Interrater Reliability Testing For Physicians

10 Questions | Total Attempts: 134

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Interrater Reliability Testing For Physicians

IRR Testing based on Medicare Guidelines


Questions and Answers
  • 1. 
    Subjective:  73 year old Hispanic male with History of Left AKA in 2006 with purchase of prosthesis in 2006.  Patient complaining that prosthesis is not fitting properly he is unable to bend L leg.    Patient states he is ambulatory and independent with ADL’s.    Objective: Height 70 inches, Weight 198 lbs.   Request from contracted Prosthetic/ Orthotic agency received for a new socket.  Documentation from the prosthetist indicated that the socket was damaged and this was preventing the patient from bending his leg.     Assessment: PCP office visit was made one month prior to the request and it was noted that patient was not wearing the prosthesis and was complaining that it was fitting poorly.    Benefit Coverage and Medical Management Guidelines CMS Local Coverage Determination A lower limb prosthesis is covered when the patient:
    1. Will reach or maintain a defined functional state within a reasonable period of time; and
    2. Is motivated to ambulate.
    FUNCTIONAL LEVELS: A determination of the medical necessity for certain components/additions to the prosthesis is based on the patient's potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating physician, considering factors including, but not limited to:
    1. The patient's past history (including prior PROSTHETIC use if applicable); and
    2. The patient's current condition including the status of the residual limb and the nature of other medical problems; and
    3. The patient's desire to ambulate.
    Clinical assessments of patient rehabilitation potential must be based on the following classification levels: Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and prosthesis does not enhance their quality of life or mobility. Level 1: Has the ability or potential to use prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator. Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands PROSTHETIC utilization beyond simple locomotion. Level 4: Has the ability or potential for PROSTHETIC ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the PROSTHETIC demands of the child, active adult, or athlete. FEET: A determination of the type of foot for the prosthesis will be made by the treating physician and/or the prosthetist based upon the functional needs of the patient. Basic lower extremity prostheses include a SACH foot. Other PROSTHETIC feet are considered for coverage based upon functional classification. An external keel SACH foot (L5970) or single axis ankle/foot (L5974) is covered for patients whose functional level is 1 or above. A flexible-keel foot (L5972) or multiaxial ankle/foot (L5978) is covered for patients whose functional level is 2 or above. A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for patients whose functional level is 3 or above. Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. This information must be retained in the physician's or prosthetist's files. A user-adjustable heel height feature (L5990) will be denied as not reasonable and necessary. KNEES: A determination of the type of knee for the prosthesis will be made by the treating physician and/or the prosthetist based upon the functional needs of the patient. Basic lower extremity prostheses include a single axis, constant friction knee. Other PROSTHETIC knees are considered for coverage based upon functional classification.
    • A high activity knee control frame (L5930) is covered for patients whose functional level is 4.
    • A fluid, pneumatic, or electronic knee (L5610, L5613, L5614, L5722-L5780, L5814, L5822-L5840, L5848, L5856, L5857, L5858) is covered for patients whose functional level is 3 or above.
    • Other knee systems (L5611, L5616, L5710-L5718, L5810-L5812, L5816, L5818) are covered for patients whose functional level is 1 or above.
    Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee. This information must be retained in the physician's or prosthetist's files. ANKLES: An axial rotation unit (L5982-L5986) is covered for patients whose functional level is 2 or above. HIPS: A pneumatic or hydraulic polycentric hip joint (L5961) is covered for patients whose functional level is 3 or above. SOCKETS: More than 2 test (diagnostic) sockets (L5618-L5628) for an individual prosthesis are not reasonable and necessary unless there is documentation in the medical record which justifies the need. Exception: A test socket is not reasonable and necessary for an immediate prosthesis (L5400-L5460). No more than two of the same socket inserts (L5654-L5665, L5673, L5679, L5681, L5683) are allowed per individual prosthesis at the same time. Socket replacements are considered reasonable and necessary if there is adequate documentation of functional and/or physiological need. It is recognized that there are situations where the explanation includes but is not limited to: changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to excessive patient weight or PROSTHETIC demands of very active amputees.    Select Approve or Deny based on the information contained in the case file. 
    • A. 

      Approve

    • B. 

      Deny

  • 2. 
    Subjective: 64 year old White male with a history of stage III CHF with current complaint of back pain.  States he has had low back pain for three months after moving a small table at home.  States he sleeps on three pillows due to SOB at night.    Objective:  Bilateral lungs clear on auscultation, slight dyspnea on exertion, O2 sat 95%.  Patient is ambulatory.   X-ray of lumbar spine normal.  Assessment: Physical Therapy x 6 visits ordered.  Patient requesting a Tempur-Pedic mattress for his bed at home to aide with back pain.       Benefit Coverage and Medical Management Guidelines A fixed height HOSPITAL BED (E0250, E0251, E0290, E0291, and E0328) is covered if one or more of the following criteria (1-4) are met:
    1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a HOSPITAL BED, or
    2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or
    3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out, or
    4. The patient requires traction equipment, which can only be attached to a HOSPITAL BED.
    A variable height HOSPITAL BED (E0255, E0256, E0292, and E0293) is covered if the patient meets one of the criteria for a fixed height HOSPITAL BED and requires a bed height different than a fixed height HOSPITAL BED to permit transfers to chair, wheelchair or standing position. A semi-electric HOSPITAL BED (E0260, E0261, E0294, E0295, and E0329) is covered if the patient meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate need for a change in body position. A heavy duty extra wide HOSPITAL BED (E0301, E0303) is covered if the patient meets one of the criteria for a fixed height HOSPITAL BED and the patient's weight is more than 350 pounds, but does not exceed 600 pounds. An extra heavy-duty HOSPITAL BED (E0302, E0304) is covered if the patient meets one of the criteria for a HOSPITAL BED and the patient's weight exceeds 600 pounds. A total electric HOSPITAL BED (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. For any of the above HOSPITAL BEDs (plus those coded E1399 - see Policy Article Coding Guidelines), if documentation does not justify the medical need of the type of bed billed, payment will be denied as not reasonable and necessary. If the patient does not meet any of the coverage criteria for any type of HOSPITAL BED it will be denied as not reasonable and necessary. ACCESSORIES: Trapeze equipment (E0910, E0940) is covered if the patient needs this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed. Heavy duty trapeze equipment (E0911, E0912) is covered if the patient meets the criteria for regular trapeze equipment and the patient's weight is more than 250 pounds. A bed cradle (E0280) is covered when it is necessary to prevent contact with the bed coverings. Side rails (E0305, E0310) or safety enclosures (E0316) are covered when they are required by the patient's condition and they are an integral part of, or an accessory to, a covered HOSPITAL BED. If a patient's condition requires a replacement innerspring mattress (E0271) or foam rubber mattress (E0272) it will be covered for a patient owned HOSPITAL BED.     Select Approve or Deny based on the information contained in the case file. 
    • A. 

