ICD-10-CM Diagnosis Codes
ICD-10-PCS Procedure Codes
CPT® Procedure Codes
HCPCS Supply/DME Codes
ICD-9-CM Diagnosis Codes
Place of Service Codes
UB04 Condition Codes
UB04 Revenue Codes
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.
Refer to the Nonmedical Necessity Coverage and Payment Rules section of the related Policy Article for information about the statutory coverage requirements for oral antiemetics drugs.
The use of the oral anti-emetic 3-drug combination of an FDA approved oral NK-1_antagonist in combination with an oral 5HT3 antagonist and dexamethasone (J8540) is covered if, in addition to meeting the statutory coverage criteria specified in the related Policy Article, they are administered to beneficiaries who are receiving one or more of the following anti-cancer chemotherapeutic agents:
Contractor Name(Contractor Number) - Contractor Info
National Government Services, Inc. (17003) - DME Region B
The appearance of a code in this section does not necessarily indicate coverage.
EY - No physician or other licensed health care provider order for this item or service
GA - Waiver of liability statement issued as required by payer policy, individual case
GZ – Item or service expected to be denied as not reasonable and necessary
KX - Requirements specified in the medical policy have been met
J8501 J8540 J8650 Q0161 Q0162 Q0163 Q0164 Q0166 Q0167 Q0169 Q0173 Q0174 Q0175 Q0177 Q0180 Q0181 Q0511 Q0512