New and Revised Local Coverage Determinations (LCD)
New York and New Jersey  

Providers: If you wish to obtain the full text of the LCDs described below, they are available on our Web site, www.empiremedicare.com, or you can write to:

Or telephone toll-free:
NY: 877-869-6504 – select “fax on demand,” option #7
NJ: 877-567-9235 – select “fax on demand,” option #4

PHYSICAL MEDICINE AND REHABILITATION

LCD Database Number
New York-L3041
New Jersey-L3502

LCD Revision Effective Date

08/11/2006

LCD Summary

Intervention with PM&R modalities and procedures is indicated when the diagnosis established by the physician or non-physician practitioner supports utilization of the intervention; there is documentation of objective physical and functional limitations; and the plan of care incorporates those treatment elements that are expected to result in improvement of these limitations in a reasonable and generally predictable period of time. If the clinical response to ongoing therapy is not satisfactory, or fails to produce significant improvement within a reasonable time, the carrier may determine that the services are not reasonable and necessary.

PM&R services in providers’ offices and patients’ homes (when the patient does not have Medicare-covered Home Health services) are covered when reasonable and medically necessary for the treatment of the patient’s condition (signs and symptoms). The type, frequency, and duration of services must be medically necessary for the patient’s condition under accepted medical, physical therapy, and occupational therapy practice standards, and relate directly to a written treatment plan. There must be an expectation that the condition or the level of function will improve within a reasonable (and generally predictable) time, or the services must be necessary to establish a safe and effective maintenance regimen required in connection with a specific disease. If the patient’s expected restoration potential would be insignificant in relation to the extent and duration of physical therapy services required to achieve such potential, the therapy would not be considered reasonable and necessary .

This revised LCD adds limits on the units of service that can be allowed per day for specific codes, and includes additional payable diagnoses for some modalities. Delayed certification information has been added to the policy.

BARIATRIC SURGERY

LCD Database Number
New York- L13918
New Jersey-L13917

LCD Revision Effective Date

08/11/2006

LCD Summary

Obesity is an increase in body weight beyond the limitation of skeletal and physical requirements, as a result of an excessive accumulation of fat in the body. In general, 20 to 30 percent above “ideal” body weight, according to standard life insurance tables, constitutes obesity. Morbid obesity is further defined as a condition of consistent and uncontrollable weight gain. Individuals who may be considered as candidates for gastrointestinal surgery include those with a body mass index (BMI) above 35 who suffer from type 2 diabetes or life-threatening cardiopulmonary problems such as severe sleep apnea or obesity-related heart disease.

BMI is a method used to quantitatively evaluate body fat by reflecting the presence of excess adipose tissue.

Treatment of Obesity

Services under the “Program” are considered to be not reasonable and necessary for the treatment of obesity when it is the sole condition. Obesity may be caused by illnesses such as hypothyroidism, Cushing’s disease, and hypothalamic lesions. Obesity can also aggravate a number of cardiac and respiratory diseases, as well as diabetes and hypertension which is poorly controlled on therapy. Therefore, services in connection with the treatment of obesity are covered when such services are an integral and necessary part of a course of treatment for one of these illnesses.

Supplemented Fasting

Supplemented fasting is not covered as a general treatment for obesity. However, in cases where weight loss is necessary before surgery in order to ameliorate the complications posed by obesity when it coexists with pathological conditions such as cardiac and respiratory diseases, diabetes or hypertension (and other more conservative techniques to achieve this end are not regarded as appropriate), supplemented fasting with adequate monitoring of the patient are covered under Medicare on an individual consideration basis.

Surgical Treatments

Effective for services on or after February 21, 2006, the Centers for Medicare & Medicaid Services (CMS) has determined that covered bariatric surgery procedures are reasonable and necessary only when performed at facilities that are: (1) certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (BSCOE) (program standards and requirements in effect on February 15, 2006).

A list of approved facilities and their approval dates will be listed and maintained on the CMS Coverage Web site at www.cms.hhs.gov/center/coverage.asp, and will be published in the Federal Register.