      Approve

    • B. 

      Deny

  • 3. 
    Subjective: 85 year old Hispanic female with history of DM Type II with neuropathy, hyperlipidemia and hypothyroidism.  Complaining of generalized joint pain and stiffness to bilateral lower extremities.      Objective: Ambulatory with a rolling walker has difficulty standing from a sitting position.   Recently prescribed Home Health Physical Therapy x 6 visits which the patient completed.  The Therapist reported the following:                     4-8-2011                             4-30-2011 Strength        2+                                            3+ ROM             2+                                            3+ Sit-Stand       fair                                           fair Gait               fair                                           good Continues to have lower extremity weakness and uncontrolled descend from sit-stand.  Assessment: Request for 6 additional Physical Therapy visits received from the home health agency to continue strength and ROM exercise.          Benefit Coverage and Medical Management Guidelines Physical therapy services are part of a constellation of rehabilitative services designed to improve or restore physical functioning following disease, injury or loss of a body part. Physical therapists use the clinical history, systems review, physical examination, and a variety of evaluations to characterize individuals with impairments, functional limitations and disabilities. Impairments, functional limitations and disabilities thus identified are then addressed by the design and implementation of a therapeutic intervention tailored to the specific needs of the individual patient. The specific interventions most commonly utilized are exercise, heat, cold, electricity, ultraviolet light, ultrasound, hydrotherapy, and massage to improve circulation, strengthen muscles, maintain or restore motion, and train or retrain an individual to perform the activities of daily living. General Physical Therapy Guidelines: 1. Physical therapy services are covered services provided the services are of a level of complexity and sophistication, or the patient’s condition is such that the services can be safely and effectively performed only by a licensed physical therapist or under his/her supervision. Services normally considered to be a routine part of nursing care are not covered as physical therapy (i.e., turning a patient to prevent pressure injuries or walking a patient in the hallway postoperatively). 2. Covered physical therapy services must relate directly and specifically to an active written treatment regimen established by the physician, with input from the qualified physical therapist, and must be reasonable and necessary to the treatment of the individual's illness or injury. 3. Additionally, in order for the plan of care to be covered, it must address a condition for which physical therapy is an accepted method of treatment as defined by standards of medical practice, and must be for a condition that is expected to improve materially within a reasonable and generally predictable period of time or establishes a safe and effective maintenance program. 4. Therefore, physical therapy is only covered when it is rendered under a written treatment plan developed and approved by the individual’s physician to address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency and duration. 5. The therapist must document the patient’s functional limitations in terms that are objective and measurable. 6. Rehabilitation Services for Vision Impairment The coverage criteria and definition of rehabilitation services for vision impairment (Low Vision) is found in Transmittal AB-02-078, dated, May 28, 2002, Change Request 2083. GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES: 1. Therapeutic procedures are procedures that attempt to reduce impairments and improve function through the application of clinical skills and/or services. 2. Use of these procedures requires that the therapist have direct (one to one) patient contact. 3. Therapeutic exercises and neuromuscular reeducation are examples of therapeutic interventions. The expected goals documented in the treatment plan, affected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any one or a combination of more than one of these modalities may be used in a treatment plan, documentation must support the use of each modality as it relates to a specific therapeutic goal. 4. Services provided concurrently by a physical therapist and occupational therapist may be covered if separate and distinct goals are documented in the treatment plans. Therapeutic Exercises (CPT code 97110): 1. Therapeutic Exercise is performed with a patient either actively, active-assisted, or passively participating (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching and strengthening). 2. Therapeutic Exercise is considered reasonable and necessary if at least one of the following conditions is present and documented: a. The patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased range of motion, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance. b. The patient needing to improve mobility, stretching, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance as part of activities of daily living training, or re-education. 3. Documentation for Therapeutic Exercise must show objective loss of joint motion, strength or mobility (e.g., degrees of motion, strength grades, or levels of assistance). Select Approve or Deny based on the information contained in the case file. 
    • A. 

      Approve

    • B. 

      Deny

  • 4. 
    Subjective: 62 year old Black male with history of bilateral BKA and upper extremity neuropathy and decubitus ulcers to L BKA stump.  Ambulates with bilateral prosthesis and uses a light weight manual wheelchair when not wearing prosthesis.  He states that he feels weak and tired if he has to go a long distance in wheelchair outside the home.  Objective: Patient observed utilizing manual wheelchair, without assistance, for mobility when not wearing prosthesis.  He has reoccurring decubitus ulcers to L BKA stump which are now healed.    Scarring to hands from burns noted, grip slightly diminished.  Patient is alert and oriented.     Assessment: Patient stated that he would like to get an electric wheelchair.  Stated he had one in the past.    Benefit Coverage and Medical Management Guidelines BASIC COVERAGE CRITERIA: All of the following basic criteria (A-C) must be met for a power mobility device (K0800-K0898) or a push-rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are listed below.
    1. The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:
      • Prevents the patient from accomplishing an MRADL entirely, or
      • Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
      • Prevents the patient from completing an MRADL within a reasonable time frame.
     
