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Local Coverage Determination (LCD)

Surgical Management of Morbid Obesity

L33411

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
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LCD ID
L33411
Original ICD-9 LCD ID
Not Applicable
LCD Title
Surgical Management of Morbid Obesity
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/01/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

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Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Surgical Management of Morbid Obesity. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Surgical Management of Morbid Obesity and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site.

Internet Only Manual (IOM) Citations:

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
    • Chapter 16, Section 120 Cosmetic Surgery
  • CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
    • Chapter 1, Part 2, Section 100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 23, Section 30.1 Maintenance Process for the Medicare Physician Fee Schedule Database (MPFSDB)
    • Chapter 32, Section 150 Billing Requirements for Bariatric Surgery for Treatment of Morbid Obesity
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual,
    • Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:  

  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. 
  • Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations. 
  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Please refer to the CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, Section 100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity for nationally covered indications and limitations.

Covered Indications

Gastrointestinal surgery for obesity, also called bariatric surgery, promotes weight loss by closing off parts of the stomach to make it smaller. Program payment may not be made for treatment of obesity alone since this treatment cannot be considered reasonable and necessary for the diagnosis or treatment of an illness or injury.

Laparoscopic sleeve gastrectomy (LSG)

The surgical management for the treatment of morbid obesity is considered reasonable and necessary for all nationally covered bariatric surgical procedures and Laproscopic sleeve gastrectomy when ALL of the following conditions are met and recorded in the medical record:

  • The patient meets the definition of morbid obesity which is defined as a body mass index (BMI) > 35 and comorbid conditions exist (e.g., hypertensive cardiovascular disease, pulmonary/respiratory disease, diabetes, sleep apnea or degenerative arthritis of weight-bearing joints). Documentation of the level of severity of the comorbid existing condition must be included in the patient’s medical record; AND
  • The patient has been previously unsuccessful with medical treatment for obesity; AND
  • Treatable metabolic causes for obesity (e.g., adrenal or thyroid disorders) have been ruled out or have been clinically treated if present.

Unsuccessful Medical Treatment for Obesity

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 and not medically reasonable or necessary. Patients considering bariatric surgical options must have been provided with knowledge and tools needed to achieve such lifelong lifestyle changes and must be capable and willing to undergo the changes.

For the purposes of this LCD, a patient will be deemed to have been unsuccessful with medical treatment of obesity if all of the following minimal requirements are met per documentation in the medical record:

  • The patient has BMI ≥ 35 at the time of surgery.
  • The patient has been provided with knowledge and tools needed to achieve such lifelong lifestyle changes, exhibits understanding of the needed changes and has demonstrated to clinicians involved in his or her care to be capable and willing to undergo the changes.
  • The patient has made a diligent effort to achieve healthy body weight with such efforts described in the medical record and certified by the operating surgeon.
  • The patient has failed to maintain a healthy weight despite adequate participation in a structured dietary program overseen by one of the following:
    • Physician (MD or DO).
    • Registered dietician (RD).
    • Board certified specialist in pediatric nutrition (CSP).
    • Board certified specialist in renal nutrition (CSR).
    • Fellow of the American Dietetic Association (FADA).

Preoperative Psychological/Psychiatric Evaluation

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.

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 covered service. A diagnostic session is appropriate, and treatment sessions are appropriate if the patient has a diagnosable disorder that is likely to adversely impact the surgical outcome including post –operative compliance. The mental health professional, the surgeon and the patient should be in agreement that the patient is an appropriate candidate for the surgery.

Comorbid Conditions

Severe obesity (BMI) ≥ 35 kg/m2 is known to exacerbate numerous medical conditions. Comorbid conditions for which bariatric surgery is covered include the following:

  • Type II diabetes mellitus (by American Diabetes Association diagnostic criteria).
  • Resistant 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).
  • Nonalcoholic fatty liver disease (NAFLD) as confirmed by physician with expertise in liver disease. 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.

Limitations

Contraindications to Bariatric Surgery

Any major procedure has significant benefit and risk (injury or death) that the treating physician discusses with the patient. To meet reasonable and necessary (R&N) threshold for covered surgeries in the treatment of morbid obesity, the physician’s documentation for the case should clearly support the indication and the medical need (the procedure does not exceed the medical need) and is at least as beneficial as existing alternatives. The following list includes contraindications to surgery to treat morbid obesity and lacking compelling arguments for an exception in the supporting documentation, the hospital and physician services can be denied if reviewed.

  • 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 conditions.
  • 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).
  • Active hepatic disease with inflammation, portal hypertension or ascites.
  • Failure to cease tobacco use at least 6 weeks prior to surgery or documentation in the medical record that the patient has received counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation.
  • 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.

