Description
Documentation will be reviewed to determine if Cardiac Pacemakers meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary.
Affected Code(s)
33206, 33207, 33208
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
4. 42 CFR §405.929- Post-Payment Review
5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare National Coverage Determinations (NCD), Chapter 1, Part 1, §20.8.3- Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers
8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9. CGS Local Coverage Article A54961- Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers; Effective 05/01/2016; Revised 03/24/2022
10. First Coast Local Coverage Article A54926- Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers; Effective 5/1/2016; Revised 10/01/2019
11. NGS Local Coverage Article A54909- Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers; Effective 4/15/2016; Revised 5/7/2020
12. Noridian Local Coverage Article A54929- Single Chamber and Dual Chamber Permanent Cardiac Pacemakers- Coding and Billing; Effective 4/15/2016; Revised 10/01/2019
13. Noridian Local Coverage Article A54931- Single Chamber and Dual Chamber Permanent Cardiac Pacemakers- Coding and Billing; Effective 4/15/2016, Revised 10/01/2019
14. Novitas Local Coverage Article A54982- Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers; Effective 5/1/2016; Revised 10/01/2019
15. Palmetto Local Coverage Article A54831- Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers; Effective 01/13/2016; Revised 05/06/2021
16. WPS Local Coverage Article A54958- Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers; Effective 5/15/2016; Revised 08/26/2021
17. Annual American Medical Association CPT Manual, Coding Guidelines