    1. The patient’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.
    2. The patient does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day.
      • Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
      • An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.
    POWER OPERATED VEHICLES (K0800-K0808, K0812): A POV is covered if all of the basic coverage criteria (A-C) have been met and if criteria D-I are also met.
    1. The patient is able to:
      • Safely transfer to and from a POV, and
      • Operate the tiller steering system, and
      • Maintain postural stability and position while operating the POV in the home.
     
    1. The patient’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home.
    2. The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided.
    3. The patient’s weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV – i.e., a Heavy Duty POV is covered for a patient weighing 285 – 450 pounds; a Very Heavy Duty POV is covered for a patient weighing 428 – 600 pounds.
    4. Use of a POV will significantly improve the patient’s ability to participate in MRADLs and the patient will use it in the home.
    5. The patient has not expressed an unwillingness to use a POV in the home. If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable and necessary. Group 2 POVs (K0806-K0808) have added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary. If a POV will only be used outside the home, see related Policy Article for information concerning noncoverage.
    Select Approve or Deny based on the information contained in the case file.  
    • A. 

      Approve

    • B. 

      Deny

  • 5. 
    Subjective: 58 year old Hispanic female with history of DM type II for 12 years, states she is compliant with medications.  Patient is a non smoker.   Patient states she lost 30 lbs following Weight Watchers plan 5 years ago, but gained this back plus 20 additional pounds. Reads nutritional labels but has not recently participated in any weight management programs.   She denies a psychiatric history.  Objective:  Patient is 5’4 and weighs 216 lbs with a BMI of 37.1.  Hgb A1c results were 6.4 to 6.8 over the past year.  She is currently on Metformin, Glipizide and Lantus.  She is also on Zoloft for depression.  Assessment: Request is for a laparoscopic adjustable gastric band procedure at a certified level 1 bariatric center with an ASBS certified surgeon.    Benefit Coverage and Medical Management Guidelines Surgical treatment for primary obesity is not a covered Medicare service. CMS national policy dictates that surgery for morbid obesity is covered for Medicare beneficiaries who have all of the following:  
    • A body mass index of 35 or higher.
    • At least one co morbidity related to obesity.
    • Have been previously unsuccessful with medical treatment for obesity.
    Bariatric surgical procedures are covered only when performed at facilities that are: (1) certified by the American College of Surgeons 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 (program standards and requirements in effect on February 15, 2006). Approved facilities and their approval dates are listed and maintained on the CMS coverage Web site: http://www.cms.gov/MedicareApprovedFacilitie/BSF/list.asp Surgical procedures for morbid obesity that are covered under national policy for qualifying Medicare beneficiaries include:  
    • Open and laparoscopic Roux-en-Y Gastric Bypass (RYGBP).
    • Open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS).
    • Laparoscopic Adjustable Gastric Banding (LAGB).
    Surgical procedures for morbid obesity that are not covered under national policy for all Medicare beneficiaries include:  
    • Open adjustable gastric banding.
    • Open and laparoscopic-sleeve gastrectomy.
    • Open and laparoscopic vertical-banded gastroplasty.
    • Gastric balloon.
    TrailBlazer Local Coverage Policy BARIATRIC SURGERY procedures must be performed by a surgeon trained and substantially experienced with surgery of the digestive tract, working in a clinical setting with adequate support for all aspects of management, assessment and follow-up. The American College of Surgeons (ACS) and American Society for BARIATRIC SURGERY (ASBS) certification requirements for physician and institutional credentialing satisfy this requirement. Physicians and institutions who do not meet ACS or ASBS certification criteria for performing bariatric procedures do not qualify for Medicare payment for these procedures. Under provisions of this LCD, the following procedures are also not covered:  
    • Intestinal bypass.
    • Mini-gastric bypass.
    • Silastic ring vertical gastric bypass (Fobi pouch).
    Co morbid Conditions Severe obesity is known to aggravate numerous medical conditions. Co morbid conditions for which BARIATRIC SURGERY is covered include the following:  
    • Type II diabetes mellitus (by American Diabetes Association diagnostic criteria).
    • Refractory hypertension (defined as blood pressure of 140 mmHg systolic and/or 90 mmHg diastolic despite medical treatment with maximal doses of three antihypertensive medications).
    • Refractory hyperlipidemia (acceptable levels of lipids unachievable with diet and maximum doses of lipid lowering medications).
    • Obesity-induced cardiomyopathy.
    • Clinically significant obstructive sleep apnea.
    • Obesity-related hypoventilation.
    • Pseudotumor cerebri (documented idiopathic intracerebral hypertension).
    • Severe arthropathy of spine and/or weight-bearing joints (when obesity prohibits appropriate surgical management of joint dysfunction treatable but for the obesity).
    • Hepatic steatosis without evidence of active inflammation.
    Though the conditions listed above need not be immediately life-threatening for Medicare to cover BARIATRIC SURGERY, the condition must not be trivial or easily controlled with non-invasive means (such as medication) and must be of sufficient severity as to pose considerable short- or long-term risk to function and/or survival. Consideration of the risk-benefit for each individual patient must be used to determine that surgery for obesity is the best option for treatment for that patient and no contraindications to BARIATRIC SURGERY may exist. Previous Unsuccessful Medical Treatment for Obesity This standard applies to the surgical management of obesity when performed as an adjunct treatment of co morbid conditions. For the purposes of this LCD, a patient will have been unsuccessful with medical treatment of obesity if he meets BMI requirements stated in national policy (at the time of surgery) and he or she has made a diligent effort to achieve healthy body weight, as evidenced in the medical record. With or without BARIATRIC SURGERY, successful obesity management requires adoption and lifelong practice of healthy eating and physical exercise (i.e. lifestyle modification) by the obese patient. Without adequate patient motivation and/or skills needed to make such lifestyle modifications, the benefit of bariatric surgical procedures is severely jeopardized. Sincere pre-operative participation in either a physician-supervised nutrition and exercise program or a multidisciplinary surgical preparatory regimen as described below demonstrates patient understanding and commitment and should provide patients with necessary skills required to achieve and maintain healthy weight, thus, unless contraindicated, is necessary for Medicare coverage of BARIATRIC SURGERY procedures. Medicare expects that contraindications to some degree of participation in nutrition program and/or exercise program are exceptionally rare and that patients deemed to have such a contraindication will have very clear medical record documentation, by the supervising physician, of such. Because most individuals are able to lose weight by following healthy eating and exercise regimens, Medicare expects a diligent effort to result in weight loss of (the lesser of) at least 20 pounds or at least 10% of body weight. Medicare expects patient failure to achieve this weight loss will have been caused by plausible circumstances and the medical record will clearly explain those circumstances. Acceptable nutrition and exercise programs are numerous and varied. Medicare expects that patients will have participated in a program with features described by one of the following:  
    • Physician-supervised nutrition and exercise program: Including dietitian consultation, appropriate calorie diet, increased physical activity and behavioral modification, documented in the medical record. This physician-supervised nutrition and exercise program must meet all of these criteria:
     
    • Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with appropriately trained dietitians and/or nutritionists.
    • Nutrition and exercise program(s) must be for a minimum cumulative total of approximately six months, with participation in one program for at least three consecutive months,
    • Within the two years prior to surgery, an attending physician who supervised the patient’s participation must document participation in a physician-supervised nutrition and exercise program in the medical record. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may not be supervised by the surgeon who will perform the surgery. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of the physician's contemporaneous assessment of the patient's progress throughout the course of the nutrition and exercise program and must include, at a minimum, summary statements of the patient’s course prepared by the nutritionist, dietitian and exercise program director. For patients who participate in a physician-administered nutrition and exercise program, program records documenting the patient’s participation and progress may substitute for physician medical records.
       
    • Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, an organized multidisciplinary surgical preparatory regimen for a minimum of approximately three months’ duration meeting all of the following criteria to improve surgical outcomes, reduce the potential for surgical complications and establish the patient’s ability to comply with postoperative medical care and dietary restrictions:
     
    • Consultation with a dietitian or nutritionist.
    • Appropriately constructed, reduced-calorie diet program supervised by dietitian or nutritionist.
    • Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by an exercise therapist or other qualified professional.
    • Behavior modification program supervised by a qualified professional.
    • Smoking cessation.
    • Documentation in the medical record of the patient’s participation in the multidisciplinary surgical preparatory regimen. A physician’s summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician’s initial patient assessment and the physician’s final patient assessment following completion of the multidisciplinary surgical preparatory regimen.
    Preoperative Psychological/Psychiatric Evaluation An objective examination by a mental health professional (psychiatrist or psychologist) experienced in the evaluation and management of bariatric surgery candidates to exclude patients who are unable to personally provide informed consent, who are unable to comply with a reasonable pre- and postoperative regimen, or who have a significant risk of postoperative decompensation is recommended. Such evaluation is a Medicare-covered service. A diagnostic session is appropriate, and treatment sessions are appropriate if the patient has a diagnosable disorder that is likely to respond to psychotherapy. The mental health professional, the surgeon and the patient should be in agreement that the patient is an appropriate candidate for the surgery. Patients who have a history of psychiatric or psychological disorder or are currently under the care of a psychologist/psychiatrist, or are on psychotropic medications, must undergo preoperative psychological evaluation and clearance and the patient’s record must include documentation of the evaluation and assessment. Other Preoperative Evaluation A patient undergoing bariatric surgical procedures should undergo preoperative evaluation that is medically reasonable and necessary based upon his co morbid medical conditions and medical/surgical history. All underlying medical conditions that will likely impact or complicate the patient’s surgical and postoperative course must be adequately controlled before surgery. Routine preoperative testing (including upper gastrointestinal endoscopy) in the absence of signs/symptoms or personal history of a disease that could be negatively impacted by anesthesia or surgery is excluded from Medicare coverage by law. Postoperative Care Appropriate postoperative care for the BARIATRIC SURGERY patient is required for Medicare coverage of bariatric surgical procedures. Follow-up must include but not be limited to:  
    • Postoperative care by the operating surgeon immediately following surgery and throughout the global period for the surgery.
    • At least three follow-up visits with the BARIATRIC SURGERY team within the first year.
    • Lifetime postoperative care for dietary issues (including vitamin, mineral and nutritional supplementation), exercise and lifestyle changes reinforced by counseling and/or support groups supervised by a physician knowledgeable in the long-term care of such patients.
    Contraindications to BARIATRIC SURGERY Surgery for severe obesity is a major surgical intervention with a risk of significant early and late morbidity and perioperative mortality. Surgery for severe obesity is not covered in the presence of absolute contraindications, including the following:  
    • Prohibitive perioperative risk of cardiac complications due to cardiac ischemia or myocardial dysfunction.
    • Severe chronic obstructive airway disease or respiratory dysfunction.
    • Non-compliance with medical treatment of obesity or treatment of other chronic medical condition.
    • Failure to cease tobacco use.
    • Psychological/psychiatric conditions:
     
    • Schizophrenia, borderline personality disorder, suicidal ideation, severe or recurrent depression, or bipolar affective disorders with difficult-to-control manifestations (e.g., history of recurrent lapses in control or recurrent failure to comply with management regimen).
    • Mental retardation that prevents personally provided informed consent or the ability to understand and comply with a reasonable pre- and postoperative regimen.
    • Any other psychological/psychiatric disorder that, in the opinion of a psychologist/psychiatrist, imparts a significant risk of psychological/psychiatric decompensation or interference with the long-term postoperative management.
    Note: A history of or presence of mild, uncomplicated and adequately treated depression due to obesity is not normally considered a contraindication to obesity surgery.  
    • History of significant eating disorders, including anorexia nervosa, bulimia and pica (sand, clay or other abnormal substance).
    • Severe hiatal hernia/gastroesophageal reflux (for purely restrictive procedures such as LAGB).
    • Autoimmune and rheumatological disorders (including inflammatory bowel diseases and vasculitides) that will be exacerbated by the presence of intra-abdominal foreign bodies (for LAGB procedure).
    • Hepatic disease with inflammation, portal hypertension or ascites.
    Select Approve or Deny based on the information contained in the case file.   
    • A. 