Under provisions of this LCD, the following procedures are not considered reasonable and necessary and will be denied:

      • Mini-gastric bypass
      • Long limb gastric bypass (i.e., more than 150 cm)
      • Silastic ring vertical gastric bypass (Fobi pouch)

The open port replacement procedures are non-covered since they are associated with the non-covered open gastric restrictive procedures.

Note: Any service associated with noncovered services are also noncovered.

Repeat bariatric surgery is generally not reasonable and necessary. Claims for more than one bariatric surgical procedure may be submitted for individual consideration, and potentially covered when clinical circumstances demonstrate reasonability and necessity (such as replacing a defective device or correcting a complication in a patient who had met medical necessity for the original procedure and has achieved acceptable weight loss).

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

Provider Qualifications

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 credentialing satisfy this requirement. Physicians who do not meet ACS or ASBS certification criteria for performing bariatric procedures do not qualify for payment for bariatric surgery procedures.
Summary of Evidence

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Proposed Process Information

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Associated Information
Sources of Information
Bibliography
Open Meetings
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Contractor Advisory Committee (CAC) Meetings
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MAC Meeting Information URLs
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Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
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Contact for Comments on Proposed LCD

Coding Information

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Revenue Codes

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CPT/HCPCS Codes

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 Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

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 Group 1 Codes:

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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 Group 1 Codes:

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Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Please refer to the Local Coverage Article: Billing and Coding: Surgical Management of Morbid Obesity (A57145) for documentation requirements that apply to the reasonable and necessary provisions outlined in this LCD.

Utilization Guidelines

Please refer to the Local Coverage Article: Billing and Coding: Surgical Management of Morbid Obesity (A57145) for utilization guidelines that apply to the reasonable and necessary provisions outlined in this LCD.
Sources of Information

First Coast Service Options, Inc. reference LCD numbers: L29317, L29477

Aarts EO, Janssen IM, Berends FJ. The gastric sleeve: losing weight as fast as micronutrients? Obes Surg. 2011 Feb;21(2):207-11.

Abbatini F, Capoccia D, Casella G, Coccia F, Leonetti F, Basso N. Type 2 diabetes in obese patients with body mass index of 30-35 kg/m2: sleeve gastrectomy versus medical treatment. Surg Obes Relat Dis. 2012 Jan-Feb;8(1):20-4. Epub 2011 Jul 13.

Alpert MA, Obesity Cardiomyopathy: Pathophysiology and Evolution of the Clinical Syndrome. Am J Med Sci. 2001 April; 321(4): 225-236

American Society for Metabolic & Bariatric Surgery. Updated Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. 2011.

Bariatic Surgery: American Society for Bariatric Surgery Guidelines retrieved from http://www.lapsurgery.com on April 10, 2007.

Bayham, B., Greenway, F., Bellanger, D., Outcomes of the Laprarscopic Sleeve Gastrectomy in the Medicare Population, OBES SURG DOI 10.1007, Published on line: 22 August 2012, Springer Science-Business Media, LLC 2012.

Bayham BE, Greenway FL, Bellanger DE, O'Neil CE. Early resolution of type 2 diabetes seen after Roux-en-Y gastric bypass and vertical sleeve gastrectomy. Diabetes Technol Ther. 2012 Jan;14(1):30-4.E.pub.2011Sep.20.

Bellinger, D.E., Greenway, F.L., Laparoscopic Sleeve Gastrectomy, 529 Cases Without a Leak: Short-Term Results and Technical Considerations, OBES SURG (2011)21:146-150 DOI 10. 1007, Published on line: 4 Dec. 2010, Springer Science-Business Media, LLC 2010.

Brolin R E. Bariatric surgery and long-term control of morbid obesity. JAMA 2002 Dec; 288(22):2793-2796.

Brolin RE, Bradley LJ, Taliwal RV. Unsuspected cirrhosis discovered during elective obesity operations. rch Surg. 1998;133:84-88

Buchwald H, Avidor Y, Braunwald E, Jensen, M, Paries W, Fahrbach K, Schoelles K. Bariatric surgery: A systematic review and meta-analysis. JAMA. 2004; 292(14): 1724-1737.

Calhoun DA, Booth JN, et al, Refractory Hypertension: Determination of Prevalence, Risk Factors, and Comorbidities in a Large Population·based Cohort. Hypertension. 2013 Dec. 9

Chang SS, Stoll CR, Song J, Varela JE, Eagon CJ, Colditz GA. "The Effectiveness and Risks of Bariatric Surgery: An Updated Systematic Review and Meta-analysis, 2003·2012" JAMA Surg. 2014; 149(3): 275-287

Clark JM. The epidemiology of nonalcoholic fatty liver disease in adults. J C/in Gastroentero/2006; 40: 539-543

Dallal RM, Mattar SG, Lord JL, et al. Results of laparoscopic gastric bypass in patients with cirrhosis. Obes Surg. 2004; 14:47-53

DeVries DR, van Herwarrden MA, Smout AJ, Samsom M. GAstroesophageal pressure gradients in gastroesophageal reflux disease: relations with hiatal hernia, body mass index, and esophageal acid exposure. Am J Gastroentero/. 2008; I03: 1349-1354

Dixon JB, Bhathal PS, Hughes NR, O'Brien PE. Nonalcoholic fatty liver disease: improvement in liver histological analysis with weight loss. Hepatology. 2004;39:1647-1654.

