Highmark Medicare Advantage Medical Policy in West Virginia

Section:	CMS National Guidelines
Number:	N-47
Topic:	Diagnostic Breath Analysis - NCD 100.5
Effective Date:	August 25, 2008
Issued Date:	August 25, 2008

General Policy

Diagnostic breath analyses are tests performed to measure either the hydrogen or carbon dioxide content of the breath after ingestion of certain compounds. The analyses are performed to diagnose certain gastrointestinal diseases.

Indications and Limitations of Coverage

A lactose hydrogen breath test (91065) to detect lactose malabsorption is eligible for payment.

The following breath tests are excluded from coverage:

Lactulose breath hydrogen for diagnosing small bowel bacterial overgrowth and measuring small bowel transit time.
C02 for diagnosing bile acid malabsorption.
C02 for diagnosing fat malabsorption.

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.

91065

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

National Coverage Determination 100.5

www.cms.gov

www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Glossary

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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.