Laparoscopic Gastric Banding for extreme obesity is covered under the program if:

1. It is medically appropriate for the individual to have such surgery; and
2. The surgery is to correct an illness that caused the obesity or was aggravated by the obesity.

Gastric Bypass Surgery for extreme obesity is covered under the program if:

1. It is medically appropriate for the individual to have such surgery; and
2. Services in connection with the treatment of obesity are covered when such services are an integral and necessary part of a course of treatment for one of the medical conditions aggravated by the obesity.

Duodenal Switch Procedure for extreme obesity is covered under the program if:

1. It is medically appropriate for the individual to have such surgery; and
2. The surgery is to correct an illness that caused the obesity or was aggravated by the obesity.

Intestinal Bypass Surgery does not meet the reasonable and necessary provisions of §1862(a)(1) of the Act and is not a covered procedure.

Gastric Balloon is not covered under Medicare, since the long-term safety and efficacy of the device in the treatment of obesity has not been established.

The evidence is not adequate to conclude that the following bariatric surgery procedures are reasonable and necessary; therefore, the following are noncovered for all Medicare beneficiaries effective for services performed on or after February 21, 2006:

• Open Vertical Banded Gastroplasty;
• Laparoscopic Vertical Banded Gastroplasty;
• Open Sleeve Gastrectomy;
• Laparoscopic Sleeve Gastrectomy; and
• Open Adjustable Gastric Banding.

Revisional Surgeries for patients who have had previous surgical treatment for morbid obesity will be covered if the patient had previously met the medical necessity indications at the time of the initial surgery.

POST-VOID RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND

LCD Database Number
New York-L9223
New Jersey-L3755

LCD Revision Effective Date

08/11/2006

LCD Summary

Post-void residual (PVR) urine volume is the volume of urine in the bladder immediately after the completion of voiding. The standard method of determining PVR urine volumes is intermittent catheterization, which is associated with increased risk of urinary infection, urethral trauma, and discomfort for the patient. Bladder ultrasound has been introduced as an alternative, noninvasive method, to avoid the potential complications of intermittent catheterization. The use of both ultrasound and catheterization during the same session to determine PVR is not medically necessary.

Bladder ultrasound or bladder scan to determine post-void residual urine employs either a standard ultrasound machine or a portable, battery-powered ultrasound device which consists of a hand-held ultrasound transducer (scanhead) and a base unit with a display screen. This unit automatically calculates and displays the bladder volume.

Bladder scan ultrasonography is utilized to assess post-void urinary bladder retention. It can be an important component in the diagnosis and ongoing management of lower urinary tract dysfunctions, including, but not limited to, urinary incontinence and/or neurogenic bladder.

When ultrasound measurement for post-void residual is the only service clinically indicated and/or rendered, it is inappropriate to report a pelvic ultrasound code (76856 or 76857) instead of, or in addition to, this service. Likewise, if a pelvic ultrasound code is appropriately billed, it is inappropriate to bill separately for the PVR measurement since payment for this has already been included in the payment of the pelvic study.

Routine ultrasound examination of incontinent patients in nursing homes and skilled nursing facilities is not warranted. PVR determination is only one component of incontinence evaluation. The patient must be capable of participating in the complete evaluation process and in the treatment plan in order for this testing to be appropriate. The use of ultrasound to measure PVR is not medically necessary if no treatment is planned, regardless of the findings.

CARDIAC COMPUTED TOMOGRAPHY AND COMPUTED TOMOGRAPHY CORONARY ANGIOGRAPHY

LCD Database Number
New York-L22378
New Jersey-L22380

LCD Revision Effective Date

08/11/2006

LCD Summary

This LCD is an update of our prior LCD that was entitled “Multislice or Multidetector Computed Tomographic (MDCT) Angiography of the Chest.” The new policy has new Category III codes that specifically address the CT of the coronaries. The service represents new and evolving technology, which provides noninvasive angiographic imaging of the coronary vessels. Proper use of this test can obviate unnecessary hospitalization and invasive cardiac catheterizations. Our policy provides a guide to the physicians, on the circumstances that the test would be considered reasonable and necessary.