ECRI Institute Health Technology Assessment Information Service. Emerging Technology. Evidence Report: Laparoscopic sleeve gastrectomy for obesity. Plymouth Meeting (PA): ECRI Institute; 2011 October.

El-Serag HB, Ergun GA, Pando! fino J, Fitzgerald S, TranT, Kramer JR. Obesity increases oesophageal acid exposure. Gut. 2007;56:749·755.

Hampel H, Abraham NS. El-Serag HB. Meta-analysis: obesity and the risk of gastroesophageal reflux disease and its complications. Ann Intern Med. 2005;143:199-211

Kral JG, Thung SN, Biron S, et al. Effects of surgical treatment of the metabolic syndrome on liver fibrosis and cirrhosis. Surgery. 2004;135:48-58

Leyba JL, Aulestia SN, Llopis SN. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the treatment of morbid obesity. A prospective study of 117 patients. Obes Surg. 2011 Feb;21(2):212-6.

Leivonen,M.K., Juuti,A., Jaser, N., Mustonen, H. Laparoscopic Sleeve Gastrectomy in Patients over 59 Years: Early Recovery and 12- Month Follow-Up, OBES SURG (2011)21:1180-1187 DOI 10.1007, Published on line: 28 May 2011, Springer Science-Business Media, LLC 2011.

Liu X, Lazenby AJ, Clements RH, et al. Resolution of nonalcoholic steatohepatitis after gastric bypass surgery. Obes Surg. 2007; 17:486-492

Madalosso CA, Gurski RR, Callegari-Jacques SM, Navarini 0, Thiesen V, Fornari F.
The impact of gastric bypass on gastroesophageal reflux disease in patients with morbid obesity: a prospective study based on the Montreal Consensus. Ann Surg. 20I0;251: 244-248

McCloskey CA, Ramani GV, Mathier MA, et al. Bariatric surgery improves cardiac function in morbidly obese patients with severe cardiomyopathy. Surg Obes Related Dis. 2007;3:503-507

Morgenthal CB, Lin E, Shane MD, Hunter JG, Smith CD. Who will fail laparoscopic Nissen fundoplication? Preoperative prediction of long term outcomes. Surg Endosc. 2007;21:1978-1984

National Institute of Health. Bariatric Surgery Clinical Research Consortium, November 1, 2002.

National Institutes of Health, National Heart, Lung and Blood Institute: Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risks.

Pandolfino JE, El-Serag HB, Zhang Q, Shah N, Ghosh SK, Kahrilas PJ. Obesity: a challenge to esophagogastric junction integrity. Gastroenterology. 2006; 130:639-649.

Patterson EJ, Davis DG, Khajanchee Y, Swanstrom LL. Comparison of objective outcomes following laparoscopic Nissen fundoplication versus laparoscopic gastric bypass in the morbidly obese with heartburn. Surg Endosc. 2003; 17:1561-1565

Perez AR, Moncure AC, Rattner OW. Obesity adversely affects the outcome of antireflux operations.
Surg Endosc. 2001;15:986-989

Persell SD, Prevalence of Resistant Hypertension in the US, 2003-2008" Hypertension. 2011 Jun; 57(6): 1076-80

Pranchand VN, Alverdy JC. Gastroesophageal reflux disease and severe obesity: Fundoplication or bariatric surgery? World J Gastroenterol. 2010 August 14; 16(30): 3757·3761

Ramani GV, McCloskey C, Ramanathan RC, Mathier MA. Safety and efficacy of bariatric surgery in morbidly obese patients with severe systolic heart failure. Clin Cardia/. 2008;31 :516-520

S. A. Brethauer et al., Systematic review of sleeve gastrectomy as staging and primary bariatric procedure, Surgery for Obesity and Related Diseases 5 (2009) 469–475

Salome CM, King GG, Bernard N. Physiology of obesity and effects on lung function. J App/Physiol. 20 I0;I08:206-211

Stavros N. Karamanakos, MD, Konstantinos Vagenas, MD, Fotis Kalfarentzos, MD, FACS, and Theodore K. Alexandrides, MD, Weight Loss, Appetite Suppression, and Changes in Fasting and Postprandial Ghrelin and Peptide-YY Levels After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy Prospective, Double Blind Study (Ann Surg 2008; 247: 401–407)

