actinomycosis
Skin test, Brucellosis
Skin test, Cat scratch fever (cat scratch disease; Bartonella Infection)
Skin test, Lymphopathia venereum
Skin test, Psittacosis
Skin test, Trichinosis

TO REPORT THE FOLLOWING SERVICES, USE THE UNLISTED CODE, 89240
Bendien's test for cancer and tuberculosis
Calcium, feces, 24-hour quantitative
Zinc sulphate turbidity, blood

TO REPORT THE FOLLOWING SERVICE, USE THE UNLISTED CODE, 91299
Rehfuss test for gastric acidity

TO REPORT THE FOLLOWING SERVICES, USE THE UNLISTED CODE, 93799
Intracardiac phonocardiogram
Phonocardiogram with ECG lead, with indirect carotid artery and/or jugular vein tracing, and/or apex cardiogram; with interpretation and report
Phonocardiogram with or without ECG lead; with supervision during recording with interpretation and report (when equipment is supplied by the physician)
Phonocardiogram; tracing only, without interpretation and report (eg, when equipment is supplied by the hospital, clinic)
Phonocardiogram; without interpretation and report
Phonocardiogram; interpretation and report only
Vectorcardiogram (VCG), with or without ECG; with interpretation and report
Vectorcardiogram; tracing only, without interpretation and report
Vectorcardiogram; interpretation and report only



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



M0100 Intragastric hypothermia using gastric freezing

M0301 Fabric wrapping of abdominal aneurysm

P2028 Cephalin flocculation, blood

P2029 Congo red, blood

P2031 Hair analysis (excluding arsenic)

P2033 Thymol turbidity, blood

P2038 Mucoprotein, blood (seromucoid)

S1030 Continuous noninvasive glucose monitoring device, purchase (for physician interpretation of data, use CPT code)

S1031 Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data, use CPT code)

S2103 Adrenal tissue transplant to brain

S2300 Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy

S9025 Omnicardiogram/cardiointegram


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA00.001a:
03/27/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on Obsolete or Unreliable Diagnostic Tests and Medical Services.
01/14/2019This version of the policy will become effective 01/14/2019. The following medical service was added to the policy: arthroscopic electrothermal joint repair. The following codes have been added to the policy: 29999, S2300.

MA00.001
08/17/2016This policy has been reviewed and reissued to communicate the Company's continuing position on obsolete or unreliable medical services.
05/13/2015This policy has been reviewed and reissued to communicate the Company's continuing position on obsolete or unreliable medical services.
01/01/2015This is a new policy.

12/15/2014: this Policy in Notification was updated in accordance with the 1/1/2015 CPT/HCPCS coding updates.

The following code was terminated and removed from the policy:
  • 87001






Version Effective Date: 01/14/2019
Version Issued Date: 01/14/2019
Version Reissued Date: 03/27/2019