      Approve

    • B. 

      Deny

  • 6. 
    Subjective: 68 year old White male with history of Type II Diabetes mellitus for 10 years, testing blood sugar two times per day, on insulin for the last 5 years.  Sugars are reported to be in the 180- 200 range.  Diabetes is complicated with neuropathy and chronic kidney disease.  Sliding scale history of values per diary prepared by member is blood sugar in low 200’s and 180’s at supper. Objective: Currently taking Levemir 50 u bid and metformin 1000 mg bid.   A1c has been in the 8-10 range for the last year, and specifically 10.8 in March and 8.6 in July.  C-peptide was .4 on the same dates, and fasting blood sugar was 202.  Normal labs for C-peptide Fasting levels range between 0.5–3.0 ng/ml while postprandial levels may range from 1.2 to 3.5 ng/ml. Assessment: Member is at high risk for coronary artery disease according to PCP documentation.  The member is requesting alternative of insulin pump over continued sub Q injections.   Benefit Coverage and Medical Management Guidelines   Secure Horizons Coverage Summary Titled, Diabetes management, Equipment and Supplies   Continuous external subcutaneous insulin infusion pump (CSII) and related drugs and supplies are covered in the home setting when either Criterion A or B is met and Criterion C or D is met   Criterion A: C peptide testing requirement-must meet criterion 1 or 2 and 3.   1)  C-peptide level is less than or equal to 110 percent of the lower limit of normal of the laboratory’s measurement method. 2)  For patients with renal insufficiency and a creatinine clearance (actual or calculated from age, weight, and serum creatinine) less than or equal to 50 ml/minute, a fasting C-peptide level is less than or equal to 200 per cent of the lower limit of normal of the laboratory’s measurement method. 3)A fasting blood sugar obtained at the same time as the C-peptide level is less than or equal to 225 mg/dl.   Criterion B:  Beta cell autoantibody test is positive   Criterion C:  The patient has completed a comprehensive diabetes education program, has been on a program of multiple daily injections of insulin (i.e., at least 3 injections per day) with frequent self-adjustments of insulin for at least 6 months prior to initiation of the insulin pump, and has documented frequency of glucose self testing an average of at least 4 times per day during the 2 months prior to initiation of the insulin pump, and meets one or more of the following criteria (1-5) while on the multiple injection regimen:   1)  Glycosylated hemoglobin level (HbA1C) greater than 7 percent 2)  History of recurring hypoglycemia 3)  Wide fluctuations in blood glucose before mealtime 4)  Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL 5)  History of severe glycemic excursions   Criterion D:  The patient has been on an external insulin infusion pump prior to enrollment in Medicare and has documented frequency of glucose self testing an average of at least 4 times per day during the month prior to Medicare enrollment.    Select Approve or Deny based on the information contained in the case file.   
    • A. 

      Approve

    • B. 

