This policy contains a list of services that are considered covered or non-covered based on National Guidelines.

A service or procedure included in this policy may be non-covered for a variety of reasons. It may be non-covered based on a specific exclusion (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.

To be considered medically necessary, items and services must have been established as safe and effective. That is, the items and service must be:

• consistent with the symptoms or diagnosis of the illness or injury under treatment;
• necessary and consistent with generally accepted professional medical standards (e.g., not experimental or investigational);
• not furnished primarily for the convenience of the patient, the attending physician or other physician or supplier; and,
• furnished at the most appropriate level that can be provided safely and effectively to the patient.

It is important to note that the fact that a new service or procedure has been issued a procedure code or is FDA approved does not, in itself, make the procedure medically reasonable and necessary. New services, procedures, drugs, or technology are evaluated and national policies are considered before these new services may be considered covered services.

When services are denied, the following guidelines apply:

• Benefit exclusion: The provider can bill the member for the denied services.
• Experimental/investigational and therefore, not medically necessary: A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.
• Not medically necessary: A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.
  

Documentation Requirements

When reporting an NOC code, include a complete description of the service in the narrative section of the electronic or paper claim.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Provider News

04/2011, Denial reason changing for selected services

Medicare Benefit Policy Manual - Pub. 100-02:  Chapter 15, Sections 20.1, 20.2, 50.2, 50.4, 50.4.4.2, 80.5.7, 110.1, 240.1, 280.2.1

Medicare Benefit Policy Manual - Pub. 100-02:  Chapter 16, Sections 20, 90, 120

Medicare National Coverage Determinations Manual (NCD) - Pub. 100-03 – See individual manual sections identified within the policy.

Medicare Claims Processing Manual - Pub. 100-04, Chapter 1, Section 30.3.13

Social Security Act (Title XVIII) Standard References, Sections:

• 1862 (a)(1)(A) Medically Reasonable & Necessary
• 1862 (a)(1)(D) Investigational or Experimental
• 1862 (a)(6) Personal Comfort Items
• 1862 (a)(7) Screening (Routine Physical Checkups)
• 1862 (a)(10) Cosmetic Surgery
• 1862 (a)(12) Dental

Transmittal 1417 CP, CR 5912

Transmittal 92 NCD, CR 6145