The following policies (Local Coverage
Determinations) are being retired effective November 12,
2004, as they are no longer used for prepay, postpay or
educational purposes.
|
DRG67
|
2 Chlorodeoxyadenoisine (CDA,
2CDA,Clararibine). Commercial name-Leustatin
|
|
YSRG29
|
Acne Surgery
|
|
YMDT11
|
Binocular Microscopy
|
|
MDT93
|
Breath Hydrogen Test
|
|
RAD97r1
|
Captopril Renal Scintigraphy
|
|
Ysurg05r1
|
Creation of Arteriovenous
Fistula
|
|
GU003G04
|
Cryosurgery of the Prostate
|
|
DRG28
|
Dermajet Injection
|
|
MED33
|
Electrosleep Therapy
|
|
SURG309
|
Extracorporeal Photopheresis
|
|
MED130
|
Food Allergy Testing and
Treatment
|
|
DRG52
|
Group C Chemotherapeutic
Agents
|
|
SURG293
|
Implantable Bone conduction
Hearing Device
|
|
CV001G03
|
Intravascular Ultrasound
|
|
PATH121r2
|
Multiple Pathology Tests
|
|
YDRG13
|
Neutrixin for Injection
|
|
YMED17r2
|
Phototherapy and
Photochemotherapy (PUVA)
|
|
YMED07
|
Range of Motion Measurement and
Report
|
|
YPTH29r4
|
Urinalysis
|
|
SU010E00
|
Stereotactic Radiosurgery
|
|
MDT132
|
Ophthalmological Medical
Diagnostic Tests
|
|
CV013E03
|
Diagnostic Cardiac
Catheterization
|
|
CV015E01
|
Dialysis Shunt Maintenance
|
|
DRUG103r3
|
Intramuscular Administration of
Immune Globulin
|
|
YSRG07r2
|
Endoscopic Examination-Upper
Gastrointestinal Tract
|
|
YDRG04
|
Zofran (Odansetron HCL)
|
|
DR012E00
|
Denileukin Diftitox (Ontak)
|
|
PATH95
|
Histocompatibility Testing
|
|
DRG97r2
|
Bleomycin Sulfate
|
|
DRG94r1
|
Nipent (Pentostatin for
Injection)
|
|
YSURG41r2
|
Cryosurgical Ablation of Liver
Tumors
|
|
YDRG05
|
Aerosolized Pentamidine
|
|
DRG59
|
Coverage for HIVID (DDC)
Dideoxycytidene
|
|
Drugs21
|
Pyridoxine Hydrochloride/Vitamin
B6
|
|
YSURG04r6
|
Proctosigmoidoscopy or
Sigmoidoscopy
|
|
YRAD24r1
|
Radiopharmaceuticals: Mono
Anti-bds
|
|
YMED31
|
Psychiatric Partial
Hospitalization Programs
|
|
SURG316
|
Endosseous Dental Implants
|
These policies are being retired
because they are covered by national regulations
(regulation links are included).