      Deny

  • 7. 
    Subjective: 70 year old Hispanic female with history of breast cancer to L breast in 2007.  Patient underwent lumpectomy, chemotherapy and radiation in 2007.  She is now complaining of L rib pain for 2 months.      Objective:  Mammogram from June 2011 normal.  Lumpectomy in 2007 with clear margins and no lymph node involvement.       Assessment: Recent follow-up visit with oncologist revealed complaint of rib pain.  Request pending for PET scan of chest.       Benefit Coverage and Medical Management Guidelines The following indications may be covered for PET under certain circumstances. Details of Medicare PET coverage are discussed later in this section. Unless otherwise indicated, the clinical conditions below are covered when PET utilizes FDG as a tracer. Note: This manual section lists all Medicare-covered uses of PET scans. A particular use of PET scans is not covered unless this manual specifically provides that such use is covered. Although this section lists some non-covered uses of PET scans, it does not constitute an exhaustive list of all non-covered uses. Clinical Condition Effective Date Coverage Solitary Pulmonary Nodules (SPNs) January 1, 1998 Characterization Lung Cancer (Non Small Cell) January 1, 1998 Initial staging Lung Cancer (Non Small Cell) July 1, 2001 Diagnosis, staging and restaging Esophageal Cancer July 1, 2001 Diagnosis, staging and restaging Colorectal Cancer July 1, 1999 Determining location of tumors if rising CEA level suggests recurrence Colorectal Cancer July 1, 2001 Diagnosis, staging and restaging Lymphoma July 1, 1999 Staging and restaging only when used as an alternative to Gallium scan Lymphoma July 1, 2001 Diagnosis, staging and restaging Melanoma July 1, 1999 Evaluating recurrence prior to surgery as an alternative to a Gallium scan Melanoma July 1, 2001 Diagnosis, staging and restaging; Non-covered for evaluating regional nodes Breast Cancer October 1, 2002 As an adjunct to standard imaging modalities for staging patients with distant metastasis or restaging patients with locoregional recurrence or metastasis; as an adjunct to standard imaging modalities for monitoring tumor response to treatment for women with locally advanced and metastatic breast cancer when a change in therapy is anticipated. Head and Neck Cancers (excluding CNS and thyroid) July 1, 2001 Diagnosis, staging and restaging Thyroid Cancer October 1, 2003 Restaging of recurrent or residual thyroid cancers of follicular cell origin that have been previously treated by thyroidectomy and radioiodine ablation and have a serum thyroglobulin >10ng/ml and negative I-131 whole body scan performed Myocardial Viability July 1, 2001 to September 30, 2002 Covered only following inconclusive SPECT Myocardial Viability October 1, 2001 Primary or initial diagnosis or following an inconclusive SPECT prior to revascularization. SPECT may not be used following an inconclusive PET scan Refractory Seizures July 1, 2001 Covered for pre-surgical evaluation only Perfusion of the heart using Rubidium 82* tracer March 14, 1995 Covered for noninvasive imaging of the perfusion of the heart Perfusion of the heart using ammonia N-13* tracer October 1, 2003 Covered for noninvasive imaging of the perfusion of the heart *Not FDG-PET.   For all uses of PET relating to malignancies the following conditions apply:
    • Diagnosis - PET is covered only in clinical situations in which the PET results may assist in avoiding an invasive diagnostic procedure, or in which the PET results may assist in determining the optimal anatomical location to perform an invasive diagnostic procedure. In general, for most solid tumors, a tissue diagnosis is made prior to the performance of PET scanning. PET scans following a tissue diagnosis are performed for the purpose of staging, not diagnosis. Therefore, the use of PET in the diagnosis of lymphoma, esophageal, and colorectal cancers as well as in melanoma should be rare. PET is not covered for other diagnostic uses, and is not covered for screening (testing of patients without specific signs and symptoms of disease).
    • Staging and or Restaging - PET is covered in clinical situations in which:
      • The stage of the cancer remains in doubt after completion of a standard diagnostic workup, including conventional imaging (computed tomography, magnetic resonance imaging, or ultrasound) or the use of PET would also be considered reasonable and necessary if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient, and
      • Clinical management of the patient would differ depending on the stage of the cancer identified. PET will be covered for restaging after the completion of treatment for the purpose of detecting residual disease, for detecting suspected recurrence or to determine the extent of a known recurrence. Use of PET would also be considered reasonable and necessary if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient.
    • Monitoring - Use of PET to monitor tumor response during the planned course of therapy (i.e. when no change in therapy is being contemplated) is not covered except for breast cancer. Restaging only occurs after a course of treatment is completed, and this is covered, subject to the conditions above. Note: In the absence of national frequency limitations, contractors, should, if necessary, develop frequency requirements on any or all of the indications covered on and after July 1, 2001.
    13 - Breast Cancer Beginning October 1, 2002, Medicare covers FDG PET as an adjunct to other imaging modalities for staging patients with distant metastasis, or restaging patients with locoregional recurrence or metastasis. Monitoring treatment of a breast cancer tumor when a change in therapy is contemplated is also covered as an adjunct to other imaging modalities. Limitations: Effective October 1, 2002, Medicare continues to have a national non-coverage determination for initial diagnosis of breast cancer and staging of axillary lymph nodes. Medicare coverage for staging patients with distant metastasis or restaging patients with locoregional recurrence or metastasis; and for monitoring tumor response to treatment for women with locally advanced and metastatic breast cancer when a change in therapy is anticipated, .is only covered as an adjunct to other imaging modalities. Documentation that these conditions are met should be maintained by the referring physician in the beneficiary's medical record, as is normal business practice.     Select Approve or Deny based on the information contained in the case file.   
    • A. 

      Approve

    • B. 

      Deny

  • 8. 
    Subjective: History of mitral valve repair two months ago due to mitral valve prolapse.  Patient complaining of fatigue and weakness.  Objective:  Blood Pressure 160/90, HR 67, O2 Sat 95% RA.  Echocardiogram results from 2 weeks ago: EF 82%, Trace to mild tricuspid insufficiency with no pulmonary hypertension, mild to moderate aortic insufficiency.  EKG normal sinus rhythm.       Assessment: Cardiologist requesting 6 weeks of cardiac rehab at contracted facility.    Benefit Coverage and Medical Management Guidelines Indications CARDIAC REHABilitation by national LCD is covered for only six groups of patients:  
    • Patients who begin the program within 12 months of an acute Myocardial Infarction (MI).
    • Patients who have had Coronary Artery Bypass Graft (CABG) surgery.
    • Patients with stable angina pectoris.
    • Patients who have had heart valve repair/replacement.
    • Patients who have had Percutaneous Transluminal Coronary Angioplasty (PTCA) or coronary stenting.
    • Patients who have had a heart or heart-lung transplant.
    Limitations A. Facilities CARDIAC REHABilitation programs may be provided either by the outpatient department of a hospital or a physician-directed clinic. Coverage for either program is subject to the following conditions:  
    • The facility meets the definition of a hospital outpatient department or a physician-directed clinic, i.e., a physician is on the premises available to perform medical duties at all times the facility is open and each patient is under the care of a hospital or clinic physician.
    • The facility has available for immediate use all the necessary cardiopulmonary emergency diagnostic and therapeutic life-saving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment or defibrillator.
    • The program is conducted in an area set aside for the exclusive use of the program while it is in session.
    • The program is staffed by personnel necessary to conduct the program safely and effectively and who are trained in both basic and advanced life support techniques and in exercise therapy for coronary disease. When conducted in a hospital, an identified physician must be immediately available. This does not require that a physician be physically present in the exercise room itself but must be immediately available and accessible at all times in case of an emergency.
    • When conducted in the hospital, the non-physician personnel are employees of the hospital conducting the program.
    • When conducted in a clinic or physician’s office, the non-physician personnel are employees of the physician or clinic conducting the program and their services are “incident to” a physician’s professional services.
    B. Diagnoses  
    • For MI, the date of entry into the program must be within 12 months of the date of infarction.
    • For CABG, the initiation of the program should be early enough to have a restorative effect on the recuperative process. Therefore, the date of entry should be within six months of the CABG procedure.
    • For angina, all patients must have a pre-entry stress test that is positive for exercise-induced ischemia within six months of starting CARDIAC REHABilitation (see “Group II Services” below). A positive stress test in this context implies a junctional depression of 2 mm or more with associated slowly rising ST segment, or 1 mm horizontal or downsloping ST segment depressions. Over the years, nuclear perfusion studies have supplanted standard Electrocardiogram (ECG) treadmill tests as a means of evaluating ischemic heart disease, especially for patients who have abnormal rest ECGs. Therefore, the positive stress test also includes perfusion studies that demonstrate ischemia.
    • For patients with heart valve repair or replacement, the program should be early enough to provide a restorative benefit. Therefore, the date of entry must be within six months of surgery.
    • For patients who have had a PTCA or stent replacement, the program should be early enough to provide a restorative benefit. Therefore, the date of entry must be within six months of surgery.
    • Patients who have had a heart or heart-lung transplant may present special and complex post transplant management problems. The date of entry is extended to within one year of the surgery.
    C. Frequency and Duration  
    • The frequency and duration of the program are generally a total of 36 sessions, two to three times per week over 12–18 weeks. Sessions extending beyond the 18 weeks may be reviewed to confirm medical necessity.
    • Services at a frequency of fewer than two sessions per week will be considered not medically necessary unless additional documentation is demonstrated verifying the patient was unable to attend due to illness or hospitalization.
    • For the purposes of this LCD, Phase II is divided into Phase IIA and Phase IIB:
     
