Title XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
Title XVIII of the Social Security Act section 1862 (a) (1) (D). This section states that no Medicare payment may be made under part A or part B for any expenses incurred for items or services that are investigational or experimental.
Title XVIII of the Social Security Act, 1862(a)(7) and 42 Code of Federal Regulations, Section 411.15, exclude routine physical examinations.
Section 1842(n)(1) of the Social Security Act (the Act) establishes payment rules for certain diagnostic tests (other than clinical diagnostic laboratory tests) where the physician performing or supervising the test does not share a practice with the billing physician or other supplier.
Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.
Section 4317(b), of the Balanced Budget Act (BBA) of 1997, specifies that referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered.
The Code of Federal Regulations (CFR), 42 CFR 410.32, specifies that all diagnostic tests “must be ordered by the physician who is treating the beneficiary.”
42 CFR, Section 411.15(k)(1) states any services that are not reasonable and necessary are excluded from coverage.
CMS Publication 100-02, Medicare Benefit Policy, Chapter 1: Inpatient Hospital Services, §50.
CMS Publication 100-02, Medicare Benefit Policy, Chapter 6: Hospital Services Covered Under Part B, §10 and §20.3.
CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.6.1; Requirements for Ordering and Following Orders for Diagnostic Tests and Definitions.
CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80, Requirements for Diagnostic X-Ray, Diagnostic Laboratory and other Diagnostic Tests sets forth the various levels of physician supervision required for diagnostic tests.
CMS Publication 100-02, Medicare Benefit Policy, Chapter 16: Laboratory Services From Independent Labs, Physicians, and Providers, §10.
CMS Manual System, Pub 100-03, National Coverage Determinations, Part 1: 20.15 Coverage for electrocardiographic services under Medicare Part B. This section sets out a framework for covered ambulatory electrocardiographic services.
CMS Manual System Pub. 100-03 National Coverage Determinations Transmittal 26: Electrocardiographic Services
CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §30.6.6.B, clarifies coverage for preoperative evaluations.
CMS Manual System, Pub.100.04, Medicare Claims Processing Manual, Chapter 32, §§140.1, 140.1.1, 140.2, 140.2.2.1, 140.2.2.3, 140.2.2.4, 140.2.2.5, 140.2.2.6, 140.3, 140.3.1., Cardiac Rehabilitation.
