National Coverage and Medical Review Policy

The Centers for Medicare and Medicaid Services (CMS) has established National Coverage Determinations (NCD) and allows local carriers to establish Local Coverage Determinations (LCD). Certain tests are then "targeted" and subsequently require proof of medical necessity in the form of specific ICD-10-CM diagnosis code(s). CMS has authorized Medicare carriers to deny payment for laboratory services on the basis of NCD and LCD guidelines.

Please contact our Client Service Department for the latest list of "targeted" tests and frequency guidelines.

 Medicare National Coverage Determinations (NCD)

Medicare Local Coverage Determinations

• Allergen (RAST) testing
• B-type Natriuretic Peptide (BNP)
• Controlled Substance Monitoring of Drugs of Abuse
• Flow Cytometry
• High Sensitivity C-Reactive Protein (hsCRP)/Biomarkers in Cardiovascular
• Human Papillomavirus (HPV)
• Vitamin D assay

Medical necessity requirements by payer

Aetna reimbursement policy

• Vitamin D assay ICD-10 codes that meet medical necessity

Anthem reimbursement policy

• Advanced Lipoprotein testing

CareSource reimbursement policies

• Acute Hepatitis panel - ICD-10 codes that meet medical necessity
• Chlamydia - ICD-10 codes that meet medical necessity
• Glycosylated Hemaglobin A1C - ICD-10 codes that meet medical necessity
• Gonorrhea - ICD-10 codes that meet medical necessity
• Hepatitis B and C - ICD-10 codes that meet medical necessity
• Herpes simplex virus, amplified probe technique - ICD-10 codes that meet medical necessity
• Respiratory virus - ICD-10 codes that meet medical necessity
• Thyroid - ICD-10 codes that meet medical necessity
• Trich Vaginalis - ICD-10 codes that meet medical necessity
• Vitamin D - ICD-10 codes that meet medical necessity

Centene product reimbursement policies

Buckeye Medicaid, Managed Health Services and Ambetter of Indiana

• Allergy testing - ICD-10 codes that meet medical necessity
• Calprotectin - ICD-10 codes that meet medical necessity
• GenitoUrinary conditions (STD) - ICD-10 codes that meet medical necessity
• Homocysteine testing - ICD-10 codes that meet medical necessity
• Thyroid - ICD-10 codes that meet medical necessity
• Vitamin D - Pediatric policy
• Vitamin D - Adult ICD-10 codes that meet medical necessity

Cigna reimbursement policy

• Vitamin D - ICD-10 codes that meet medical necessity

Medical Mutual reimbursement policies

• Allergy testing - ICD-10 codes that meet medical necessity
• Drug testing - ICD-10 codes that meet medical necessity

United Health Care Community Plan clinical lab and other reimbursement policies

• Acute Hepatitis panel - ICD-10 codes that meet medical necessity
• Allergen (RAST) - ICD-10 codes that meet medical necessity
• Alpha Fetoprotein (AFP) - ICD-10 codes that meet medical necessity
• CA-125 - ICD-10 codes that meet medical necessity
• CA 15-3 / CA 27.29 - ICD-10 codes that meet medical necessity
• CA 19-9 - ICD-10 codes that meet medical necessity
• Carcinoembryonic Antigen (CEA) - ICD-10 codes that meet medical necessity
• Collagen crosslinks - ICD-10 codes that meet medical necessity
• Digoxin - ICD-10 codes that meet medical necessity
• Gamma Glutamyl Transferase (GGT) - ICD-10 codes that meet medical necessity
• Hemoglobin A1C - ICD-10 codes that meet medical necessity
• Human Chorionic Gonadotropin (HcG) - ICD-10 codes that meet medical necessity
• Iron serum - ICD-10 codes that meet medical necessity
• Lipid panel - ICD-10 codes that meet medical necessity
• PSA - ICD-10 codes that meet medical necessity
• Prothrombin Time (PT) - ICD-10 codes that meet medical necessity
• Partial Thomboplastin Time (PTT) - ICD-10 codes that meet medical necessity
• Thyroid - ICD-10 codes that meet medical necessity
• Urine Culture - ICD-10 codes that meet medical necessity
• Viral Hepatitis - ICD-10 codes that meet medical necessity
• Vitamin D - ICD-10 codes that meet medical necessity

Medical necessity requirements following Medicare

The following Insurance plans follow Medicare (CMS) LCD/NCD guidelines. The CMS NCD/LCD resources can be used to identify testing and diagnosis that will be affected by this policy.