    • Phase IIA is the initial outpatient CARDIAC REHABilitation, not to exceed a total of 36 sessions, two to three sessions per week for 12–18 weeks.
    • Phase IIB consists of an additional series of 36 sessions, two to three times per week for 12–18 weeks and will only be allowed if determined to be medically necessary. The total number of allowable sessions (Phase IIA and IIB combined) is 72 within a 36-week period. Phase IIB benefits must meet additional medical necessity criteria; specifically, there must be clear demonstration the patient is benefiting from CARDIAC REHABilitation and that the exit criterion below has not been met.
    D. Exit Criterion Exit criteria include, but are not restricted to, the following clinical parameters:  
    • The patient has achieved a stable level of exercise tolerance without ischemia or dysrhythmia.
    • Symptoms of angina or dyspnea are stable at the patient’s maximum exercise level.
    • The patient’s resting blood pressure and heart rate are within normal limits.
    • The stress test is not positive during exercise. A positive stress test in this context implies an ECG with a junctional depression of 2 mm or more associated with slowly rising, horizontal or down-sloping ST segment.
    • For patients with valvuloplasty or valve replacement, benefits are available for Phase IIA only. Data showing that extension of the program beyond the 36 sessions is reasonable and necessary is not available.
    • The post transplant patient poses a special challenge for the CARDIAC REHABilitation team. Issues such as deconditioning and cachexic deterioration may complicate the definition of a reasonable exit criterion. Based on the study of long-term cardiopulmonary exercise performed after heart transplant by Osade et al, this contractor will use a peak oxygen consumption (VO2) of greater than 90 percent predicted as the exit criterion for Phase IIA. Patients whose VO2 is less than 90 percent predicted may qualify for the additional Phase IIB.
    E. Non-Covered Diagnoses  
    • Use of any ICD-9-CM diagnosis code not in the “ICD-9-CM Diagnosis Codes That Support Medical Necessity” section of this LCD will be cause for denial of claims.
    • A patient with unstable angina will not qualify for CARDIAC REHABilitation services.
    • Congestive heart failure in the absence of other covered conditions is not included as a covered condition of CARDIAC REHABilitation in the CMS National Coverage Determination Manual, Publication 100-03, Section 20.10.
    F. Other Services  
    • Evaluation and Management (E/M) services, ECGs and other diagnostic services may be covered on the day of CARDIAC REHABilitation if these services are separate and distinct from the CARDIAC REHABilitation program and are medically necessary.
    • Forms of counseling, such as dietary counseling, psychosocial intervention, lipid management and stress management, are components of the CARDIAC REHABilitation program and are not separately reimbursed.
    G. Definition of Group Services  
    • Group I services include:
     
    • Continuous ECG telemetric monitoring during exercise.
    • ECG rhythm strip with interpretation and physician’s revision of exercise prescription.
    • Limited examination for physician follow-ups to adjust medication or for other treatment changes.
    A visit including one or more of the Group I services is considered as one routine CARDIAC REHABilitation visit. For the visit to be reimbursable, at least one of the Group I services must be performed. The same rate of reimbursement would be allowed for each visit, but not all services need to be performed at each visit.  
    • Group II services include:
     
    • New patient comprehensive evaluation, including history, physical and preparation of initial exercise prescription. One will be allowed at the beginning of the program if not already performed by the patient’s attending physician or if that performed by the patient’s physician is not acceptable to the program’s director.
    • ECG stress test (treadmill or bicycle ergometer) with physician monitoring and report. One will be allowed at the beginning of the program and one after three months (usually the completion of the program).
    • Other physician services, as needed.
    For requirements on physical medicine and rehabilitation modalities and procedures, see TrailBlazer’s LCD “ Physical Medicine and Rehabilitation, Outpatient - 4Y-22.” Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. As published in CMS IOM 100-08, Section 13.5.1, in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:  
    • Safe and effective.
    • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary).
    • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
     
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient's medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient's medical needs.
    • At least as beneficial as an existing and available medically appropriate alternative.
    Select Approve or Deny based on the information contained in the case file.     
    • A. 

      Approve

    • B. 