Sugerman HJ, DeMaria EJ, Felton WL 3m, Nakatsuka M, Sismanis A. Increased intra-abdominal pressure and cardiac filling pressures in obesity-associated pseudotumor cerebri. Neurology. 1997;49: 507-511

Takata MC, Campos GM, Ciovica R, et al. Laparoscopic bariatric surgery improves candidacy in morbidly obese patients awaiting transplantation. Surg Obes Related Dis. 2008;4: 159-164

Tevar AD, et al. Clinical Review of Nonalcoholic Steatohepatitis in Liver Surgery and Transplantation. JAm Col/ Surg, April2010; 20(4): 515-526

Trailblazer Health Enterprises,LLC., Contract Number 04202, Local Coverage Determination (LCD) for Bariatric Surgical Management of Morbid Obesity - 4S-155AB-R7,(L26758),12/29/2011Revised Date

Wikiel KJ, McCloskey CA, Ramanathan RC. Bariatric surgery: A safe and effective conduit to cardiac transplantation. Surg Obes Related Dis. 2014; 10 (3): 479-484
Bibliography

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Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/01/2019 R8

Revision Number: 6
Publication: September 2019 Connection
LCR A/B2019-058

Explanation of Revision: Based on Change Request (CR) 10901, the LCD was revised to remove all billing and coding and all language not related to reasonable and necessary provisions (“Bill Type Codes”, “Revenue Codes”, “CPT/HCPCS Codes”, “ICD-10 Codes that Support Medical Necessity”, “Documentation Requirements” and “Utilization Guidelines” sections of the LCD) and place them into a newly created billing and coding article. During the process of moving the ICD-10-CM diagnosis codes to the billing and coding article, the ICD-10-CM diagnosis code ranges were broken out and listed individually. In addition, the Social Security Act and IOM reference sections were updated. The effective date of this revision is for claims processed on or after January 8, 2019, for dates of service on or after October 3, 2018.

Based on CR 11322/CR 11333 (Annual 2020 ICD-10-CM Update) the newly created Billing and Coding Article was revised. Descriptor revised for ICD-10-CM diagnosis code Z68.43. The effective date of this revision is for dates of service on or after 10/01/19.

10/01/2019: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this LCD.
  • Revisions Due To ICD-10-CM Code Changes
  • Other (Revisions based on CRs 10901, 11322, 11333)
11/06/2018 R7

Revision Number: 5
Publication: November 2018 Connection
LCR A/B2018-083

Explanation of Revision: Based on an annual review, the LCD was revised to update the “CMS National Coverage Policy” section of the LCD, for CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2. Deleted sections 100.0, 100.01, 100.08, 100.11, 100.14 and replaced them with section 100.1. The effective date of this revision is based on date of service.

11/06/2018:  At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this LCD.
  • Other (Revisions based on annual review completed on 08/29/2018.)
10/01/2018 R6

Revision Number: 4

Explanation of Revision: Based on CR 10847 (Annual 2019 ICD-10-CM Update), the LCD was revised to indicate that diagnosis codes were added, deleted and descriptor revised within existing diagnosis code ranges. The effective date of this revision is based on date of service.
  • Revisions Due To ICD-10-CM Code Changes
03/15/2018 R5

Revision Number: 3

Publication: March 2018 Connection

LCR A/B2018-028

Explanation of Revision:  Based on an annual review of the LCD, it was determined that some of the italicized language in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the LCD does not represent direct quotation from the CMS sources listed in the LCD; therefore, this LCD is being revised to assure consistency with the CMS sources. The effective date of this revision is based on date of service.

03/15/2018:  At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice.  This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Other (Revisions made based on an annual review completed on 12/26/2017.)
10/01/2017 R4

Correction made to ICD-10 Code range in Group 2 codes.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2017 R3

Revision Number: 2

Publication: September 2017 Connection 

LCR A/B2017-038 

Explanation of Revision: Based on CR 10153 (Annual 2018 ICD-10-CM Update) the LCD was revised. Added ICD-10-CM diagnosis codes I27.21 -  I27.29, I27.83. Changed ICD-10-CM diagnosis code range M48.06-M48.07 to M48.061-M48.07. Deleted ICD-10-CM diagnosis code I27.2, M48.06. The effective date of this revision is based on date of service.

 

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice.  This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R2 Revision Number: 1 Publication: October 2016 Connection LCR A/B2016-097

Explanation of Revision: Based on CR 9677 (Annual 2017 ICD-10-CM Update) the LCD was revised. Deleted diagnosis code E78.0 and changed diagnosis code range E78.0-E78.5 to read E78.00-E78.5. The effective date of this revision is based on date of service.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R1 03/25/15 - The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.
  • Provider Education/Guidance
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10/02/2019 10/01/2019 - N/A Currently in Effect You are here
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