Medicare Coverage Updates August 2010

on Wednesday, 04 August 2010. All News Items

Cahaba GBA Coverage Updates

Cahaba GBA recently updated the following Local Coverage Determinations (LCDs).

Drugs and Biologicals: Antiangiogenic Therapy for Ophthalmic Conditions (L30555) 
Effective date: June 22, 2010
Coverage was expanded for Ranibizumab (Lucentis™) (J2778) to include the new FDA approved indication for ‘Macular Edema Following Retinal Vein Occlusion (RVO).’

The following ICD-9 diagnosis codes were added to the list of ‘ICD-9 Codes that Support Medical Necessity’ for J2778:

  • 362.35  Central retinal vein occlusion
  • 362.36  Venous tributary (branch) occlusion

This LCD has also been updated to more clearly delineate between the FDA indications and the Off-label uses.

Medicine: Physical Therapy – Outpatient (L30009) and
Medicine: Occupational Therapy – Outpatient (L30007)
Effective date: August 1, 2010
These LCDs were updated to clarify language in the ‘Indications’ section relating to Wheelchair Management/Propulsion Training (CPT 97542).  The new language addresses CPT codes 97001, 97003, and 97542. 

The new section reads:

CPT 97542 - Wheelchair Management/Propulsion Training
a. This procedure is considered reasonable and necessary only when it requires the professional skills of a therapist.
b. The patient or caregiver must have the capacity to learn from instructions.
c. Visits made for restraint reduction are generally non-covered.
d. Subsequent to the initial evaluation, utilization of 97542 should correlate to the complexity of the equipment.
e. The National Coverage Determination (NCD) 280.3 outlines the necessary components of documentation that need to be met and documented in the initial evaluation. ‘Yes’ and ‘No’ responses alone to the NCD requirements do not meet medical necessity.
f. Additional Documentation Requirements

  1. When billing CPT 97542 for wheelchair propulsion training, documentation must relate the training to expected functional goals that are attainable by the patient and /or caregiver.
  2. The specific wheelchair management activity must be clearly documented and address a specific measurable goal related to functional activity.

Retired Local Coverage Determinations
Effective date: July 31, 2010
The following Local Coverage Determinations (LCDs) were retired:

  • Radiology: Computed Tomography of the Head or Brain (L30016)
  • Surgery: Upper Gastrointestinal Endoscopy (L30021)

New Local Coverage Determinations
Effective date: August 1, 2010
The following new LCDs are now effective:

  • Pathology and Laboratory: Vitamin D Assay Testing (DL30905)
  • Radiology: Computed Tomographic (CT) Colonography (DL30896)

Cahaba GBA’s LCDs can be accessed from their web site at Local Coverage Determinations (LCDs) and Articles (choose your state and select “LCDs” for active LCDs)

Notices of updates to Cahaba GBA’s LCDs can be viewed on the Part A What’s New page of their website at

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