      Deny

  • 9. 
    Subjective: 71 year old Hispanic female with history of DM II and HTN.  Complaining of lower back pain for the past month.     Objective: X-ray obtained during office visit with results of lumbar spondylosis.        Assessment: Patient requesting chiropractic referral as she had this problem in the past and the chiropractic treatment helped to resolve the pain.    Benefit Coverage and Medical Management Guidelines CHIROPRACTIC services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of CHIROPRACTIC service. Please see Medicare Benefit Manual sections referenced above for national definitions, indications and limitations. Medicare expects that acute symptoms/signs due to subluxation or acute exacerbation/recurrence of symptoms/signs due to subluxation might be treated vigorously. Improvement in the patient’s symptoms is expected and in order for payment for CHIROPRACTIC services to continue, should be demonstrated within a time frame consistent with the patient’s clinical presentation. Failure of the patient’s symptoms to improve accordingly or sustained worsening of symptoms should prompt referral of the patient for evaluation and/or treatment by an appropriate practitioner. This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. Medicare will allow up to 12 CHIROPRACTIC manipulations per month and 30 CHIROPRACTIC manipulation services per beneficiary per year. Despite allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment, and Medicare does not expect that patients will routinely require the maximum allowable number of services. Additionally, Medicare requires the medical necessity for each service to be clearly demonstrated in the patient’s medical record. Covered diagnoses are displayed in four groups in this policy, with the groups being displayed in ascending specificity. Medicare does not expect that substantially more than the following numbers of treatments will usually be required:  
    • Twelve (12) CHIROPRACTIC manipulation treatments for Group A diagnoses.
    • Eighteen (18) CHIROPRACTIC manipulation treatments for Group B diagnoses.
    • Twenty-four (24) CHIROPRACTIC manipulation treatments for Group C diagnoses.
    • Thirty (30) CHIROPRACTIC manipulation treatments for Group D diagnoses.
    Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules. As published in CMS IOM, Pub. 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:  
    • Safe and effective.
    • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the clinical trials NCD are considered reasonable and necessary).
    • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
     
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical needs.
    • At least as beneficial as an existing and available medically appropriate alternative.
     Select Approve or Deny based on the information contained in the case file.     
    • A. 

      Approve

    • B. 

      Deny

  • 10. 
    Subjective: 86 year old White female with history of actinic keratosis beginning 2 months ago.   Patient complaining that lesion to left shoulder is growing.  She also reports a history of skin cancer 30 years ago.      Objective: Dermatologist office notes revealed that multiple actinic keratosis lesions to back, face, chest and arms were destroyed by cryosurgery.  A .5 cm lesion to left shoulder and a .5 cm lesion to left lower chest were biopsied.     Diagnosis:  Basel cell carcinoma to left shoulder (superficial and infiltrative) and inflamed intradermal nevus to left chest.  Assessment: Patient was counseled regarding avoiding sun exposure and tanning as well as to use a sun screen > 30 spf daily.  Request from Dermatologist for MOHS surgery to left shoulder.       Benefit Coverage and Medical Management Guidelines Current accepted diagnoses and indications for MMS are:  
    • Basal cell carcinomas, squamous cell carcinomas or basalosquamous cell carcinomas in anatomic locations where they are prone to recur:
     
    • Central facial areas, nose and temple areas of the face (the so-called “mask area” of the face), which includes the eyebrows and periorbital areas, the superolateral temple areas and the preauricular and postauricular areas.
    • Lips, cutaneous and vermilion.
    • Eyelids.
    • The entire external ear and ear canal.
       
    • Other skin lesions:
     
    • Angiosarcoma of the skin.
    • Keratoacanthoma, recurrent or rapidly growing destructive variants.
    • Dermatofibrosarcoma protuberans.
    • Malignant fibrous histiocytoma.
    • Sebaceous gland carcinoma.
    • Microcystic adnexal carcinoma.
    • Extramammary Paget’s disease.
    • Bowenoid papulosis.
    • Merkel cell carcinoma.
    • Bowen’s disease (squamous cell carcinoma in situ).
    • Adenoid type of squamous cell carcinoma.
    • Rapid growth in a squamous cell carcinoma.
    • Longstanding duration of a squamous cell carcinoma.
    • Verrucous carcinoma.
    • Atypical fibroxanthoma.
    • Leiomyosarcoma or other spindle cell neoplasms of the skin.
    • Adenocystic carcinoma of the skin.
    • Erythroplasia of Queryrat.
    • Oral and central facial, and paranasal sinus neoplasm.
    • Apocrine carcinoma of the skin.
    • Malignant melanoma or melanoma in situ (facial, auricular, genital and digital) when anatomical or technical difficulties do not allow conventional excision with appropriate margins.
    • Rare, biopsy-proven skin malignancies not otherwise addressed in this section.
    • Basal cell carcinomas, squamous cell carcinomas or basalosquamous cell carcinomas having one or more of the following features:
     
    • Are recurrent.
    • Biopsy proven lesions with aggressive pathology as documented by at least one of the following microscopic characteristics:
    • Sclerotic.
    • Fibrosing.
    • Morphealike.
    • Metatypical/infiltrative/spikey shaped cell groups.
    • Perineural or perivascular invasion.
    • Nuclear pleomorphism.
    • High mitotic activity or superficial multicentric.
    • Located in the following areas: genitalia, digits or nail unit/periungual.
    • Large size (1.0 cm or greater in the non-mask areas of the face and 2.0 cm or greater in other areas).
    • Positive margins on recent excision.
    • Poorly defined borders.
    • Present in the very young (less than 40 years of age).
    • Radiation-induced.
    • In patients with proven difficulty with skin cancers or who are immunocompromised.
    • Basal cell nevus syndrome.
    • Present in an old scar (e.g., Marjolin’s ulcer).
    • Associated with xeroderma pigmentosum or difficulty estimating depth of lesion.
         
    • Laryngeal carcinoma in certain limited clinical situations.
    Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. As published in CMS IOM 100-08, Section 13.5.1, in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:  
    • Safe and effective.
    • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary).
    • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
     
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient's medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient's medical needs.
    • At least as beneficial as an existing and available medically appropriate alternative.
    Select Approve or Deny based on the information contained in the case file.     
    • A. 

      Approve

    • B. 

      Deny