HEALTH AND BEHAVIOR ASSESSMENT/INTERVENTION

LCD Database Number
New York-L13974
New Jersey-L13965

LCD Revision Effective Date

08/11/2006

LCD Summary

Health and Behavior Assessment procedures are used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems. The focus of the assessment is not on mental health but on the biopsychosocial factors important to physical health problems and treatments.

Health and Behavior Intervention procedures are used to modify the psychological, behavioral, emotional, cognitive, and social factors identified as important to or directly affecting the patient’s physiological functioning, health and well being, or specific disease-related problems.

1. The Health and Behavioral Assessment, initial (CPT code 96150) and Reassessment (CPT code 96151), and Intervention services (CPT codes 96152-96153) may be considered reasonable and necessary for the patient who meets all of the following criteria:
   1. The patient has an underlying physical illness or injury,
   2. The patient has not been diagnosed with mental illness, and
   3. For whom there is reason to believe that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or an injury, and
   4. The patient is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, and
   5. The patient has a documented need for psychological support in order to successfully manage his/her physical illness, and activities of daily living, and
   6. The assessment is not duplicative of other provider assessments.
2. In addition, in order for Reassessment to be considered reasonable and necessary, there should be documentation that there has been a sufficient change in mental or medical status warranting reevaluation of the patient’s capacity to understand and to respond meaningfully to the psychological intervention.
   
3. Health and Behavioral Intervention, individual or group (two or more patients) (CPT codes 96152-96153) require that:
   1. Specific psychological intervention(s) and patient outcome goal(s) have been clearly identified, and
   2. Psychological intervention is necessary to address:
   - Noncompliance with the medical treatment plan, or
   - The biopsychosocial factors associated with a new diagnosed physical illness, or an exacerbation of an established physical illness, when such factors affect symptom management and expression, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness, and
   3. The specific psychological interventions(s) and patient outcome goals have been clearly identified.
      
4. Health and Behavioral Intervention (with the family and patient present) (CPT code 96154) is considered reasonable and necessary for the patient who meets all of the following criteria:
   1. The family representative* directly participates in the overall care of the patient, and
   2. The psychological intervention with the patient and family is necessary to address biopsychosocial factors that affect compliance with the plan of care, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness.
5. For dates of service prior to January 1, 2004, Health and Behavioral Intervention (with the family and without the patient present) (CPT code 96155) is considered reasonable and necessary for the patient if he/she meets all of the following criteria:
   1. If the patient is withdrawn or uncommunicative, legally incompetent or is a minor, or severely cognitively impaired, and
   2. The specific, psychological intervention is to be used to successfully manage the patient’s physical illness requires the family representative* to resolve the psychological barriers to the management of the patient’s physical disease, or it is necessary to ensure patient compliance with the medical treatment plan, and
   3. The family representative* participates directly in the care of the patient.

* For the purpose of this policy, “ family representative” is defined as immediate family members (only husband, wife, siblings, children, grandchildren, grandparents, mother, and father), any primary caregiver who provides care on a voluntary, uncompensated, regular, sustained basis, guardian, or healthcare proxy.

For dates of service on or after January 1, 2004, there is no coverage for CPT code 96155.

This revision adds ICD-9-CM code 318.0 to the list of noncovered diagnoses.

ENDOTHELIAL CELL PHOTOGRAPHY

LCD Database Number
New York-L22384
New Jersey-L22382

LCD Effective Date

08/11/2006

LCD Summary

Endothelial cell photography may be performed using either specular or confocal microscopy. Although national coverage is available for multiple corneal conditions, the use of this service prior to cataract surgery is not separately reimbursable unless the beneficiary has a visual problem other than the cataract for which this service is being provided. Conditions identified solely as items of past medical history are not considered visual problems.

When a presurgical examination for cataract surgery is performed and the only visual problem is cataracts, endothelial cell photography is covered as part of the presurgical evaluation and not in addition to it. (See also, National Coverage Determinations 10.1 and 80.8.)

© All current procedural terminology (CPT) codes and descriptors copyrighted by the American Medical Association.